Attention to the Editor - Case series: "Laparoscopic robot-assisted extravesical repair of vesicovaginal fistula post-hysterectomy: a study of peritoneal flap inlay technique and outcomes".

The study analysed 21 women who underwent vesicovaginal fistula repair in our department between 2011 and 2022. Patient characteristics are summarized in Table  1 . Table 1 Patient characteristics  Characteristic Cohort ( N  = 21) Age at Surgery 51 (27, 72) BMI (Kg/m2) 25.2 (18.3, 38) Gravidity 2 (0, 5) Parity 2 (0, 4) Time from hysterectomy to leakage (weeks) 1 (0, 12) Time from hysterectomy to repair (weeks) 16 (6, 170) BMI = Body-Mass-Index Estimates were given as median (quartile 1, quartile 3) Patient characteristics BMI = Body-Mass-Index Estimates were given as median (quartile 1, quartile 3) Nineteen patients had simple supratrigonal fistulas without ureteral involvement resulting from hysterectomy, and two had complex VVF Table 2 . Table 2 Fistula characteristics Simple VVF N  = 19 (90%) Complex VVF N  = 2 (10%) Aetiology Hysterectomy due to: Myomatosis 15 (70) M.Crohn with tuboovarial abscess formation 1 (5) Endometriosis 2 (10) Radiation and resection of the rectum with bladder injury 1 (5) Uterine necrosis 1 (5) Uterine adenocarcinoma 1 (5) Approach Robot-assisted laparoscopic 1. Laparotomy with adhesiolysis 2. Robot-assisted laparoscopic* * Lower medial laparotomy, cranialisation of the bowel mass, separate placement of the robotic trocar Fistula characteristics 1. Laparotomy with adhesiolysis 2. Robot-assisted laparoscopic* * Lower medial laparotomy, cranialisation of the bowel mass, separate placement of the robotic trocar One patient with a complex fistula had Crohn’s disease and had undergone multiple abdominal operations, including left hemicolectomy with terminal colostomy (Hartmann procedure). A tubo-ovarian abscess led to VVF formation and complete incontinence. The second complex VVF patient underwent radiation and rectal resection due to advanced rectal adenocarcinoma, resulting in iatrogenic bladder injury and injury to the right ureter. Despite subsequent ureterocystoneostomy with Boari flap, the patient continued to experience complete incontinence. Robot-assisted vesicovaginal fistula repairs were conducted at a median of 16 weeks post-surgery (range: 6–170 weeks). The median surgical time was 216 min (range: 110–459 min). The median duration of hospitalization and catheterization were both 5 days (range: 2–13 days), respectively. All procedures were successfully completed without intraoperative complications. The median hemorrhage was below 50 ml (range: 10–500 ml). None of the cases necessitated a switch to open surgery. Postoperative complications following vesicovaginal fistula repair were primarily classified as Clavien-Dindo grade II, occurring in 52% of cases, one Patient with a Clavien-Dindo grade III complication suffering postoperatively from a bladder tamponade which required a transurethral tamponade evacuation. No severe complications (Clavien–Dindo grades IV or V) were observed in this series. A more detailed breakdown of complications by classification is provided in Table  3 . Table 3 Perioperative information Variable Operation time (min) 216 (110, 459) Hospital stay (days) 5 (2, 13) Blood loss (ml) < 50 (10, 500) Catheterisation time (days) 5 (2, 13) Post-op Complications (Clavien – Dindo) I, n (%) 0 (0) Post-op Complications (Clavien – Dindo) II, n (%) 11 (52) Post-op Complications (Clavien – Dindo) III, n (%) 1 (5) Post-op Complications (Clavien – Dindo) IV, V, n (%) 0 (0) Estimates were given as median (quartile 1, quartile 3) or frequency (percentage) Perioperative information Estimates were given as median (quartile 1, quartile 3) or frequency (percentage) Cystography was performed 10 days postoperatively and showed bladder sutures without leakage in all cases. No rehospitalizations related to VVF repair occurred within 30 or 90 days. With a median observation period of 20 months (range: 3–57 months), all patients maintained continence without requiring pads, and no fistula recurrence was detected. Seventeen out of the twenty-one patients completed the FLZ, SCL-K-9, and FSFI-d questionnaires for preoperative and postoperative assessments. Three patients were unable to complete the questionnaires due to language barriers, one patient was lost to follow-up. Functional outcomes assessed via patient questionnaires demonstrated significant improvements postoperatively, particularly in overall life satisfaction, health, and sexual function ( p  < 0.001). A comprehensive summary of the pre- and postoperative scores is presented in Table  4 . Table 4 Functional outcome questionnaires Item Preoperative assessment Postoperative assessment FLZ (Questionnaire to overall life and health satisfaction; 1 = not satisfied, 5 = completely satisfied) N  = 17 N  = 17 Dimension Mean ± SD Mean ± SD p-value How satisfied were you with Friends/acquaintances 4.1 (± 1.39) 4.6 (± 0.62) 0.048* Leisure/hobbies 1.5 (± 1.37) 4.8 (± 0.58) < 0.001* Health 1.1 (± 0.25) 4.6 (± 0.62) < 0.001* Income/financial security 3.8 (± 1.48) 4.6 (± 0.62) 0.023* Occupation/work 2.9 (± 1.57) 4.8 (± 0.45) < 0.001* Living situation 4.4 (± 1.03) 4.7 (± 0.48) 0.3 Family life/children 4.2 (± 1.17) 4.8 (± 0.47) 0.028* Partnership/sexuality 2.3 (± 1.79) 4.5 (± 0.74) < 0.001* Life in general 2.95 (± 0.62) 4.56 (± 0.46) < 0.001* Item Preoperative assessment Postoperative assessment SCL-K-9 (questionnaire to psychological distress (4 = maximal distress, 0 = no distress) N  = 17 N  = 17 Dimension Mean ± SD Mean ± SD p-value Distress 1.29 (± 0.62) 0.11 (± 0.18) < 0.001* Item Preoperative assessment Postoperative assessment FSFI (Female Sexual Function Index) (2 = low sexual function, 36 = good sexual function) N  = 17 N  = 17 Dimension Mean ± SD Mean ± SD p-value Sexual function 5 (± 7.45) 27.5 (± 7.55) < 0.001* FLZ = Questions on Life Satisfaction, SCL-K-9 = Symptom-Checklist-K-9, FSFI = Female Sexual Function Index Mean values, standard deviation (SD) and p-values for assessment before and after surgery *Paired t-test: Significant difference ( p  ≤ 0.05) between preoperative and postoperative assessment Functional outcome questionnaires SCL-K-9 (questionnaire to psychological distress (4 = maximal distress, 0 = no distress) FSFI (Female Sexual Function Index) (2 = low sexual function, 36 = good sexual function) FLZ = Questions on Life Satisfaction, SCL-K-9 = Symptom-Checklist-K-9, FSFI = Female Sexual Function Index Mean values, standard deviation (SD) and p-values for assessment before and after surgery *Paired t-test: Significant difference ( p  ≤ 0.05) between preoperative and postoperative assessment

This research includes 21 female individuals who underwent vesicovaginal fistula repair at our facility between 2011 and 2022. Patients younger than 18 years old or patients without signed informed consent were excluded. Cases were selected from the medical records of our clinic. Patient medical records were reviewed to collect data on age at the time of surgery, BMI, gravidity, parity, interval from hysterectomy to urine leakage, time from hysterectomy to fistula repair, total operative duration (skin-to-skin), hemorrhage, duration of hospitalization, and catheterization period. By characterization of the VVF, the cases got divided into 19 simple VVF and two complex VVF. Simple fistulas were classified as single primary fistulas with healthy surrounding tissue, no history of pelvic radiotherapy, no ureteral involvement, and no history of major previous pelvic surgery. Recurrent vesicovaginal fistulas, fistulas occurring after radiotherapy, those following multiple pelvic surgical procedures, fistulas with associated ureteral involvement, as well as vesicovaginal fistulas with extensive fibrosis or scarred or inflamed perilesional tissue were classified as complex. The distinction between simple and complex fistulas had a significant impact on surgical planning and the choice of operative approach. Two experienced console surgeons, each with over 2000 robot-assisted surgeries performed, conducted surgeries. The surgeries were performed at our institution and followed the standards of previously published protocols [ 7 ]. The diagnosis was established through prior physical examinations, as well as cystoscopic and cystographic assessments. Preoperatively urine cultures were obtained from all patients. In cases of positive cultures, pathogen-directed antibiotic therapy was administered for at least 48 h prior to surgery. The surgical procedure for a simple VVF began with cystoscopy and stenting of the VVF from the bladder through the fistula into the vagina, with the patient placed in the lithotomy position. Bilateral ureteral stents were placed, and all procedures were performed using the da Vinci Si/Xi ® system (Intuitive Surgical, Sunnyvale, California, USA) with a transperitoneal four-arm technique. The surgical technique was carried out in accordance with the method outlined by Kurz et al. [ 8 ]: Initially, the patient was positioned in a 20° Trendelenburg posture. Dissection of the small pelvis and the recto-uterine pouch was performed. Vaginal exposure was facilitated using a bougie. The spatium vesicovaginale was prepared, and the fistula was identified using a guidewire stent. The fistula was then resected by sharp dissection, including peri-fistular scar tissue followed by continuous suturing of the vagina with an absorbable braided suture (Fig. 1 ). Fig. 1 Suture of the vaginal wall (© KSW) Suture of the vaginal wall (© KSW) The peritoneal flap is harvested from the parietal peritoneum situated lateral of the urinary bladder, covering the vaginal suture line and ensuring full coverage of the vaginal suture layer (Fig. 2 ). Fig. 2 Preparation of the peritoneal flap (© KSW) Preparation of the peritoneal flap (© KSW) The size of the flap with its pedicle measures about 5 × 2 cm and is fixed over the continues vaginal suture with an absorbable synthetic monofilament (Monocryl 5 − 0) continuing suture, thus separating the monolayer vaginal and double layer bladder closure from each another with vital tissue. The flap receives its blood supply from the right lateral side via the flap pedicle (Fig. 3 ) . Fig. 3 Peritoneal flap (P) covering the vaginal suture line (arrow). The flap is vascularized from its pedicle from the parietal peritoneum at the right lateral side (X). The bladder is closed in two layers thereafter (© KSW) Peritoneal flap (P) covering the vaginal suture line (arrow). The flap is vascularized from its pedicle from the parietal peritoneum at the right lateral side (X). The bladder is closed in two layers thereafter (© KSW) The bladder portion of the fistula was removed, after bladder wall closing with a tension-free, double-layer suturing technique. Absorbable synthetic monofilament or self-anchoring suture material was used. To assess impermeability, the bladder was instilled with 300 ml of isotonic saline solution. The procedure was completed with site irrigation, fascial closure, and skin suturing. For the two complex fistulae, a combined open and laparoscopic approach was employed. After stenting the fistula and bilateral ureteral stenting, a lower median laparotomy was performed. Adhesiolysis in the supine position and cranialization of the small bowel package were carried out. The camera and trocars for the 4-arm transperitoneal approach were then inserted under visualization. The laparotomy was closed, and the vesicovaginal fistula was resected and closed with robotic assistance in the Trendelenburg position as previously described. The follow-up period extended from the day of surgery to the date of the last information received. Follow-up parameters included postoperative complications (Clavien-Dindo Classification), re-hospitalization within 30 and 90 days, and recurrence of incontinence six weeks postoperatively (use of pads). Additionally, quality of life, psychological distress, and sexual function were assessed both before and after surgery using the following questionnaires: An adapted version of the Questions on Life Satisfaction (FLZ) [ 9 ], the Symptom-Checklist-K-9 (SCL-K-9), and the Female Sexual Function Index (FSFI-d) [ 10 ]. The modified FLZ questionnaire evaluates overall quality of life, emphasizing eight relevant aspects: social connections, leisure activities, health, financial stability, employment, housing situation, family life, and intimate relationships. Each item is evaluated using a five-level scale, where a score of 1 reflects complete dissatisfaction and a score of 5 denotes maximal satisfaction. Results are compared to standard values for the healthy population, considering age and gender differences. A Cronbach’s alpha of 0.80 signifies strong reliability [ 9 , 11 ]. The SCL-K-9 is a condensed version of the SCL-90-R, designed to assess emotional distress across nine aspects: Physical symptoms, compulsive behaviors, sensitivity in relationships, feelings of sadness, nervousness, anger, anxiety triggered by fear, distrustful thoughts, and severe mental disturbances. Answers are evaluated on a five-level scale (4 = maximum mental suffering, 0 = no mental suffering). The scores are added together/summed up and divided by 10. This instrument is seen as reliable and efficient, with internal consistency and high correlation to other tests. Age and gender differences are considered in the evaluation [ 12 , 13 ]. The FSFI-d is an established instrument employed to evaluate essential aspects of female sexuality across six domains. Each domain is rated on a scale from 2 to 36 (2 = poor sexual function, 36 = good sexual function). Cronbach’s alpha of 0.83 (0.75–0.95 for the six domains) indicates good reliability [ 10 , 11 ]. Descriptive analyses and frequency measurements were carried out, with association measurements also being made where appropriate. Quantitative variables are presented as median values along with their respective ranges. Pre- and postoperative questionnaire results were compared using a paired t-test, with a p-value of < 0.05 signifying statistical relevance.

By integrating the fundamental principles of fistula surgery with the benefits of robotic technology, consistent long-term outcomes, including improved quality of life, can be achieved. Our findings indicate that laparoscopic, robot-assisted extravesical repair of vesicovaginal fistulas (VVF) following hysterectomy, utilizing a peritoneal flap inlay, leads to notable improvements in patient outcomes such as quality of life, psychological well-being, and sexual function. This study highlights the critical role of surgical expertise and the need for an individualized approach, ensuring that the chosen technique aligns with the unique characteristics of each fistula. Robotic technology helps overcome the technical limitations of laparoscopic surgery by enhancing visualization, precision, and ergonomic control. Further research, particularly randomized controlled trials, are necessary to assess the cost-effectiveness and long-term outcomes of robot-assisted VVF repair in comparison to other surgical techniques. Our results suggest that this minimally invasive approach could be considered a valuable treatment option for VVF following hysterectomy, particularly in cases where conventional methods may carry greater risks or limitations.

This study outlines and assesses our surgical approach for robot-assisted closure of 21 vesicovaginal fistulas using a peritoneal graft insertion. The variation in fistula dimensions, position, and underlying factors presents challenges when comparing different surgical techniques and approaches. As a result, the choice of approach, technique, interposition grafts, and closure layers is guided by the surgeon’s expertise and the distinctive features of the fistula [ 14 ]. The effectiveness of vesicovaginal fistula repair largely relies on the surgeon’s proficiency with the chosen technique [ 15 ]. There is ongoing debate over whether the abdominal or vaginal approach is the most suitable option for repairing a vesicovaginal fistula. The vaginal approach is frequently favored due to its benefits, including reduced patient morbidity, minimal blood loss, and lower postoperative bladder irritation [ 16 ], in contrast, the abdominal approach is recognized for its consistency and long-term success [ 5 ]. In addition, the abdominal approach minimizes the risk of vaginal shortening, a potential complication of the vaginal approach which can lead to postoperative sexual dysfunction [ 6 ]. The transabdominal approach is indicated for high vaginal fistulae that are difficult to reach via the vaginal route [ 8 ]. Regardless of the chosen technique, certain fundamental principles must be followed in vesicovaginal fistula repair. These include ensuring adequate tissue vascularization and infection control, complete removal of the fistulous tract, a tension-free and watertight multilayer closure, interposition of well-vascularized tissue between the bladder and vaginal sutures, along with sustained bladder drainage after surgery [ 17 ]. In our series, the criteria for selecting a transabdominal approach included supratrigonal localization and/or the complexity of the fistulae. We combined open surgery with robot-assisted laparoscopy on two patients with complex vesicovaginal fistulas, performing laparotomy for adhesiolysis and trocar introduction under visual control followed by robot-assisted dissection of the complex fistulas and sealing of bladder and vagina using a tension-free double-layer technique with peritoneal-flap inlay. Both patients suffering from severe incontinence after multiple prior surgeries and radiotherapy experienced significant improvements in their continence and quality of life postoperatively. Laparoscopic surgery is regarded as a secure therapeutic approach, offering the typical benefits of minimally invasive interventions—such as reduced hospitalization and accelerated recovery—that contribute to improved patient outcomes [ 18 ]. Moreover, laparoscopic approach provides excellent exposure of the fistula and superior visualization for dissection [ 8 ]. Despite its advantages, laparoscopic repair is rarely performed due to its technical difficulties in contrast to the conventional open abdominal technique [ 19 ]. The use of robotic assistance helps address these challenges by allowing precise intracorporeal suturing while preserving the advantages of minimally invasive surgery. Moreover, robotic technology enhances surgical performance by offering high-definition three-dimensional visualization, magnification, articulated instruments for improved maneuverability, and an ergonomically optimized control system [ 5 ]. The robot-assisted extravesical approach through the vesico-vaginal space, which we prefer, provides extensive insight into the surgical field, enabling wide fistula exposure, achieving a secure, tension-free sealing of the bladder and vagina, accompanied by additional reinforcement through a peritoneal graft [ 7 ]. Limitations associated with robotic VVF repair encompass the need for advanced surgical expertise, extended operative duration, elevated financial burden, restricted availability, and a more complex learning trajectory [ 18 ]. Concerning the ideal timing for repair, choice of surgical technique, and postoperative care, controversy remains. Agrawal et al. [ 17 ] performed repair at a median of 4 week (range 2–42 week) post-diagnosis. Performing fistula repair within 1–2 weeks after diagnosis has become more widely practiced with Zimmern et al. reporting no higher morbidity or failure rates associated with early VVF repair [ 20 ]. In contrast, fistulae resulting from radiotherapy or obstetric procedures necessitate sufficient time for tissue healing prior to initiating repair, with a 3-to-6-month being generally recommended [ 21 ]. Conversely, Waaldijk et al. advocated for immediate repair of fresh obstetric fistulae, citing high effectiveness in closure and continence, avoiding medical, social, and mental degradation [ 20 ]. These factors should also be considered when assessing the timing and technique for VVF repair. Our data shows that waiting for 16 weeks until fistula repair provides reliable results. Furthermore, we performed cystoscopy and vaginoscopy in all cases to visualize the fistula and splint the VVF. For interposition grafting, a peritoneal flap was harvested, which is considered less time-consuming than other vital tissue flaps [ 8 ]. Peritoneal tissue has been reported to be an excellent graft for interposition [ 22 ]. The success of healing seems to be influenced by the vascular pedicle condition of the interposition graft [ 18 ]. However, in our experience, a tension-free bladder suture is the most critical factor for definitive fistula closure. Our excellent success rate in this series, with the absence of fistula recurrences, is naturally also dependent on the extensive surgical experience of our surgeons, both of whom had each performed more than 2,000 robotic procedures prior to this study. This high level of experience likely contributed to optimal patient selection, thorough preoperative preparation, refined manual skills with precise dissection and suturing techniques, as well as appropriate graft preparation and interposition. Furthermore, the long study period (2011–2022) may be considered a potentially positive factor influencing outcomes, as both the surgical technique and the robotic platforms evolved during this time, transitioning from the da Vinci Si to the Xi system. Improvements in instrumentation, visualization, ergonomics, and surgical workflow have likely contributed to increased operative efficiency and outcome optimization over time. Accordingly, our excellent results cannot be attributed solely to the surgical technique itself but should be interpreted within the broader context of substantial surgical experience and ongoing technological advancements. These factors limit the generalizability of our findings, particularly when compared with centers with less experienced surgeons or those using older-generation or less advanced robotic systems. Further limitations of the study include its retrospective design and the small sample size. Furthermore, a cost-benefit analysis comparing the robot-assisted technique to vaginal and open surgical methods was not conducted. The heterogeneity of this pathology complicates a precise comparative analysis of the different surgical methods [ 23 , 24 ]. To mention the overall incidence of postoperative complications classified as Clavien–Dindo grade II was relatively high (52%) in our series. These events were clinically mild and predominantly consisted of uncomplicated postoperative urinary tract infections in all grade II complications ( n = 11), which were successfully managed with oral antibiotic therapy, without the need for intravenous antibiotics, prolonged hospitalization, or invasive interventions. The comparatively high rate of urinary tract infections in this cohort is most likely related to the perioperative urinary drainage strategy. All patients underwent prolonged bladder catheterization, and bilateral ureteral pigtail stents were placed intraoperatively—both well-recognized risk factors for catheter-associated urinary tract infections. In the context of vesicovaginal fistula repair, extended urinary diversion is often unavoidable to ensure optimal fistula healing, which may inherently increase the risk of infectious complications. Extended perioperative antibiotic coverage until catheter removal could be considered in future patients to potentially reduce infection rates; however, this approach must be balanced against principles of antimicrobial stewardship and requires further investigation. In addition to other studies [ 17 ], we collected information on quality of life and sexual health both pre- and postoperatively. The preoperative data indicated devastating quality of life and a high level of suffering due to urinary incontinence. All patients reported having no sexual activity preoperatively due to continuous urine leakage. Postoperatively, we observed a significant increase in sexual activity and overall life satisfaction, as well as nearly all subdomains of the FLZ questionnaire including social relationships, leisure activities, health perception, financial security, occupational satisfaction, family life and partnership/sexuality. The only FLZ domain that did not show a statistically significant change was satisfaction with the living situation. Otherwise, postoperative values measured by subjective questionnaires were even higher compared to the healthy population, although the differences did not achieve statistical relevance. We attribute this to the subjective nature of the questionnaires; postoperative improvements are rated higher after a challenging preoperative phase. The extended follow-up period is a key strength of this study, together with the evaluation of patient-reported outcomes, such as quality of life, psychological distress, and sexual function, in comparison to the preoperative condition.

In countries with advanced healthcare systems, vesicovaginal fistulae (VVF) typically occur after abdominal hysterectomy with an incidence of 1 in 1800 cases [ 1 ], leading to substantial physical and emotional distress, along with a decline in quality of life [ 2 ]. Non-surgical approaches for treating vesicovaginal fistulas, such as extended bladder drainage, antibiotic therapy when required, or fistula tract fulguration, generally show low success rates (7%−12.5%) [ 1 ]. When conservative treatments fail, surgery is often required. Selection of the surgical approach is guided by the specific characteristics of the fistula, with potential strategies encompassing transvaginal, open transabdominal, laparoscopic-transvesical, transurethral endoscopic methods, as well as urinary diversion [ 3 ]. However, there are only a few randomized studies comparing these techniques. The transvaginal approach is less invasive with reduced operative time for most simple fistulae. The open transabdominal approach is indicated for supratrigonal fistulas, complex fistulae or when vaginal access is inadequate [ 2 ]. In contrast to the conventional transabdominal method, laparoscopic repair of vesicovaginal fistulas provides benefits like a reduced hospital stay, quicker postoperative recovery, and improved cosmetic results [ 4 ]. With advancements in technology, laparoscopy has largely superseded laparotomy. However, this approach presents technical challenges, including restricted visibility, the use of non-wristed instruments, and limited access to intricate surgical areas. Robotic assistance can mitigate these challenges and potentially lead to better outcomes [ 5 ]. Interposition of a peritoneal flap, which has been investigated in open surgery approaches, has been shown to reduce recurrence rates [ 6 ]. This study explores a surgical technique that integrates two approaches: utilizing a peritoneal flap alongside a robot-assisted laparoscopic extravesical procedure.