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Keywords:

  • pelvic organ prolapse;
  • robotics;
  • urinary fistula

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Robotic surgery for POP
  5. RSC for vaginal vault prolapse
  6. RSH for uterine prolapse
  7. Lower urinary tract fistula
  8. VVF
  9. VUF
  10. UVF
  11. Conclusions
  12. Conflict of interest
  13. References

Pelvic organ prolapse and lower urinary tract fistulas are two disorders frequently managed in female urology. New techniques have been adapted and improved to decrease morbidity and improve clinical outcomes of these disorders. The adaptation of minimally-invasive approaches for the management of pelvic organ prolapse and lower urinary tract fistulas began with laparoscopy. However, laparoscopic surgery has not gained widespread popularity as a result of the associated technical challenges, such as intracorporeal suturing and pelvic dissection. Robotic surgery has been widely carried out in urological oncology since 2001, and has been widely adapted because of its advantages over conventional laparoscopy for the management of pelvic organ prolapse and lower urinary tract fistulas. The current literature has shown the safety, feasibility and favorable clinical outcomes of robotic surgery for the treatment of these disorders. Robotic surgery in the management of pelvic organ prolapse and lower urinary tract fistula repairs might offer a promising advancement and benefits. However, further long-term data should be followed to assess the durability of this newer, and minimally-invasive approach.


Abbreviations & Acronyms
ASC

abdominal sacrocolpopexy

EBL

estimated blood loss

FU

follow up

LOS

length of hospital stay

LSC

laparoscopic sacrocolpopexy

NR

not reported

OP

operation

POP

pelvic organ prolapse

POPQ

pelvic organ prolapse quantification

RSC

robot-assisted sacrocolpopexy

RSH

robot-assisted sacrohysteropexy

UVF

ureterovaginal fistula

VUF

vesicouterine fistula

VVF

vesicovaginal fistula

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Robotic surgery for POP
  5. RSC for vaginal vault prolapse
  6. RSH for uterine prolapse
  7. Lower urinary tract fistula
  8. VVF
  9. VUF
  10. UVF
  11. Conclusions
  12. Conflict of interest
  13. References

The da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) was approved by the U.S. Food and Drug Administration for use in general laparoscopic surgery in 2000, followed by clearances in 2001 for radical prostatectomy and in 2005 for urological surgical procedures.[1] Over time, it has become clear that one of the benefits of robot-assisted surgery is the ability to assist with and perfect reconstructive procedures. The applications of robotics have thus been broadened in female urology (pelvic organ prolapse and lower urinary tract fistulas), as well as urological oncology.

Robotic technology retains the advantages of laparoscopy, including less postoperative pain, decreased blood loss, shorter hospitalization, quick postoperative recovery and better cosmesis. The use of robotics could also overcome the limitations of pure laparoscopic repair related to steep learning curves, and the technical challenge of deep pelvic dissection and intracorporeal suturing, while providing robot-specific advantages, such as 3-D imaging with improved depth perception, higher magnification, wristed instrumentation with increased degrees of freedom, tremor filtration, motion scaling and an ergonomic interface.

In the present article, we review the current literature with regard to robotic applications for the management of pelvic organ prolapse and lower urinary tract fistulas.

Robotic surgery for POP

  1. Top of page
  2. Abstract
  3. Introduction
  4. Robotic surgery for POP
  5. RSC for vaginal vault prolapse
  6. RSH for uterine prolapse
  7. Lower urinary tract fistula
  8. VVF
  9. VUF
  10. UVF
  11. Conclusions
  12. Conflict of interest
  13. References

The prevalence of any degree of POP is estimated to be approximately 33% in women aged 20–59 years,[2] and it has a negative impact on quality of life.[3] In the USA, approximately 3.3 million women are currently reported to have POP, and an estimated 4.9 million women will be affected by the year 2050.[4] As many as 11% of women will undergo surgical treatment for POP or urinary incontinence by age 80 years, resulting in approximately 200 000 inpatient surgical procedures each year for POP in the USA alone.[5]

ASC is considered to be the gold standard treatment for apical vaginal vault prolapse.[6] However, this procedure requires a laparotomy, such as low transverse or low midline incision, which is invasive and can be associated with considerable morbidity. Some groups have reported a laparoscopic approach to ASC in an attempt to provide minimally-invasive surgery, and improve postoperative pain, duration of recovery, LOS and blood loss.[7-10] However, LSC is technically challenging and requires advanced laparoscopic skills. For example, peritoneal dissection of the rectovaginal junction or sacral promontory and the extensive suturing required all require advanced skills. Thus, as LSC is associated with a steep learning curve, it has not been widely adopted.

Recently, treatment of apical prolapse has evolved with the advent of robotic surgery, which has enabled surgeons to carry out this surgery with greater ease and feasibility. There have been a series of RSC studies published since the first report in 2004.[11] Most of these reports have shown the functional outcomes of RSC, and the success and recurrence rates of apical support have been reported to be equivalent to ASC or LSC. However, some studies have reported minimal or no superiority of RSC in regards to cost, operative time and pain control. Furthermore, there have been no prospective randomized control studies of the benefits of RSC over ASC for the treatment of apical prolapse. A summary of the data for robotic surgery for apical prolapse is listed in Table 1.

Table 1. Summary of robotic surgery for apical prolapse
SeriesNo. patientsMean FU (months)Mean OP time (min)Mean EBL (mL)Mean LOS (days)OutcomesComplications
Elliott et al.[12] (case series)30 RSC241861Success rate: 95%

Conversion: 1 (open)

Mesh erosion: 2

Daneshgari et al.[13] (case series)15 RSC and RSH3.1317812.4Improvement in C-point of POPQ : from +2.1 to −8.28

Conversion: 3

(open, laparoscopic, vaginal)

Serosal injury 1

Akl et al.[14] (case series)80 RSC4.8197.996.82.6After completion of the first 10 cases, mean operative time decreased by 25.4% (64.3 min)

Conversion: 4 (open)

Bladder injury: 2

Small bowel injury: 1

Ureteral injury: 1

Pelvic abscess: 1

Mesh erosion: 5

Geller et al.[15] (retrospective cohort study)

73 RSC

105 ASC

6 weeks

RSC: 328

LSC: 225

(P < 0.001)

RSC: 103

ASC: 255

(P < 0.001)

RSC: 1.3

LSC: 2.7

(P < 0.001)

No differences in POPQ points improvements

Conversion: RSC 1 (open)

LSC 0

No differences in overall complications

Collins et al.[16] (prospective, non-randomized)

30 RSC

20 ASC

10 days

RSC: 262

ASC: 245

(P = 0.437)

RSC: 83

ASC: 215

(P < 0.001)

No differences in recovery time of physical activity and pain control
Paraiso et al.[17] (randomized controlled)

35 RSC

33 LSC

12

RSC: 265

LSC: 199

(P < 0.001)

RSC: 1.8

LSC: 1.4

(P = 0.17)

No differences in POPQ points improvements and QOL measure

Longer use of NSAIDS, more cost, and greater pain at rest and during normal activity in RSC

Conversion: RSC 3 (open)

LSC 2 (open, vaginal)

Cystotomy: RSC 2

LCS 2

Mesh erosion: RSC 2

LSC 0

No differences in overall complications

Tan-Kim et al.[18] (retrospective cohort study)

43 RSC

61 LSC

RSC: 25

LSC: 36

(P = 0.15)

RSC: 281

LSC: 206

(P < 0.001)

RSC: 86

LSC: 85

(P = 0.85)

RSC: 1

LSC: 1

(P = 0.48)

No differences in POPQ points improvements and objective cure rate

(RSC: 37/40 (90%), LSC: 44/55 (80%), P = 0.19)

Mesh erosion: RSC 2

LSC 2

No differences in overall complications

Seror et al.[19] (prospective, non-randomized)

20 RSC

47 LSC

RSC: 15

LSC 18

(P = 0.05)

RSC: 217

LSC: 231

(P = 0.4)

RSC: 55

LSC: 280

(P = 0.03)

RSC: 5.1

LSC: 6.4

(P = 0.5)

Success rate 95.5%

Recurrence: RSC 1

LSC 0 (P = 0.3)

No differences in PFDI score

Conversion: RSC 1 (open)

LSC 0

Mesh erosion RSC 1

LSC 0

Gocmen et al.[20] (case series)

6 RSC

6 RSH

12

RSC: 150

RSH: 146

RSC: 12.5

RSH: 32.5

RSC: 2.8

RSH: 1.6

Age: RSC 65.6

RSH 38.1

No recurrence

No conversion

No intra- or postoperative complications

Successful pregnancy and delivery (cesarean section) in one patient of RSH

Mourik et al.[21] (case series)50 RSH16223<503

Overall repair rate: 98%

Recurrence: 2%

Conversion: 2 (open)

Mesh erosion: 0

RSC for vaginal vault prolapse

  1. Top of page
  2. Abstract
  3. Introduction
  4. Robotic surgery for POP
  5. RSC for vaginal vault prolapse
  6. RSH for uterine prolapse
  7. Lower urinary tract fistula
  8. VVF
  9. VUF
  10. UVF
  11. Conclusions
  12. Conflict of interest
  13. References

Di Marco et al. first reported five cases of RSC for the treatment of vaginal vault prolapse.[11] Conventional laparoscopy was used for peritoneal dissection, followed by a robot-assisted procedure to suture a silicon Y-shaped graft, and reperitonealization was achieved with a mean operative time of 222 min. No recurrent apical prolapse occurred during the short-term follow up of 4 months. Using a hybrid technique, the same group presented long-term results of RSC, with a mean follow up of 24 months.[12] With the exception of one patient, all were discharged from the hospital after an overnight stay. All patients were satisfied with the results, although there were some complications during the follow-up period, such as recurrence (1 patient) or vaginal extrusion of the mesh at the level of the vaginal cuff (2 patients). Daneshgari et al. carried out RSC and RSH in 15 women, and conversion to LSC, ACS and a transvaginal approach were required in one patient each, with all conversions due to bowel adhesions.[13] The mean operative time was 317 min and the mean blood loss was 81 mL. All patients had resolution of their prolapse during the mean follow up of 3.1 months. A total of eight patients had additional procedures, namely mid-urethral sling in seven patients and Burch colposuspension in one patient. The authors suggested that RSC is a viable option for surgical management of complex female POP. Regarding the learning curve of RSC, Akl et al. verified that RSC is a feasible procedure with acceptable complication rates and a short learning curve.[14] After the first 10 cases, the mean operative time decreased significantly by 25.4% (64.3 min, P < 0.01). During the operation, complications such as bladder injury (2.5%), ureteral injury (1.2%) and small bowel injury (1.2%) occurred. During a mean follow up of 4.8 months, vaginal mesh erosion (6%), pelvic abscess (1.2%) and ileus (5%) developed. After this RSC case series, several comparative studies of RSC with ASC or LSC were reported. In 2008, Geller et al. carried out a retrospective cohort study comparing RSC (73 cases) with ASC (105 cases).[15] They concluded that RSC is associated with slight improvements in the C-point of the POP quantification system at 6 weeks compared with ASC (−9 vs −8, P < 0.01), longer operative time (328 vs 255 min, P < 0.01), less blood loss (103 vs 255 mL, P < 0.01) and shorter lengths of hospitalization (1.3 vs 2.7 days, P < 0.01). However, this data is limited by the lack of long-term data to assess the durability of this newer minimally-invasive approach for prolapse repair. Improved pain control and faster recovery after laparoscopy compared with laparotomy are commonly considered to be advantages for several procedures. However, one study reported that RSC has no advantages compared with ASC. Collins et al. prospectively measured recovery of activity and pain control after RSC (30 patients) and ASC (18 patients) using accelerometers.[16] They found that women who underwent RSC did not recover physical activity faster than those who underwent ASC at postoperative days 5 and 10. There were also no differences between RSC and ASC regarding secondary end-points, pain control measured by a visual analog scale or narcotic analgesic use. The authors used the Short Form-36 questionnaire for evaluating quality of life as another secondary end-point. Of the eight subscales, vitality subscale scores were lower after surgery in the ASC group than in the RSC group.

With respect to comparative studies of RSC and LSC, there have been three reports to date. In 2011, Paraiso et al. carried out a single-blinded randomized controlled trial comparing RSC with LSC for apical prolapse.[17] Interestingly, they found that RSC results in a longer operating time (including docking time, 265 vs 199 min, P < 0.01) and increased pain, without advantages in clinical outcome measures during the perioperative period, at 6 months, or at 1-year follow up compared with LSC. They concluded that robotic surgery can accelerate the learning curve of less experienced surgeons, but that it does not offer any clear advantages for surgeons experienced in advanced laparoscopy. Tan-Kim et al. also reported that the mean operative time was longer in RSC than in LSC (281 vs 206 min, P < 0.01).[18] Cure rates, blood loss and complications were not different for RSC vs LSC. In contrast, Seror et al. reported the superiority of RSC vs LSC in terms of blood loss (44 vs 280 mL, P < 0.01) and strict operative time (excluding time for docking of robot, 125 vs 220 min, P < 0.01) with an equivalent functional outcome between the two techniques.[19] However, this time advantage was nullified when comparing overall operating room time (215 vs 220 min, P > 0.05).

In regards to the cost of robotic surgery, Judd et al. carried out a cost analysis comparing RSC, LSC and ASC.[22] A cost-minimization analysis method was used that measured operative time, risk of conversion, risk of transfusion and LOS. Respective baseline estimates for RSC, LSC and ACS included operative time (328, 269 and 170 min), conversion (1.4%, 1.8% and 0%), transfusion (1.4%, 1.8%, 3.8%) and LOS (1.0, 1.8 and 2.7 days). They concluded that RSC was more expensive compared with LSC or ASC under the baseline assumption in the robot purchase model, and even in the robot existing model. Patel et al. also verified that RSC produced the highest costs among ASC, LSC and RSC.[23] In contrast, Elliott et al. reported that RSC can be equally or less costly than ASC in the USA, and that cost depends on a sufficient institutional robotic case volume and a shorter postoperative stay for patients who undergo RSC.[24]

RSH for uterine prolapse

  1. Top of page
  2. Abstract
  3. Introduction
  4. Robotic surgery for POP
  5. RSC for vaginal vault prolapse
  6. RSH for uterine prolapse
  7. Lower urinary tract fistula
  8. VVF
  9. VUF
  10. UVF
  11. Conclusions
  12. Conflict of interest
  13. References

A common treatment option for uterine prolapse is hysterectomy; however, this procedure is associated with a high POP recurrence rate.[25, 26] Women frequently request uterine conservation for a variety of reasons, including a perceived benefit in terms of sexual function, cultural factors or other personal reasons.[27] Additionally, there are a growing number of women who desire uterine preservation with symptomatic POP.[28] Recent results of hysteropexy show short-term success rates comparable with sacrocolpopexy in patients with POP.[29, 30] In those women who desire a uterine-sparing repair, RSH could be an ideal option for minimally-invasive surgery in select cases.

There are several major controversies associated with uterus-preserving surgery for POP.[3] First, uterine sparing can expose the patient to potential malignancies or other pathologies. In postmenopausal women without bleeding who underwent hysterectomy for uterine prolapse, 2.6% carried a risk for unanticipated pathology, such as endometrial cancer or hyperplasia.[31] However, women with a history of postmenopausal bleeding, even with a negative endometrial evaluation, had a risk as high as 13.3%. This concern should be considered at the time of evaluation and patients must be informed. Second, there are complications associated with hysterectomy. Altman et al. reported that hysterectomy increases the risk for subsequent stress urinary incontinence.[32] They concluded that women should be counseled on the risks associated with hysterectomy, and other treatment options should be considered before surgery. Pregnancy after uterus-sparing surgery in fertile women is also a matter of debate, because the effects of any reconstructive procedure on pregnancy and delivery are still poorly understood.[3] Unfortunately, there is no data available regarding pregnancy after RSH. However, there have been several case reports of successful pregnancies after other types of sacrohysteropexy.[20, 33, 34] Maher et al. reported two full-term pregnancies and deliveries (2 elective cesarean sections) among 43 women who underwent laparoscopic sacrohysteropexy.[33]

At Samsung Medical Center, Seoul, Korea, a brief surgical technique of robotic sacrohysteropexy is as follows. Patients are placed in dorsal lithotomy with steep Trendelenburg position (30°). A pneumoperitoneum is created and five laparoscopic ports are placed in a W-figure (one 12-mm trocar for camera port above the umbilicus, three 8-mm trocars for robotic arms and one 12-mm trocar for the assistant). A 0° or 30° lens was used interchangeably. A vaginal retractor is used to push up the vaginal wall anteriorly, and then the peritoneum of the anterior utero-vesical junction was dissected (Fig. 1a,b). A peritoneal dissection between the posterior uterus and vagina is made to carry out peritoneal tunneling at the lateral level of the broad ligament opening (Fig. 1c). A peritoneal incision is made over the sacral promontory at the bifurcation of the aorta, and sacral dissection is carried out until anterior longitudinal ligament is exposed (Fig. 1d). Anterior mesh (4 × 5 cm sized, non-absorbable polypropylene monofilament mesh, Gynemesh, Gynecare; Ethicon, Somerville, NJ, USA) is placed and sutured with one or two non-absorbable sutures (Fig. 1e). Anterior mesh could be omitted in the case of a small-sized uterus. T-shape mesh is placed on the posterior dissection plane (Fig. 1f), and both arms of the mesh were drawn through the peritoneal tunnel of the broad ligament (Fig. 1g). Anterior and posterior meshes are combined with suture on the anterior side of the uterus (Fig. 1h). The tail of the T-shape posterior mesh is fixed with the anterior longitudinal ligament on the sacral promontory (Fig. 1i). The peritoneum is then re-approximated over the mesh with absorbable sutures (Fig. 1j).

figure

Figure 1. Brief surgical illustration of sacrohysteropexy. (a,b) Opening the uterovesical peritoneum. (c) Dissecting the peritoneum between the posterior uterus and vagina. (d) Opening the peritoneum over the sacral promontory. (e) Incorporation of the anterior mesh. (f) Suturing the posterior mesh strip to the posterior uterus and (g,h) combined with anterior mesh. (i) Fixation of a mesh to the sacral promontory. (j) Repair of the peritoneum. Meshes designed for sacrohysteropexy; (k) anterior and (l) posterior.

Download figure to PowerPoint

To date, there have been few studies regarding RSH. Gocmen et al. reported six RSC and six RSH cases in 2012.[20] The mean age of the RSH group was 38.1 years compared with 65.6 years in the RSC group. The mean operation time was 146 min and the mean blood loss was 32 mL. Intra- or postoperative complications and recurrence of the original condition did not occur during the 12-month follow-up period. Only one patient became pregnant after the operation in the second month, and a cesarean section was carried out without complication. Vitobello et al. reported two cases of RSH, which is a safe and feasible option for uterine prolapse.[28] There were neither intra- nor postoperative complications. No additional reconstructive procedures were necessary at the end of the surgery. Mourik et al. carried out a prospective cohort study of 50 women treated with RSH for uterine prolapse.[21] There were two conversions to laparotomy because of limited exposure. The mean operating time, including robot docking, was 223 min, and the overall repair rate was 98%. The authors also measured quality of life using a self-questionnaire, and found that nervousness, shame and frustration were significantly improved after RSH surgery.

The best approach for reconstruction of the apical prolapse remains controversial. Robotic surgery might offer a promising advancement and benefits in the treatment of POP in terms of the restoration of vaginal anatomy and improved quality of life. However, further long-term data are required to assess the durability of this newer, minimally-invasive approach to POP repair.

Lower urinary tract fistula

  1. Top of page
  2. Abstract
  3. Introduction
  4. Robotic surgery for POP
  5. RSC for vaginal vault prolapse
  6. RSH for uterine prolapse
  7. Lower urinary tract fistula
  8. VVF
  9. VUF
  10. UVF
  11. Conclusions
  12. Conflict of interest
  13. References

The term, lower urinary tract fistula, includes various conditions, such as vesicovaginal, vesicouterine and ureterovaginal fistulas. Recently, there has been widespread exploration of the application of robotic approaches in the treatment of these fistulas.

VVF

  1. Top of page
  2. Abstract
  3. Introduction
  4. Robotic surgery for POP
  5. RSC for vaginal vault prolapse
  6. RSH for uterine prolapse
  7. Lower urinary tract fistula
  8. VVF
  9. VUF
  10. UVF
  11. Conclusions
  12. Conflict of interest
  13. References

VVF have presented challenges for surgeons, and a significant social and hygienic problem for patients, especially when this condition recurs or leads to severe complications.[35] Although iatrogenic gynecological procedures account for most cases in developed countries,[35] poor obstetric care in developing countries continues to be the predominant cause of VVF, usually as a result of obstructed labor.[36, 37] Generally, VVF occurs 1–6 weeks after gynecological or obstetric surgery, and a recurrent fistula can develop within the first 3 months after primary VVF repair.[38] The proper timing of repair and the ideal approach is currently controversial.[39] When the VVF is large or does not react to conservative treatments, corrective surgery is indicated. The principles of fistula repair have remained largely unchanged over the decades, and include adequate exposure, separation of the bladder and vagina, trimming of any devascularized edges of the bladder and vagina, tension-free closure of the bladder and vagina with non-overlapping suture lines, interposition of vascularized tissue (omentum, peritoneum or Martius flap), and postoperative bladder drainage.[40-42] Various surgical techniques for the correction of VVF have been described depending on the cause and location of the fistula, and the familiarity of the surgeon with the approach. VVF can be repaired by a transvaginal or transabdominal approach. As most VVF are as a result of difficult or complicated hysterectomies, the initial repair is usually attempted through a transvaginal approach, as this approach has less morbidity and is more familiar to urogynecologists.[43] However, the vaginal approach has some limitations, especially when the VVF is high on the posterior bladder wall and the vagina is severely scarred.[39] Although the morbidity of an open abdominal approach is significant compared with that of a vaginal approach, an abdominal approach is usually preferred in patients with large (>3 cm) fistulas, supratrigonal fistulas, fistulas in close proximity to or involving ureteral orifices and in patients with recurrent or multiple complicated fistulas after transvaginal repair.[42, 44] To decrease the morbidity of the abdominal approach, a laparoscopic approach to VVF repair has been utilized with similar success rates, minimal surgical trauma, lesser morbidity and more rapid convalescence.[45] However, despite these advantages, the laparoscopic approach has not gained in popularity, most likely because of the technical challenges with VVF dissection and intracorporeal suturing. Even in challenging cases of recurrent VVF, robotic assistance has overcome these technical difficulties.[46] The current literature on robot-assisted laparoscopic repair of VVF is summarized in Table 2.

Table 2. Previous studies on robot-assisted laparoscopic repair of VVF
SeriesNo. patientsEtiologyMean OP time (min)Mean LOS (days)Mean EBL (mL)Mean FU (months)ComplicationsOutcomes
Melamud et al.[47]1Hysterectomy2802504NoneContinent
Sundaram et al.[48]5

Hysterectomy (4)

Myomectomy (1)

2335706None

All patients

continent

Schimpf et al.[49]1Hysterectomy2402NR3NoneContinent
Hemal et al.[46]7

Hysterectomy (3)

Cesarean section (2)

Obstetric (2)

1413903–12None

All patients

continent

Gupta et al.[50]12

Obstetric (6)

Hysterectomy (4)

Cesarean section (2)

1403.188NRNone

All patients

continent

Kurz et al.[51]3HysterectomyNR5NR1–10None

All patients

continent

Rogers et al.[52]2HysterectomyNR2NR12None

All patients

continent

The first case report of robotic-assisted VVF repair was reported by Melamud et al. in 2005.[47] After dissection and excision of the fistula with conventional laparoscopy, a surgical robot was used to close the vagina and bladder without complications. Fibrin glue was injected between the bladder and vagina to separate the suture lines. The total operative time was 280 min and the estimated blood loss was 50 mL. The patient went home on the second postoperative day and continued to void normally without fistula recurrence at week 16 of follow up. Sundaram et al. carried out robotic VVF repair in five patients in 2006.[48] Four of these patients underwent hysterectomy and one underwent myomectomy. All patients failed conservative treatment with continuous Foley catheter drainage. After 12 weeks of recovery from their original surgery, robotic repair of the VVF was carried out. Bilateral ureteral catheterization was performed at the time of the surgery. Intentional cystotomy was carried out to permit excision of the fistula tract, allowing for separation of the vagina and bladder. After the fistula tract was excised, the margins were freshened. The vaginal opening was closed horizontally, the bladder opening was closed vertically with interrupted Vicryl sutures and the omentum was interposed between these suture lines. The mean operative time was 233 min, the estimated blood loss was less than 70 mL and the mean LOS was 5 days. The Foley catheter was removed on the 10th postoperative day. At month 6 of follow up, all patients continued to void normally without VVF recurrence. Schimpf et al. published a case report on a robotic-assisted VVF repair technique without intentional cystotomy.[49] A stent was placed through the fistula to facilitate the identification and localization of the fistula tract. No cystotomy was made, the bladder was dissected away from the anterior vaginal wall at the fistula site, and the defects were closed independently with interposition of a fatty epiploica from the sigmoid colon. Total operative time was approximately 4 h, and the patient had no recurrent symptoms at 3 months after surgery. The authors suggested that this technique could decrease the risk of recurrence and the length of postoperative catheterization, as less dissection is required. However, more data is required to confirm this finding. Hemal et al. reported on a case series of seven recurrent supratrigonal VVF.[46] Robotic-assisted repair was carried out at least 4 months after the last VVF repair effort. They used a technique similar to that of Sundaram et al.[48] They noted difficulty regarding the establishment of pneumoperitoneum, extensive adhesiolysis, dissection of the fistula, tension-free closure of the larger defect and the absence of omentum for interposition because of previous surgeries. The mean operative time was 141 min, the mean blood loss was 90 mL and the mean LOS was 3 days. No significant complications were observed. All patients had a successful outcome and voided normally during the 3–12 months of follow up. The conclusion was that robotic repair for recurrent VVF was feasible, resulted in low morbidity and provided outstanding results. Gupta et al. reported a retrospective comparative analysis between open and robot-assisted repairs of recurrent VVF.[50] A total of 32 patients (12 robot-assisted and 20 open repairs) with recurrent VVF were in the study. All patients in the robot-assisted group were successfully managed (100% success rate) as compared with 90% in the open repair group, but these findings were not statistically significant. The mean blood loss and the mean LOS were significantly lower in the robot-assisted group than in the open group (88 mL vs 170 mL, 3.1 days vs 5.6 days, P < 0.05 for all). The authors concluded that robot VVF repair was a better option for recurrent fistulas compared with conventional open repair as based on the reduced morbidity without compromising surgical results. Kurz et al. published a report of a series of three cases of VVF treated with robot-assisted repair using a peritoneal flap inlay.[51] All patients were diagnosed with a supratrigonal fistula as a complication after abdominal hysterectomy. Robot-assisted laparoscopic repair was chosen due to high vaginal fistulas, which are difficult to reach by a vaginal approach. The interposition of the peritoneum flap was used as a vital layer between the vaginal and bladder sutures. All patients were discharged after 5 days. At 4–42 weeks of follow up, all patients were continent and were without signs of fistula recurrence. The authors concluded that peritoneal inlay flap was an alternative to time-consuming mobilization of the greater omentum, and that robotic-assisted repair with peritoneal flap inlay was very promising for cases with a high VVF. Recently, Rogers et al. reported two cases of robotic-assisted VVF repair utilizing an extravesicular approach.[52] They used a similar technique to that by Schimpf et al.[49] However, unlike Schimpf et al. the omental flap was interposed between the vaginal and bladder sutures. Both patients were discharged on postoperative day 2 without complications. There was no VVF recurrence after 1 year of follow up. The authors concluded that it is possible to repair a VVF with a robotic-assisted extravesical approach while avoiding the morbidity of a large cystotomy. They suggested that patient selection was key for the success of extravesical VVF repair, and that if it is not possible to identify the fistula, then a midline cystotomy is required for VVF identification.

VUF

  1. Top of page
  2. Abstract
  3. Introduction
  4. Robotic surgery for POP
  5. RSC for vaginal vault prolapse
  6. RSH for uterine prolapse
  7. Lower urinary tract fistula
  8. VVF
  9. VUF
  10. UVF
  11. Conclusions
  12. Conflict of interest
  13. References

VUF is an uncommon condition, accounting for 1–4% of all genitourinary fistulas.[53] The most common etiology of VUF is a lower segment cesarean section, the prevalence of which is increasing because of the increased rate of lower segment cesarean sections.[54] Other less common causes include uterine rupture, manual removal of the placenta, placenta percreta, local tumor invasion or radiation injury, contraceptive intrauterine device causing uterine injury, congenital anomalies, pelvic infections such as tuberculosis or actinomycosis and uterine artery embolization.[55-57] The classical triad of VUF is menouria and amenorrhea without incontinence. Management options for VUF include conservative, medical and surgical approaches. Surgical correction is still considered the mainstay and the most definitive management modality. The repair of VUF is carried out by a transabdominal approach, as it cannot be accessed vaginally.

Hemal et al. reported three cases of VUF treated with robot-assisted repair.[58] Two patients had a prior history of multiple cesarean sections and one patient had a history of obstructed labor. Hysterectomy was carried out at the time of surgery in one case, and omental interposition was carried out between the uterus and bladder in the other two cases. The mean operative time was 127.5 min, and the average blood loss was 120 mL. All patients were discharged on day 3 and continent at month 3 of follow up. The authors concluded that robotic repair of VUF is safe, and effective, and has successful outcomes.

Chang-Jackson et al. published a case report of robotic-assisted VUF repair.[59] The patient had undergone four cesarean deliveries, and presented with a persistent VUF after failing conservative treatment with bladder decompression and amenorrhea-inducing agents. Only one accessory port was used to carry out the robot-assisted VUF repair, in comparison with the two to three accessory ports used by Hemal et al.[58] The operative time (with hysteroscopy and cystoscopy) was 190 min, and the estimated blood loss was 100 mL. The patient was discharged on the second postoperative day. At month 3 of follow up, the patient was continent and did not complain of menouria.

Perveen et al. reported three cases of VUF managed with robot-assisted repair.[60] Two of the patients had a prior history of lower segment cesarean section complicated by bladder injury, and one patient had a difficult labor with vaginal birth after a previous cesarean section. Robot-assisted VUF repair was successful in all patients. There were no intraoperative or postoperative complications. The mean operative time was 131.7 min and the mean blood loss was 40 mL. All patients were discharged on the second postoperative day and remained asymptomatic at month 18 of follow up. The conclusion was that robot-assisted repair is safe, feasible and effective for the repair of complex VUF, with all of the added advantages of being a minimally-invasive surgery.

UVF

  1. Top of page
  2. Abstract
  3. Introduction
  4. Robotic surgery for POP
  5. RSC for vaginal vault prolapse
  6. RSH for uterine prolapse
  7. Lower urinary tract fistula
  8. VVF
  9. VUF
  10. UVF
  11. Conclusions
  12. Conflict of interest
  13. References

The incidence of UVF varies from 0.5% to 2.2% for benign gynecological cases.[61] Possible causes include obesity, endometriosis, pelvic inflammatory disease, radiation, cancer and a history of vascular or colorectal surgery. There is ongoing debate regarding the optimal treatment modality for the management of UVF. Open surgical repair is advocated for the initial treatment modality, but open surgery is related to significant morbidity. There has been a minority of series published on robot-assisted UVF repair.

Laungani et al. reported three cases of UVF after total abdominal hysterectomy,[62] and carried out robot-assisted repair of UVF with ureteral reimplantation. The mean console time was 100.33 min, the mean estimated blood loss was 72.66 mL and the mean LOS was 1.2 days. At 6 months of follow up, all patients were completely dry, and follow-up excretory urography showed no residual hydronephrosis. The authors concluded that the robotic system provided an advantage for the gross identification of viable structures within dense scar tissue, in addition to the identification of a healthy ureter for reimplantation, which decreased the period of morbidity for the early repair of UVF.

Siddighi et al. published a case report of robotic-assisted UVF repair using a lighted ureteral stent.[63] The lighted ureteral stent was placed preoperatively to assist with ureter identification and dissection. Additionally, a lacrimal duct probe was transvaginally inserted for easy identification of fistula tract. The mean console time was 284.3 min, and the mean LOS was 3.3 days. The conclusion was that preoperative planning, and an experienced and multispecialty robotic surgical team are paramount for the success of robot-assisted UVF repair.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Robotic surgery for POP
  5. RSC for vaginal vault prolapse
  6. RSH for uterine prolapse
  7. Lower urinary tract fistula
  8. VVF
  9. VUF
  10. UVF
  11. Conclusions
  12. Conflict of interest
  13. References

Improved and less invasive surgical methods continue to evolve, and decrease the need for reoperation while increasing patient satisfaction after female urological procedures. The application of robotics in the management of POP and lower urinary tract fistula could offer a promising advancement and benefits. Several series have shown the feasibility, safety, and outcomes of robot-assisted repairs compared with traditional abdominal sacrocolpopexy and repair of lower urinary tract fistulas. However, robot-assisted surgery has some disadvantages, including the cost of robot instrumentation and maintenance, a longer set-up time and a lack of tactile feedback. We anticipate that these disadvantages will be overcome in the near future through developments in instrumentation and technology. Robot-assisted surgery for POP and lower urinary tract fistula can be carried out with improved efficacy and substantial cost. In addition, further prospective, randomized control studies should be carried out to compare the robotic approach with an abdominal or conventional laparoscopic approach.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Robotic surgery for POP
  5. RSC for vaginal vault prolapse
  6. RSH for uterine prolapse
  7. Lower urinary tract fistula
  8. VVF
  9. VUF
  10. UVF
  11. Conclusions
  12. Conflict of interest
  13. References