title: Robotic management of genitourinary injuries from obstetric and gynaecological operations: a multi-institutional report of outcomes.
abstract: OBJECTIVE
  To evaluate the utility of robotic repair of injuries to the ureter or bladder from obstetrical and gynaecological (OBGYN) surgery
  
  
  METHODS
  A retrospective review of all patients from four different high-volume institutions between 2002 and 2013 that had a robot-assisted (RA) repair by a urologist after an OBGYN genitourinary injury.
  
  
  RESULTS
  Of the 43 OBGYN operations, 34 were hysterectomies: 10 open, 10 RA, nine vaginally, and five pure laparoscopic. Nine patients had alternative OBGYN operations: three caesarean sections, three oophorectomies (one open, two laparoscopic), one RA colpopexy, one open pelvic cervical cerclage with mesh and one RA removal of an invasive endometrioma. In all, 49 genitourinary (GU) injuries were sustained: ureteric ligation (26), ureterovaginal fistula (10), ureterocutaneous fistula (one), vesicovaginal fistula (VVF; 10) and cystotomy alone (two). In all, 10 patients (23.3%) underwent immediate urological repair at the time of their OBGYN RA surgery. The mean (range) time between OBGYN injury and definitive delayed repair was 23.5 (1-297) months. Four patients had undergone prior failed repair: two open VVF repairs and two balloon ureteric dilatations with stent placement. In all, 22 ureteric re-implants (11 with ipsilateral psoas hitch) and 15 uretero-ureterostomies were performed. Stents were placed in all ureteric cases for a mean (range) of 32 (1-63) days. In all, 10 VVF repairs and two primary cystotomy closures were performed. Drains were placed in 28 cases (57.1%) for a mean (range) of 4.1 (1-26) days. No case required open conversion. Two patients (4.1%) developed ureteric obstruction after RA repair requiring dilatation and stenting. The mean (range) follow-up of the entire cohort was 16.6 (1-63) months.
  
  
  CONCLUSIONS
  RA repair of GU injuries during OBGYN surgery is associated with good outcomes, appears safe and feasible, and can be used successfully immediately after injury recognition or as a salvage procedure after prior attempted repair. RA techniques may improve convalescence in a patient population where quick recovery is paramount.
authors.affiliation: Department of Urology, Indiana University, Indianapolis, IN, USA.
authors.forename: Paul T
authors.initials: PT
authors.lastname: Gellhaus
authors.forename: Akshay
authors.initials: A
authors.lastname: Bhandari
authors.forename: M Francesca
authors.initials: MF
authors.lastname: Monn
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Gardner
authors.forename: Prashanth
authors.initials: P
authors.lastname: Kanagarajah
authors.forename: Christopher E
authors.initials: CE
authors.lastname: Reilly
authors.forename: Elton
authors.initials: E
authors.lastname: Llukani
authors.forename: Ziho
authors.initials: Z
authors.lastname: Lee
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Eun
authors.forename: Hani
authors.initials: H
authors.lastname: Rashid
authors.forename: Jean V
authors.initials: JV
authors.lastname: Joseph
authors.forename: Ahmed E
authors.initials: AE
authors.lastname: Ghazi
authors.forename: Guan
authors.initials: G
authors.lastname: Wu
authors.forename: Ronald S
authors.initials: RS
authors.lastname: Boris
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003559:Cystostomy; D005260:Female; D013509:Gynecologic Surgical Procedures / Q000009:adverse effects*; D006801:Humans; D008875:Middle Aged; D013513:Obstetric Surgical Procedures / Q000009:adverse effects*; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000379:methods* / Q000706:statistics & numerical data; D016896:Treatment Outcome; D014519:Ureterostomy; D014548:Urinary Fistula / Q000601:surgery*; D014624:Vaginal Fistula / Q000601:surgery*
keywords: gynaecology injury; robotic surgery; ureteroneocystostomy; ureterovaginal fistula; vesicovaginal fistula