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Minimally Invasive Repair of Genitourinary Fistula ...
Minimally Invasive Repair of Genitourinary Fistula ...
Minimally Invasive Repair of Genitourinary Fistulas
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Good evening, everyone. Welcome to the OGG Zero Gynecology webinar series. My name is Collin Johnson. I'm a member of the OGG's education committee and the moderator for tonight. Today's webinar is titled Minimally Invasive Repair of Genital Urinary Fistulas. Our speaker today is Dr. Sarah Collins. She is board certified in obstetrics and gynecology and female pelvic medicine and reconstructive surgery. She completed her medical school at Wayne State University School of Medicine, her OB-GYN residency at MetroHealth Medical Center in Cleveland, Ohio, and her FPMRS fellowship at Hartford Hospital. She has been in academic practice in urogynecology in the Chicago area since 2011, and she works at the University of Chicago. She has special interests in clinical practice efficiency and shared decision making for pelvic floor disorders. She is passionate about teaching as well as global health and leads an annual surgical mission to Rwanda, where she teaches local surgeons in the treatment of complex obstetric injuries and fistula repair. Thank you so much for joining us tonight, Dr. Collins. So just a few quick reminders before we get started. The presentation will run around 45 minutes, and the last 15 minutes will be for question and answers. This designates this live activity for a maximum of 1.0 AMA PR Category 1 credits, and to claim your credit, you must log into the Aussie Learning Portal and complete the evaluation following the completion of the webinar. This webinar is being live streamed and recorded, and a recording of the webinar will be made available in the Aussie Learning Portal after tonight. And then please use the Q&A function below to ask any questions to the speaker, and we'll address them at the end of the presentation. And then use the chat feature if you have any technical issues, and Ogg's staff will be monitoring this and can assist with any help you need. And Dr. Collins, you can go ahead and start. Okay. Hi, everybody. These are my disclosures. I'm really excited to talk to you today about this topic, and while we are going to be talking quite a bit about minimally invasive abdominal approaches to the repair of genital urinary fistula, I'm also going to be presenting some vaginal and stent-based treatments as well, which I consider to be minimally invasive. So we'll talk about those. We'll talk about these in terms of the evidence to support their use and also the critical steps, and I have a couple of videos to kind of help supplement some of what we'll be talking about today. I'm going to start with vesicovaginal fistula. As Colin mentioned, I do go to Rwanda every year, and my very first exposure to genital urinary fistula was in the developing world, where the mechanism of genital urinary fistula is usually obstructed labor or has been historically, which leads to prolonged vascular necrosis of the tissue between the vagina and the bladder, the vagina and the urethra. There can be ureteric injuries as well, but increasingly with the advent of cesarean delivery becoming more and more available in the developing world, without a commensurate increase in training for these surgeries, we are actually seeing quite a few genital urinary complications resulting from cesarean delivery as well. In the developed world, however, most of the fistulae that we see are iatrogenic, and they're usually a result of pelvic surgery, whether that's gynecologic or as a result of cesarean section here in the States. Some of the traditional tenets of fistula surgery have really persisted despite some evolving evidence that we could be doing things differently. So I'll be talking a little bit about that today as well, starting with some of the tenets that we hear a lot, that you can either operate on a fistula right away, like within two or three days, or you have to wait, and you've got to wait like three months, and that's what you got to do. The idea of trimming out a fistula tract, where does that come from? Do we really need to do that? And what are the pros and cons of doing that? Layered approaches, and then there are so many others that we'll talk about as well that have been sort of lore, but maybe not as evidence-based. In terms of vesicovaginal fistula, the signs and symptoms are probably not new to you, copious vaginal leakage. Often it's really helpful, especially to ask about whether or not patients ever feel like their bladders are getting full. With a big fistula, they may never really feel like their bladder is full, and that nighttime leakage is kind of a ringer. They wake up in a soaked bed. There aren't that many other things that you would be thinking about if that's happening. There are some confounders. Not everyone with a genitourinary fistula is going to have that clinical picture. There are tiny pinpoint fistulas from cautery injuries or even recurrences of maybe bigger fistulae that are now smaller, and then location. There are positional leakage if the location is very lucky or unlucky, depending on how you look at it, so that's something that also we want to be considering. This is often with just a pelvic exam. You can see vaginal pooling of urine in the vagina, but if you can't see that, you can backfill the bladder with dye. You can cysto the patient. You can image them with just a cystogram, like a fluoroscopic cystogram image or a VCUG. The timing of surgery is interesting. I think that there's always been this idea that we need to, again, either address this right away or wait a very long time. We do have actually a prospective series of a lot of women in Northern Nigeria in the 90s that looked at two major centers. All of these women had obstetric vesicovaginal fistula due to obstructed labor, and there had been a longstanding algorithm in place there of doing either these immediate or delayed surgeries. They chose to institute a new algorithm and then study what the results would be of basically operating as soon as it looked like there were clean wound edges. They had a couple of really low resource options for improving the tissue, but once the tissue was improved, they operated right away whenever that was. All of these women had surgery within three months. 43% had surgery within a month of the injury and 88% within two months. Regardless of the timing, the surgical efficacy of the repair was pretty high, over 95%. This decreased with increasing complexity and size of the fistula, as you might expect. Surgery alone really only cured a very few patients. These were women who had a delivery very recently or a very small fistula. This challenges that idea that we need to wait three months. That's kind of arbitrary. We can look at the tissue edges and know maybe when a good repair is, a good timing is. When we talk about a vaginal approach to vesicovaginal fistula, I mean, this is by no means a new or innovative or brand new approach, but it is minimally invasive. We'll talk about the traditional Latsco approach. I have a citation here for where I got these images, but in a Latsco approach, you basically want to cannulate the fistula and the idea of inflating a Foley balloon to apply traction to the fistula to bring it closer to you and then to create two circumferential incisions. One really close to the fistula and then one about a centimeter or two centimeters out from that, and then scored into four quadrants and do your dissection to create a layer of mucosal stitches, remove that Foley, tie those down, and then do a secondary imbricating layer that incorporates vaginal muscularis and paravesical tissue, connective tissue. Do that with absorbable suture and then close the vaginal epithelium. There's discussion of whether or not you should do a Martius graft. Martius grafts basically involve mobilizing the labial fat pad to in a vesicovaginal fistula. Usually you end up mobilizing the posterior vascular supply to ligate that and then swing it underneath the ischiopubic ramus to basically add a layer of tissue, a vascular tissue between the two structures that you're trying to close. In a lateral view, it looks a little bit like this and you can see the utility. It's very easy to understand that that would hopefully make it less likely for that tract to reform. The downsides of using a Martius flap are, you know, there are some anatomic limitations while most people do have, even really thin women do have a fat pad there. There is still some limitation, like you do need to be able to swing that and make it reach the defect. And it can also cause some significant scarring, which some women will find disfiguring. So I would say that use of a Martius fat pad or a graft is best applied judiciously. So you don't want to necessarily do it routinely, but if you're doing a repeat repair, or if you feel like there's some potential compromise to the repair, you can't get it to be totally tension-free, then this is a great approach. I mentioned the one or two layer approach, and there is actually some data from one of the Hamelin fistula centers in Ethiopia, which I was lucky enough to go and visit back in 2008. And this is a retrospective analysis of over a thousand patients with obstetric VVF. And this was not by any stretch a randomized trial, but the surgeons used certain indicators to help them to determine whether to do a one or two layer closure. And essentially bladder capacity plays a pretty big role in this decision, because if the bladder capacity is low, there's not a lot of tissue to bring around for a second layer in that detrusor layer. So in the women who had a larger bladder capacity, two layer closures were accomplished. And in those women who had a moderate or large bladder capacity who could accommodate that two layer closure, which was 55% of them, there was a 93% success rate. In those women who fell into that large or moderate bladder capacity group, who did not have enough tissue or other limitations that made a second layer impossible, their success rate was still 91%. So the confounding variable here was always about bladder capacity, but not really about the one to two layers. In terms of trimming, we actually do have a randomized controlled trial for this of 64 women, again, with obstetric vesicovaginal fistula. And in patients who were randomized to trimming, basically the fistula tract itself was excised. Usually this involves taking about a half a centimeter circumferentially. All of these women actually got a Martius graft and the primary outcome was absence of fistula at three months. The success rates didn't differ by groups. The one trend that was observed is that in those women who had recurrent fistula, the fistula were larger statistically in the women who underwent trimming. In my practical experience, you trim the tissue if you think it looks vascularly compromised or isn't going to close well, but a lot of times you don't have a ton of choice about whether or not there's enough tissue. And so knowing that the trimming doesn't seem to improve outcomes, it may be best at, at sometimes to just not do that. Um, so when we're talking about root of repair, um, whether you want to be doing a minimally invasive vaginal vesicovaginal fistula repair, or whether we should be looking at doing an abdominal approach, a lot of this decision is based on anatomy. So the fistula location in a high vesicovaginal fistula, a vaginal approach can be really challenging. Um, but also other things to consider is, you know, has this, is this a secondary repair? Is this a primary repair? What other things are going on? Is this, um, you know, what was the mechanism of the injury? If it's obstetric, it's often really low, um, but it's not always low. And sometimes the uterus itself can be involved. And so if the uterus or cervix is involved, and you don't think that you can get a good repair without doing a hysterectomy, then an abdominal approach may make more sense. And then there is of course, always room for that shared decision-making with the patient talking to her about, um, you know, what might be the best approach, um, what are the risks and what are the values that she's bringing to the table in terms of what she wants out of the surgery? Um, there was a pretty big, um, systematic review and meta-analysis of 282 articles. Um, this was published in, I think, yeah, 2017, um, uh, in all there were, um, uh, about 1,430 patients treated surgically, and there are, um, basically pretty equivalent outcomes for abdominal transvesical approach to surgery, which we'll talk about transvaginal approach to surgery and laparoscopic laparoscopic or robotic all in the nineties in terms of percentages of improvement. There is also a conservative, um, approach in when people talk about conservative approach, a lot of times they're talking about using a fiber and glue or some other plug material, um, in a very small fistula that may be amenable to, um, this kind of repair. Again, you, you know, the, the success rates are pretty high and similar to what we saw from the Nigerian study, just drainage alone tends to only work in about 8%, you know, in that study, I think it was a little higher, but, um, so when approaching a fistula repair from the abdominal side, from, you know, whether robotically or laparoscopically or even open, you can actually approach the fistula from either a transvesical approach or an extra vesicle approach, um, transvesical approaches in my experience tend to be a little bit more popular from the urology trained side to actually enter the bladder itself to approach the fistula that way. I've always been trained to use the extra vesicle approach, um, which is, um, depicted here on the right in which you really separate the structures from the outside of the viscous. Um, there was, uh, a systematic review of the literature done by Miklos and Moore, um, in the late nineties, early two thousands that looked at laparoscopic or robotic vesicovaginal fistula repair, um, and a total of 44 articles were included. And essentially transvesical and extra vesicle approaches seemed to have similar efficacy rates. Um, the only thing that made a difference in their analysis in terms of success of these minimally invasive vesicovaginal fistula repairs was whether or not a backfill bladder test was performed. Um, so the, the relative risk is actually higher and not by much, but if you don't water water test seal test for a watertight seal after your first layer of the, of your fistula repair, um, I'm going to talk a little bit about robotic vesicle, vaginal fistula repair, which, um, is a really great approach to these surgeries, especially if you're doing that extra vesicle approach, um, the kinds of things that are important to consider when you're planning one of these repairs is that counseling and pre-op planning is essential. Um, you really need to think about your port placement, um, and you probably will need an assist port. So planning that as well as really important. Um, we've got a picture, see if I've got, um, up here, you know, we very often we'll do almost like a straight across approach with this, um, with eight, eight millimeter trocars, um, two on the patient's left, one on the right, one at the umbo and then an assist port a little bit higher on the right side. Um, vaginal manipulation is key for these because, um, you know, getting that plane is sort of the, really the heart of this repair wide mobilization is, is, is really helpful in terms of minimizing tension. And then again, testing for that water seal. Um, I mentioned vaginal manipulation. What we found most helpful in these cases for our patients is using the leucite vaginal stents. These distend the vagina. They come in a lot of different sizes. So if you're dealing with a lot of scarring, then you can use a small one. If you have a really lax vagina, you can use a larger one, but it basically, it, that distends, distends the vagina enough that you can really see the planes much better. They're simple, they're reusable, and I can't recommend them enough. So some things to keep in mind before I show this video are, and this is going to be an extra vesicle approach to vesicovaginal fistula repair. It is very helpful to have experience as you're a gynecologist in sacrocopalpexy for a lot of, you know, the experience and the way that we place our ports. We're very used to vaginal manipulation and we're used to that vesicovaginal dissection. In terms of a robotic approach, the visualization is vastly improved over an open approach, which I think you'll see here. I don't know, I apologize for the buzzing noise, but you can see here at the bottom of the screen is the vagina and above that is the bladder. And then opening this plane, they just get right into that fistula tract here. We're going to kind of speed through a little bit as this dissection is developed a little bit further. And then that mucosal layer, this is a little one, as you can see, is closed. And this is obviously sped up. And on this first layer, we typically use any fine absorbable suture. I actually like polysorb or vicryl because I find it a little bit easier to work with, but certainly bison here is fine. And you can run this or you can do interruptives on this layer. But you do want to get a nice watertight seal. You can see that stitch pretty much does it. And that's your extra vesicle approach. At this point, I'm going to switch over to some of the upper urinary tract injuries and talk a little bit about ureterovaginal fistula repair. And without further ado, one of the most important things to consider when you're approaching one of these injuries is how did the injury occur? And that will help you to determine how you can approach this and the location of the injury. These injuries tend to happen in a few different ways. One is by kinking or by involving a ureter in a cystotomy repair that tends to happen very low at the vaginal cuff. As your gynecologist, um, you will get called in a lot. You probably do get called in a lot for, um, concern about an abnormal system after hysterectomy. And, you know, the first place I often start is at that vaginal cuff, because I think nine times out of 10, if you can get the vagina dissected or the bladder dissected down a little further, you can kind of open up those ureters and you, you kind of release, um, some of that tension that a lot of people, um, inadvertently create in that kinking. Um, then at the uterine artery artery level at the lower uterine segment or higher up at the IP, you can get crush injuries from, you know, um, just grasping, you can get a thermal injury, or you can get a complete transsection. And these things will be helpful in terms of your approach to how to fix them. Um, you know, timing is also, you know, an important thing to consider when you're approaching upper urinary tract injuries, as well as lower ones. Um, ideally you want to try to find these intraoperatively that is much better for everyone involved. Um, but if you don't, and, um, and they're detected more at the one to four day post-op, they're rarely fistula at this point, but that's a different clinical scenario than that definitive fistula phase. That's usually after about five days. Um, and in terms of upper urinary tract injuries, when I talk about minimally invasive repairs, I'm going to be talking about stenting and also, um, uretero neocystotomy, which is a minimally invasive ureteral re-implant. Um, in that post five day period, we'll talk about stenting percutaneous necrostomy if stenting doesn't work from below, and then a plan for a delayed repair. Um, how do ureteral injuries present? They're different often than, um, cystotomy, although not, I mean, then a vescovaginal fistula, um, but not always. So in the pre-fistula phase, this is where your patients are going to get sick. They'll have that flank pain, fever, ascites, and these often will present, and then you can address the issue and hopefully, um, ward off a fistula. But once it progresses to that, you know, that, um, kind of copious urine per vagina, then you're seeing, um, uh, you know, we're going to have to deal with this more like a fistula. Um, the clinical picture of an immediate injury that hasn't fistulized, it mimics post-op ileus. So, you know, one of the things we can really emphasize and always emphasize to our trainees is that when, um, you're seeing that, um, post-op nausea and vomiting, you want the ureter and ureteral injury, um, to be on your differential and lab evaluation can be not as helpful as you might hope. Um, there is a lot of utility, like I said, to diagnosing those ureteral injuries at the time of surgery, um, in this gray hashed, um, column, these are the unrecognized ureteral injuries, and they are associated with all of the bad things. So acute renal insufficiency, sepsis, a need for a nephrostomy tube, fistula, and also death. Um, so let's say we do unfortunately get to that point of a delayed recognition of an injury, and this has developed into a fistula, then, um, our ways of identifying them are going to again, include just your, your office evaluation, um, and then, you know, some more advanced evaluations as well. But, um, if you are seeing pooling on a vaginal exam, and you're suspicious that this may not be assist just a cystotomy related to a cystotomy, that it may not just be a vesicle vaginal fistula, then there are some office-based tests you can do, including, um, an office cystoscopy. We all feel relatively comfortable with that. If what you would see in a ureteral injury, along with your vaginal pooling is that on cystoscopy, you're able to distend the bladder. Um, you don't see a defect. The bladder may look pretty normal. You'll probably see, um, normal ureteral efflux on one side. Um, you might not on the affected side, or you might see some, it depends on the size of the injury. And then there's the infamous, um, tampon dye test, which I found this really nice picture online. Um, the way this is done is to give a patient, um, peridium prior to presentation to the office. So that by the time she sees you, her urine is coming out orange. And then in the office, you backfill the bladder with, um, methylene blue or any blue dye that you can get. I'm methylene blue. I know is, um, sometimes are at this time, a little bit hard to find, um, keep in mind, there is often a blue, you know, there's some blue at the end of the tampon, and that's going to just be your transurethral leakage. Don't read too much into that. Um, if you see both, um, and there is a significant amount of the blue at the top of the tampon, then you probably have a bladder injury and a ureteral injury. If you really only have this apical, um, orange, then that's something you want to be worried about a ureterovaginal fistula. And if the whole thing is blue, then this is probably a bladder injury. Um, there are also very helpful radiologic evaluations. Um, if you can do a retrograde pylogram, this is sort of the most direct, um, quickest way to identify one of these injuries. Um, you take the patient to the operating room, um, you do a cystoscopy, you cannulate the ureter first on the normal side, um, and make sure you get a good nephrogram and a fully complete and normal caliber ureter, um, using a cone tip catheter and a dye like isovume. And then the affected side, you cannulate and repeat the same. And what you may see is, you know, you've got a transaction here or like a full ligation of the, of the ureter, and you only get a distal opacification, or you may actually not have a complete transaction and have some proximal dilation, um, and maybe a distal normal caliber or even decreased caliber. And you may see some extravasation of dye, which is what that arrow is pointing to. CT urogram is also helpful on this requires IV contrast, and you got to actually follow a pretty good algorithm for this and make sure that patients are getting pre and delayed post-contrast imaging. And that the image includes both the abdomen and the pelvis. Again, in a uretero vaginal fistula, you will probably see proximal ureteral dilation and extravasation of contrast. You may or may not see and contrast in the vagina. Um, so how do we approach these, um, in the most conservative way? There's a really good series of, um, 19 patients out of one center, um, over a 13 year period of time that really, I think gives the best sense of how effective stenting can be. Um, the, um, basically the antecedent surgeries and all of the surgical characteristics are in this table here of these patients. Um, basically, um, Patients were evaluated all 19, um, 12 were candidates for stenting. Six were not candidates for stenting and went straight to surgery. And one resolved with just drainage. Um, 11 out of the 12 stents were placed successfully. And of those 10 completely resolved. Um, so essentially the, um, you know, the surgeries were, um, the index surgery was median, uh, 25 days prior to surgery, um, stem placement resulted. If you look at the 10 out of 12, um, placement attempts, this is an 83% success rate was just stenting. And this isn't necessarily immediate. It's not intraoperative. Um, and so, uh, and one stent placement failed. Uh, and so that person went on to surgery. Um, what we can learn from this is that if a patient, um, is complaining of fistula and you diagnose this uretero vaginal fistula, you want to evaluate right away if they're a stent candidate and they probably are, um, if they aren't, if they don't have a really complex genital urinary fistula that also involves the bladder might consider stenting them. And if they, if this is, you know, not somebody that's already gone, undergone a surgical repair, then you there's no harm in trying. If you succeed in placing the stent, um, then, uh, great. You can leave the stent in for, and we usually do six weeks, um, put in a catheter, um, into the bladder to really minimize the tension around the injury, um, keep them on prophylactic antibiotics, manage their stent symptoms. And then, you know, six weeks, three months, remove the, the stent. And if you're really concerned, um, you can do that under anesthesia and then shoot a retrograde to take a look at your repair, you know, look, take a look at the healing. And then if, you know, if the, you all looks good and, and that, um, fistula is resolved, then, um, that's a great patient to follow up in about six weeks with a, with an ultrasound to evaluate for, um, hydro on the affected side. If there is hydro on the affected side, you can determine whether that hydro is clinically significant, or if it's just a dilated ureter, that's going to look dilated forever now, but it's functionally normal. And that you can do with a Lasix renal scan. That's a really good thing to keep in mind that a Lasix renal scan, um, will tell you if a dilated ureter is something you need to worry about, or if that dilated ureter is just dilated, but, but doesn't represent, um, uh, um, actual pressure on the, on the kidney. Now, if you're unsuccessful accessible at, um, placing a double J stent, then if all else fails, you can call, um, interventional radiology and see if they can place an anterograde stent. They'll still accomplish the same thing by getting a double J stent into that ureter. And you can use the same algorithm. Um, and you're just as likely to, um, see success with that approach. Um, just some pearls about, um, placing stents. It's always easiest to, um, start with a, uh, a glide wire and a double open-ended stent that you can pass one over the other. You advance the wire first, then the catheter, then the wire, then the catheter sort of, you know, hand over hand. Um, you can do this under continuous fluoroscopic guidance so that you can see when you're actually at the, um, at the renal pelvis. Um, and then you retrieve your double open-ended and place the double J over your wire. And then once you've got that wire, um, or, you know, out, you want to make sure that your coils are appropriately placed, that you see a good, healthy coil in the bladder. You want to be very careful, um, when, uh, pulling out, uh, those wires, because you can actually lose the stent all the way into the ureter. And then you've got a different, not unsolvable, but very painful problem. Um, ureteral stents come in lots of different sizes and dimensions for our patients. Um, the caliber can be anywhere from five to seven French and the length. And we want to select based on the patient's height. So we want to pick, um, a length of stent in centimeters that equals the patient's height in inches minus 42. Um, often, um, if you send a patient to, um, interventional radiology, they may come back with a stent larger than what is ideal for a woman. Um, we typically stay in the five to six range and occasionally seven, uh, French stents. Um, you, you want to remember that when you're doing operative cystoscopy, you need that 30 degree scope. You want to use your light cord to help you angle, um, the wire into the ureteral orifice, maintain close proximity between the cystoscope, um, and the bladder always keep that ureteral orifice in view. Um, and remember you have options for your glide wires. They don't have to be, um, super flexible. They can be angled, they can be straight. And there is this little handy twerking device. If you're having a difficult time getting traction on the wire to get a good angle into the ureter. Um, if you're having trouble, remember to use a smaller caliber stent. Um, and also if a patient does have significant hydro, they may require a larger, a longer stent than what, um, your equation leads you to believe. Um, we found that these, um, strings are best cut off because all too often you will get your stent in a great place and then inadvertently pull on that and pull your coil out of your renal pelvis and you got to start over. So our best advice is to, to go ahead and cut that. Um, after you place a double J stent, you need to make sure that the stent is in the right spot. So we, you know, in our protocol is always to get a PACU K U B. You want to use your landmarks, um, of your T 11 and T 12, T 12 will be the last, last vertebrae. You see your ribs coming off of, and you want your right-sided stent to be false somewhere between L one and L two. And on the left side, it would be about one vertebrae higher, um, just anatomically as that left renal pelvis is always a little higher. Um, so now we'll talk a little bit about the surgical approach. Um, so how do we know that a minimally invasive approach to ureter vaginal fistula is safe? Well, we do actually have a pretty good systematic review of 12, 12 retrospective studies. Um, we have a lot of data actually, but this is, this is one pretty high level one. Um, so there are 245, um, cases of robotic assisted, um, ureteroneal cystotomy versus 76 open repairs in this systematic review of including 12 studies. The indications for, um, the repairs were strictures, tumors, iatrogenic injury. So all comers, not just, um, the lower urinary tract injury scenario that we often see. Um, and what we saw was that the risk of postoperative stricture, which is one of the things you worry about most after a ureteroneal cystotomy is similar between, um, open and minimally invasive, invasive approaches. EBL definitely lower in the robotic assisted group, operative time, length of stay outcomes depended on the study. So those weren't completely consistent, um, extrapolating data from a slightly different scenario. Um, we can see that, um, it's certainly reasonable to approach uretero of like a ureteroneal cystotomy, um, minimally invasively. This is a study that was actually performed, um, using NISQIP data to look at route of hysterectomy and resultant, um, ureteral injuries. But along the way, there were 214 injuries that were incurred from minimally invasive hysterectomy that were repaired minimally invasively at the time. So intraoperatively and basically, um, the overall success rate of the repair was hot, was very high. The operating room time was overall lower than if these patients were converted to an open repair. Um, length of stay was definitely lower, um, and other complications seem to trend towards lower as well. Um, so I'm going to next shift over to a case. This is a real case that happened, um, that we took care of, and this is a 50 year, 50 year old who underwent a robotic assisted, um, total hysterectomy. And I've subtly hinted in gray, some of the risk factors that, um, you might associate with a fistula formation, but the, the hysterectomy was for fibroids. The surgery was complicated by a four centimeter cystotomy. Um, it was repaired with chromic, um, and PDS quill suture. No cystoscopy was done. The patient was left with a Foley in place and that seven days, um, she underwent a cystogram and that was negative for a leak. So her Foley was removed, but two days later, she developed continuous vaginal leakage and left flank pain on exam, um, was notable for some vaginal pooling. Now we talk a little bit about labs in terms of, um, how we can interpret them and help us to determine whether, you know, whether somebody is likely to have certain, um, genital urinary, um, injuries. So, you know, in a, in a patient for her, she had, um, basically normal labs and that could basically be a unilateral ureteral injury or a cystotomy. We're not really sure. Um, we've got a coronal view of her CT and I'm just going to play it like a scrolling, see if this works. Okay. So you can see right away, you've got a dilated chaliceal system on the left. You can see dilation of the left ureter coming down into the pelvis. And, um, and I think you, I think we see a little bit of a fluid collection too. This is the Foley catheter here, um, coming into view and there's some distal narrowing of the ureter and some vaginal spillage of, uh, system of the dye. On this side, we're going to take a look at the axial view. Um, and this is going to be coming down again. You see the dilated left side. Um, you can really see that caliber of that ureter is abnormal. And then getting down into the pelvis it starts to get very narrow. And so imaging for her was really helpful. Um, so, okay. So, um, again, um, I think this is a repeat of my other review of that study. Um, when we're talking about robotic ureteroneosystotomy, some of the principles that we want to think about, again, that appropriate port placement, dissecting the ureter is something you need to pay attention to. The, the anatomy of the ureter is such that the adventitia holds most of the vascularity of the, of the ureter. So handling that carefully is really important to maintaining the integrity of the ureter. You don't want to remember that you're going to be making an anastomosis here between the ureter and the bladder, and you want to minimize tension on that. So there are some tricks you can use. Retropubic dissection and really big bladder mobilization can help. You want to isolate that, um, ureter and you really want to spatulate it. That means you want to make a big opening of the ureter that you're connecting to the bladder so that you're minimizing that risk of stricture. Um, when you create your anastomosis, you want mucosa to mucosa. That's very important. You want to place that double J stent and think of whether or not there's enough tension or I'm sorry, enough, but not any tension on the repair. And if you need to do a psoas hitch to accomplish that, you want to inspect for a watertight seal around the bladder by backfilling the bladder a little bit. And then you want to consider whether or not an interpositional graft is, is possible. Um, this is again, a sped up, um, uh, video of this robotic ureterone neocystotomy. Um, we're approaching the, um, scarred, um, pelvic sidewall here and identifying the ureter. Um, again, we're trying to maintain some of that adventitia and also we're identifying where that ureter, um, becomes unhealthy. So we're putting a vessel loop here around the ureter. This is going to help us dissect further. And again, we're leaving a lot of that fatty tissue around the ureter, um, to maintain that blood supply. And then we're getting into the retropubic space here. This is going to allow that bladder to flop down and allow us to get attention free re-implantation. And so now we're kind of positioning the bladder to where it needs to reach, making sure that this is a reasonable thing to do. Now we can backfill the bladder so that we can create our cystotomy. And this is really right through the bladder serosa and then a nice clean cystotomy layer by layer. And then transecting the ureter above the injury. And then that mucosal to muco- oh, the spatulation. This is to make that a nice big opening and you got to handle super gently to make sure to avoid disrupting that adventitia. Next is the mucosal to mucosal repair. So incorporating that bladder mucosa and then incorporating that, um, ureteral mucosa and making sure to place those knots outside of the lumen. And then placing a few more of these stitches before placing the double J stent, which you can place right through from the abdomen. You don't have to go down below. And your visualization and ability to do this is so much easier through this approach than it is open. So now you can see you've got like a, the entire posterior aspect of the defect is closed. You place your stent over a glide wire cephalad until you meet resistance and then you can pull out the wire and place this coil into the bladder. And then you can complete your, your closure. Once you've got that healthy coil into the bladder, finish your repair. And there is a water test backfill and it looks good. Now, um, we talked a little bit about minimizing tension. Performing a psoas hitch is something, um, that once you've mobilized that bladder, isn't too tough to do. You would just throw a suture into the psoas tendon, making sure to avoid anything that looks like a nerve. Um, you can usually see the genital femoral nerve pretty well up there. So you can avoid that. And then, um, into some of the bladder muscularis and perivascular tissue with a permanent suture, just to minimize any of the tension. A Bowari flap, um, is something I've never had to do, but basically involves creating a big flap using the bladder wall itself to tubularize and connect to the ureter for a higher injury. Um, postoperatively we talked a little bit about, um, anytime you have a stent in to leave that in for a prolonged period of time to allow for healing. We usually put a Foley in for about a week also to minimize tension. Some things you can do to minimize stents and symptoms are to use an anti-muscarinic medication for a short period of time, um, possibly Tamsulosin to minimize any kind of, um, colicky symptoms and the stent removal can be in the office. Um, or if you're worried about possible stricturing or a failure, then to do it at the time of, um, a retrograde in the OR and then renal ultrasound, like I said, six weeks after stent removal. And so I had hoped to be done three minutes ago, but, um, I'm done now. So I want to field any questions. I look forward to answering any questions that you might have. Thank you so much, Dr. Collins for such a wonderful presentation. Um, there are a couple of questions, um, in the Q and a section. Um, the first one is, uh, can you review again the time you would consider a Martius flap? Sure. So a Martius flap, I mean, I, there are people out there who do them more routinely in my practice. I do them if I have a failed initial attempt, um, or if I really don't have a lot of tissue to work with. So when I go to Rwanda, there are times when there's so much tissue necrosis that I don't have a lot to work with. And I'm really worried about the, um, separation of my layers. So that's when I'll bring in a Martius flap. Perfect. Um, the next question was, uh, during training fellows often will not manage many fistula cases. At what point did you feel comfortable managing these cases and do you have any recommendations regarding educational opportunities? Fellows should take advantage. You have to become more comfortable. Yeah, definitely. Um, as a fellow, I scrubbed in on several ureteroneal systotomies and, and, um, I also passed a lot of stents, but that was on a formal urology rotation. Um, I, my vesicle vaginal fistula experience came largely from going on mission trips. Um, they don't happen as often in the States, but, you know, typically if you are comfortable in that space, doing a LASCO repair for an iatrogenic low vesicle vaginal fistula is totally within the scope of most urogynecologists after most programs of training. Um, I would say to get really facile with this, you want as much exposure as possible. I didn't become fully comfortable doing all of this until I did them as an independent attending. And I had the support of a really good group and we double scrubbed a lot of these until everybody feels really comfortable doing them. Cause there can be a lag between the time that you're doing those stents and fellowship and the time that you're, um, you know, seeing them as an attending. I will say that a lot of the opportunity comes from how your system, how your institution is set up. Um, I think that there's often a pattern of referring some of these cases to urology with the assumption that urologists do this more. I think that that's the big misconception. Nobody does this very much. Um, these are rare injuries, the lower urinary tract injuries that happened from gynecologic surgery and cesarean sections. And you would be so surprised to learn that a lot of urologists will just open these patients. That's how they were trained to do it. That's how they feel comfortable. Even if they're doing robotic prostates and, you know, and nephrectomies, they still would open for this. Um, and it really is, it takes maybe a little bit of, uh, changing your paradigm a little bit and how you're thinking about these, but the people who see these injuries, the most are most comfortable with, um, the anatomy and understand how they happen is us. Um, and so we really should be, I think, taking over this particular group of lower urinary tract injuries that happened from obstetric and gynecologic complications. Now that being said in a cancer situation, radiation, these are things that I think, you know, a high, a high injury, these are things that I probably would reach out to urology for. Perfect. Thank you so much. Um, the next question, um, is do you use live fluoroscopy when placing the double J stem from the abdomen? I think they were referring to, um, when you were doing your robotic, uh, ureter vaginal. Oh, no, you don't need fluoro at all for that. That's a definitely by feel you you've got your dimensions of the patient. Um, you've got your stent that you think is going to work. Um, if you have a super dilated system, maybe you go up a size and then, you know, over the wire, you're going to be placing that stent. You will run into resistance at the renal pelvis. That's when you keep your stent in place, pull back the wire and then tuck the coil into the bladder. Um, awesome. I think we have time for a couple more. There's two more. It looks like short questions. Um, one person wants to know how many Martius flaps have you done? I've done maybe a dozen, not, not many. Um, and, uh, somebody else says, uh, thank you. A very formative lecture. Um, you mentioned the bladder capacity and number of layers in suturing. Um, how can we measure the bladder capacity? Good question. Um, the study that that comes from was, um, that was done in Ethiopia. This was very much a subjective assessment by the surgeons. Um, now most, I would say in the developed world, when you're talking about, um, injuries that are diagnosed and, and relatively quickly addressed, um, most of the time your bladder capacity is going to be moderate, but you want somebody to be able to hold maybe 300 CCs or more. And that's a pretty good bladder capacity for somebody with a fistula where you really see the small bladder capacities are when there's been a lot of necrosis or just a giant fistula. So the bladder hasn't held anything for a long time. Um, that's where you can really lose a lot of that bladder capacity, but that may take a few years. And so we don't see that as often here. Great. Um, I think that was the last question. Um, thank you so much, Dr. Collins. That was a wonderful presentation. Just a few quick things, um, to go over, um, on behalf of AUGS, I'd like to thank all of our faculty today, um, for this excellent webinar and then, um, be sure to register for the upcoming webinars on July 19th. Um, Dr. Pamela Coleman will be giving a talk on, um, cystoscopy pathology. And August 16th, Dr. Henry Lai will be presenting, um, a talk titled diagnosis and treatment of interstitial cystitis and bladder pain syndrome. Um, so thank you everybody and have a great evening.
Video Summary
The video is a webinar titled "Minimally Invasive Repair of Genital Urinary Fistulas" presented by Dr. Sarah Collins. Dr. Collins is a board-certified OB-GYN and female pelvic medicine and reconstructive surgery specialist. She has expertise in minimally invasive and robotic surgical techniques.<br /><br />The webinar covers topics such as vesicovaginal fistula repair, ureterovaginal fistula repair, and the use of specific surgical approaches. Dr. Collins discusses the signs and symptoms of these conditions, as well as various treatment options and their efficacy. She also shares insights from studies and reviews the evidence supporting different surgical techniques.<br /><br />Dr. Collins emphasizes the importance of individualized patient care and shared decision-making. She highlights the need for careful evaluation of each case to determine the best approach based on factors such as the cause and location of the fistula, bladder capacity, and other anatomical considerations.<br /><br />The webinar includes a video demonstration of a robotic ureterovaginal fistula repair surgery, showcasing the steps involved in the procedure. Dr. Collins also provides guidance on postoperative care, stent placement, and follow-up evaluations.<br /><br />Overall, the webinar aims to educate healthcare professionals on the management of genital urinary fistulas, emphasizing the importance of a minimally invasive approach when appropriate.
Keywords
Minimally Invasive Repair
Genital Urinary Fistulas
Webinar
Dr. Sarah Collins
OB-GYN
Female Pelvic Medicine
Reconstructive Surgery
Vesicovaginal Fistula Repair
Ureterovaginal Fistula Repair
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