title: Robotic reconstruction for recurrent supratrigonal vesicovaginal fistulas.
abstract: OBJECTIVE
  We report our experience with robotic reconstruction for recurrent supratrigonal vesicovaginal fistulas and its outcome.
  
  
  METHODS
  From August 2006 to October 2007 we treated 7 cases of recurrent supratrigonal vesicovaginal fistula. Salient features of our technique are 1) vaginoscopy and cystoscopy with bilateral Double-J stent or ureteral catheter placement and placement of a catheter through the fistula from vagina to bladder, 2) patient positioning in a low lithotomy position with a 60-degree Trendelenburg tilt and a 5-port transperitoneal approach, 3) peritoneoscopy and adhesiolysis with minimal posterior cystotomy encircling the fistulous opening, 4) mobilization of the bladder and vaginal flaps to allow tension-free closure, 5) excision of the fistulous rim, 6) bladder and vaginal edge freshening, 7) bladder and vaginal closure, 8) omental, peritoneal or sigmoid epiploic tissue interposition and 9) insertion of a Foley catheter and drain. Difficulty was primarily noted with regard to the safe establishment of pneumoperitoneum, the need for extensive adhesiolysis, dissection of the fistula from perifistulous fibrosis in close vicinity to the ureteral opening, tension-free closure of the larger defect and occasional absence of omentum for use as interposition tissue.
  
  
  RESULTS
  The average size of supratrigonal fistulas was 3.0 cm. Mean operative time was 141 minutes (range 110 to 160). Mean blood loss was 90 cc. No significant intraoperative or postoperative complications were observed. Mean hospital stay was 3 days. The catheter was removed 14 days postoperatively. All patients had a successful outcome.
  
  
  CONCLUSIONS
  Our experience suggests that robotic repair for recurrent vesicovaginal fistulas is feasible, results in low morbidity and provides outstanding results. It provides an attractive option for vesicovaginal fistula repair by a minimally invasive approach for the surgeon and the patient alike.
authors.affiliation: All India Institute of Medical Sciences, New Delhi, India. ahemal@wfubmc.edu
authors.forename: Ashok K
authors.initials: AK
authors.lastname: Hemal
authors.forename: Surendra B
authors.initials: SB
authors.lastname: Kolla
authors.forename: Pankaj
authors.initials: P
authors.lastname: Wadhwa
mesh_terms: D000328:Adult; D003558:Cystoscopy; D005260:Female; D006801:Humans; D007044:Hysterectomy; D011183:Postoperative Complications; D019651:Plastic Surgery Procedures / Q000379:methods*; D012008:Recurrence; D012086:Reoperation; D012371:Robotics; D000267:Tissue Adhesions / Q000601:surgery; D016896:Treatment Outcome; D014719:Vesicovaginal Fistula / Q000601:surgery*