Robotic management of congenital urethra-vaginal fistula with transverse vaginal septum

ABSTRACT Introduction: The transverse vaginal septum (TVS) with congenital urethra-vaginal fistula (CUVF) is a rare anomaly of the mullerian duct (1, 2). Incomplete channelling of the vaginal plate, or an abnormality in the fusion of the vaginal component of mullerian duct with the urogenital sinus results in TVS (1, 3, 4). High CUVF occurs due to the persistent communication between the urogenital sinus and utero-vaginal primordium at the tubercle sinus, whereas low CUVF is due to excessive apoptosis of the vaginal plate during channelling (5). The principles of management of CUVF with TVS include: 1) TVS resection, 2) Create a neovagina. We present a case of CUVF with TVS managed by robotic assistance. Material and methods: A 24-year-old female, married for 3 years, presented with cyclical hematuria since menarche, dyspareunia and primary infertility. Examination revealed blind ending vagina 4cm from the introitus. Magnetic resonance imaging revealed a fistulous communication between urethra and vagina, and TVS. Cystourethroscopy confirmed a proximal urethra-vaginal fistula. Urethroscopy guided puncture of the TVS was performed, tract dilated and a catheter was placed across it. Robotic assisted transvaginal approach was planned. Air docking of robot was performed. Traction on the catheter was given to identify the incised edges of the septum. Vaginal flaps were raised laterally, fistulous tract was excised. Proximal vagina mucosa was identified and vaginoplasty was performed. Result: Patient's postoperative recovery was uneventful. Urethral catheter was removed after 5 days. She had normal voiding and menstruation. Vaginoscopy performed at 1st month follow-up, revealed an adequate vaginal lumen. Vaginal moulds were advised for 6 weeks during the night, following which she resumed her sexual activity. She conceived 6 months post-surgery, and delivered a child by caesarean section. Conclusion: We successfully managed this case by resection of septum, neovagina creation and thereby achieving normal menstruation and conception. The advantages of robotic approach were magnification, precision and manoeuvrability in a limited space, avoiding a vaginal release incision.

Transvaginal repair of neobladder vaginal fistula with martius flap

ABSTRACT Introduction: Neobladder vaginal fistula (NVF) is a known complication after cystectomy and orthotopic diversion in women, occurring in 3-5% of women. Possible risk factors for fistula formation include compromised tissue vascularity due to surgical dissection and/or radiotherapy, suture line proximity, local tissue recurrence, and injury to the vaginal wall during dissection. The surgical repair of a NVF can be challenging secondary to vaginal shortening, atrophy, local inflammation from chronic exposure to urinary leakage, and the proximity of the neobladder to the anterior vaginal wall. In this video, we present transvaginal repair of a NVF with Martius flap interposition. Materials and Methods: This is the case of a 47 year old woman with a history of radical cystectomy and creation of a Studer pouch secondary to bladder cancer two years prior who subsequently developed a NVF. Evaluation included an office cystoscopy which demonstrated a 3-4mm left-sided neobladder vaginal fistula at the level of the ileal-urethral anastomosis. No pelvic organ prolapse or evidence of bladder cancer recurrence was appreciated. Results: A vaginal approach for the NVF repair was performed with a Martius flap interposition. A water-tight closure was achieved without any intraoperative or immediate postoperative complications. The urethral Foley was removed at 2 weeks and by 4 weeks the patient did not report any urinary leakage. Conclusions: Neobladder vaginal fistula is a rare complication following cystectomy and orthotopic urinary diversion that can be repaired using a transvaginal approach. A Martius flap interposition is important to augment success of the repair. If a transvaginal approach fails a transabdominal approach or conversion to cutaneous diversion may be necessary.

Neovagina construction and continent cutaneous urinary reservoir using a previous orthotopic ileal neobladder

ABSTRACT Standard radical cystectomy (RC) in women involves removal of the distal ureters, bladder, proximal urethra, uterus, ovaries, and adjacent vagina. Furthermore, pelvic organ-preserving RC to treat selected women has become an accepted technique and may confer better postoperative sexual and urinary functions than standard RC, avoiding complications such as incontinence, prolapse, neobladder-vaginal fistula (NVF), and sexual dysfunction, without compromising oncological outcome. This article reports a different surgical approach: a patient who underwent a cutaneous continent reservoir and neovagina construction using a previous ileal orthotopic neobladder after RC. Patient presented no complications and she has no evidence of recurrent disease and is sexually active, with a satisfactory continent reservoir. This case is the first report of this procedure that was able to treat concomitant dyspareunia caused by short vagina and neobladder-vaginal fistula. In conclusion, standard radical cystectomy with no vaginal preservation can have a negative impact on quality of life. In the present case, we successfully treated neobladder fistula and short vagina by transforming a previous ileal orthotopic neobladder into two parts: a continent reservoir and a neovagina. However, to establish the best approach in such patients, more cases with long-term follow-up are needed.

Colecistectomía transvaginal asistida por minilaparoscopia: con uso de instrumental convencional: experiencia inicial / Transvaginal cholecystectomy assisted with minilaparoscopy: with conventional instruments: initial experience

Describir la técnica quirúrgica en la colecistectomía transvaginal sin cicatriz visible con el uso de instrumental laparoscópico convencional, en el Hospital “Dr. Domingo Luciani”. Caracas. Se presenta caso de paciente femenina de 52 años de edad, con litiasis vesicular sintomática a quien se le practica colecistectomía transvaginal. Se realizó colecistectomía transvaginal sin complicaciones intraoperatorias. No se administraron analgésicos orales ni parenterales, el alta hospitalaria se dio a las 12 horas del procedimiento. Evolución satisfactoria de la paciente con un seguimiento de 30 días. La cirugía asistida por minilaparoscopia puede considerarse intermedia entre el NOTES, y la cirugía laparoscópica. El siguiente caso demuestra la factibilidad y seguridad del procedimiento realizado por cirujanos generales con entrenamiento laparoscópico y con el uso de instrumental convencional.

Describe the surgical technique in the transvaginal cholecystectomy without a scar using conventional laparoscopic instruments, in the “Dr. Domingo Luciani” Hospital. Caracas. Presents female patient 52 years old, with sintomatic gallstones who is practicing transvaginal cholecystectomy. Was performed transvaginal cholecystectomy without intraoperative complications. No analgesics were administered oral or parenteral, was discharged at 12 hours of the procedure. There was a satisfactory progress of the patient with a follow upof 30 days. Minilaparoscopy assisted surgery can be considered intermediate between NOTES, and laparoscopic surgery. The following case demonstrates the feasibility and safety of the procedure performed by general surgeons with laparoscopic training and the use of conventional instruments.

Diagnosis and management of ureterovaginal fistula in a resource-constrained setting: experience at a district hospital in northern Nigeria

During 2007 we were invited at different times to review and manage four women with ureterovaginal fistula following caesarean section performed in different rural hospitals. We describe our experience of a simple technique of diagnosis and management of these indigent patients in a resource-constrained hospital. The condition was diagnosed by the three-swab test in all four patients, and abdominopelvic ultrasound was employed to help find the ureter involved. Transvesical ureteral implantation with a stent was carried out. Stent was removed after 2 weeks. All four patients were dry. Amidst the complexity of and sophistication of modern health care, it is important to remind ourselves of the common occurrence of this distressing condition following caesarean section and the use of a well known simple diagnostic technique and subsequent management in resource-poor communities

Management of ureterovaginal fistula

To evaluate the outcome of surgical management of uretero-vaginal fistula [UVF]. It was a descriptive study. Setting and Duration of study: The study was conducted at the Department of Urology, Chandka Medical College teaching Hospital and Almas Kidney and Lithotripsy Centre Larkana from February 1995 to November 2006. The criterion for selection of the patients and screening workup included complete history, clinical examination and investigations like complete blood count and biochemistry, ultrasound, intravenous urography and retrograde ureteric brash or ureterogram were performed to confirm the level of fistula and also to assess the function of affected kidney. The neo-ureterocystostomy was made with modified Lich Gregoir, Boari Ockeblade flap, Psoas hitch and endoscopic methods as deemed necessary. Our study included 20 cases. The ages of the patients ranged from 22 year to 45 years [average 36 years]. We used modified Lich George method, Boari Ockeblade flap, Psoas hitch method and internal stenting in 09[45%], 05[25%], 04[20%] and 02[10%] of cases respectively. The ureteric catheter or DJ stent were kept postoperatively in 06[30%] and 04[20%] cases respectively. Although all patients had no leakage after surgery; but 06[30%] cases developed transient urgency, frequency, dysuria and persistent pain. These were resolved with conservative treatment. The complications occurred in 4[20%] cases which were wound infection in 01[05%], recurrent urinary tract infection in 02[10%] cases and 01[5%] developed a small bladder capacity. There was no significant difference in outcome of different techniques, rather choice depends upon individual case and preference of surgeon. We conclude that modified Lich surgical procedure is simple, successful and quick method of treatment for repairing the cases of uretero-vaginal fistulae. We suggest bilateral ureteric catheterizations prior to difficult female pelvic and gynecological surgery to prevent such disaster

Fístula ileovaginal actínica / Actinic ileo-vaginal fistula

Se presentan dos casos clínicos de pacientes que desarrollaron fístulas tardías entre íleon y la vagina secundario a radioterapia pelviana por tumores cervicouterinos. Se detalla el estudio radiológico y el diagnóstico, además de la resolución quirúrgica y evolución postoperatoria.

Surgical Outcome of Female Genital Fistula in Korea

This purpose of this study was to establish a new standard for the surgical management of female genital fistula in Korea. From January 1992 to October 2001, 117 patients with female genital fistula who were admitted to the departments of obstetrics and gynecology, urology and general surgery were analyzed. Nine patients with congenital etiologies and 48 patients who were treated conservatively were excluded. The relationships between surgical outcome and the cause of fistula, the location of fistula, and the various surgical methods were analyzed. In spite of appropriate surgical treatment, fistulas due to cervix cancer management had the worst prognosis. In terms of location, fistula recurrence after surgical repair was most common in the bladder fundus and base. The transvaginal and transrectal approaches are suitable for fistulas located in the lower vagina. The transabdominal approach is appropriate for fistulas located in the functional portions such as the bladder and ureter, for fistulas which are difficult to expose surgically by either the vaginal or rectal approach, or in cases with severe adhesions. In cases of cervix cancer, extra care should be taken during surgical expiration or definitive radiotherapy, especially when the areas involved are the bladder fundus and base. The nature of the surgical approach should be decided by the location of the fistula, the functional importance of the area, and the degree of surgical exposure during the corrective procedures.

Cirugía laparoscópica colorrectal: experiencia inicial / Laparoscopic colorectal surgery: initial experience

Antecedentes: La cirugía laparoscópica colónica es un procedimiento novedoso, cuyos primeros resultados aún no permiten sacar conclusiones respecto de su verdadera utilidad. Objetivo: Análisis clínico retrospectivo de pacientes intervenidos por esta vía. Lugar de aplicación: Práctica hospitalaria y privada. Diseño: Estudio observacional retrospectivo basado en criterios clínicos. Población: Selección de 30 pacientes (1,5 por ciento) intervenidos por afecciones colorrectales, sobre un total de 1950; entre 1992 y 1996. Métodos: Exclusión de pacientes con grandes eventraciones, tumores adheridos a pared u otros órganos, ostomías, obstrucción o perforación. Resultados: Mortalidad: 3,3 por ciento, complicaciones: 16,7 por ciento. Conversión, 25,9 por ciento. Promedio de ganglios resecados, 15. No hubo diferencias en la conversión respecto de afecciones benignas o malignas, segmento operado, aunque en el recto medio fueron todos convertidos (3/3). El intervalo de confianza esperado para el éxito laparoscópico fue del 53,3-88,9 por ciento. Conclusiones: La cirugía laparoscópica colorrectal puede ser realizada con igual amplitud que la cirugía a cielo abierto. El índice de conversión es alto, aunque con un mayor entrenamiento y una mejor selección de casos puede ser disminuído

Tratamiento de la fístula uretrovaginal de la infancia: informe de dos casos / Treatment of childhood urethrovaginal fistula: report of two cases

Las fístulas uretrovaginales adquiridas son una condición rara en la edad pediátrica y requieren tratamiento quirúrgico diferente al empleado en mujeres adultas, ya que la mayoría de éstas presentan introitos amplios y tejidos perineales fláccidos que permiten la correción transvaginal. Proponemos el acceso sagital posterior trans-rectovaginal para identificar las fístulas uretrovaginales adquiridas durante la infancia, y su tratamiento racional

Fistulas genitais: estudo de 21 casos / Genital fistulae

Tendo como base um estudo retrospectivo de 21 casos de fistulas genitais, foram analisados alguns aspectos considerados importantes nessa patologia. As mulheres acima dos 30 anos e multíparas foram as mais acometidas. As fistulas mais comuns foram as genito-urinárias e o parto vaginal foi o fator mais apontado como causa. Os meios diagnósticos utilizados foram os mais variados assim como o tipo do tratamento cirúrgico empregado. A recidiva foi observaçäo frequente.

Tratamiento quirúrgico de la rectitis actínica grave / Surgical treatment of serious actinic rectitis

Se presentan los resultados iniciales de un protocolo de tratamiento de la rectitis actínica grave. A los pacientes con fístula y/o estenosis rectales se les efectúa una colostomía de transverso en hipocondrio derecho y, luego de 6 meses, una reparación del recto con la técnica de Parks. Las hemorragia se tratan médicamente; si persisten las necesidades de transfusión se efectúa una colostomía de transverso. Los que dejan de sangrar durante un año y teniendo un recto adecuado se cierra la colostomía. En caso contrario, se efectúa una operación de Parks. Se han tratado 22 pacientes en quienes se han efectuado 37 operaciones. Sin mortalidad quirúrgica y con una morbilidad de 21,6%. En 12 pacientes se reparó el recto con la técnica de Parks. En 11 se ha reconstituído el tránsito; con una buena continencia en 9; regular, en 1;y mala, que requiere nueva colostomía, en 1 paciente. Los resultados preliminares nos hacen mantener el protocolo. La técnica de Parks permite dar solución a varias de las manifestaciones de la rectitis actínica grave, con una baja morbimortalidad y una continencia rectal adecuada