Robotic Cystotomy for Pessary Extraction With Vesicovaginal Fistula Repair.

STUDY OBJECTIVE: To demonstrate a robotic approach to foreign body extraction and vesicovaginal fistula repair.

DESIGN: Video case presentation with narration discussing the step-by-step robotic surgical approach to the removal of a pessary, via cystotomy, followed by vesicovaginal fistula and cystotomy repair.

SETTING: University of Louisville Hospital. The local Institutional Review Board deemed the video exempt from formal approval (Canadian Task Force Classification III).

PATIENT: A 77-year-old woman presented with complaints of vaginal leakage of urine, dysuria, and pelvic pain. She had a Gellhorn pessary placed 12 years prior without further evaluation or removal. The patient had a leukocytosis with a pseudomonal urinary tract infection. Imaging confirmed a Gellhorn pessary free floating within the urinary bladder.

INTERVENTIONS: The patient was taken to the operating room for an exam under anesthesia where a copious amount of urine was found coming from the vagina. A small vesicovaginal fistula was appreciated but could not be thoroughly explored. Cystoscopy revealed the foreign object in the urinary bladder. A robotic approach to the foreign body extraction was then performed with the davinci Xi robot (da Vinci Xi Intuitive Surgical, Sunnyvale, CA). The pessary was evident in the bladder on abdominal entry. Cystotomy was performed with the monopolar curved scissors. A vaginal EEA sizer was found to be advanced through the vesicovaginal fistula. The pessary was then grasped and removed from the bladder. Bilateral ureteral orifices were visualized. The fistula was then closed in 2 layers with 3-0 vicryl V-loc sutures (Covidien Medtronic, St. Paul, MN). The bladder was then closed in 2 layers with 3-0 vicryl V-loc sutures. A no. 15 Jackson-Pratt drain was then inserted through the right lower quadrant port and placed in the pelvis under direct visualization. The pessary was then removed via mini-laparotomy. A Foley catheter was left in place for prolonged drainage for a total of 6 weeks because of the multiple bladder repairs on the inflamed tissue. The patient denied any leakage of urine at her following postoperative appointment.

CONCLUSION: A robotic surgical approach, as an alternative to vaginal surgery, improves ease of dissection, provides a method for thorough anatomy surveillance, and can be used for successful repairs in complicated urogynecologic cases.