7. Close the bladder
Stitch the bladder in a running fashion using three layers of 3-0 rapid absorbable synthetic suture (FIGURE 6 and Video 3 . I prefer polyglactin 910 (Vicryl; Ethicon, Somerville, New Jersey) because it is easier to handle.
FIGURE 6: Close the bladderStitch the bladder in a running fashion using three layers of 3-0 rapid absorbable synthetic suture. Keep the closure line free of tension.
8. Close the vaginal side of the fistula
Stitch the vaginal side of the fistula in a running fashion with 2-0 absorbable synthetic suture.
9. Verify closure
Check for watertight closure by retrofilling the bladder with 100 mL of sterile milk (obtained from the labor/delivery suite). Observe the suture line for any evidence of milk leakage. (Sterile milk does not stain the tissues, and this preserves tissue visibility. For this reason, milk is preferable to indigo carmine or methylene blue.)
10. Remove the stents from the bladder
Cystoscopically remove all stents.
11. Close the laparoscopic ports
12. Follow up to ensure surgical success
Leave the indwelling Foley catheter in place for 2 to 3 weeks. After such time, remove the catheter and perform voiding cystourethrogram to document bladder wall integrity.
Discussion
I have described a systematic approach to robotic VVF repair. The robotic portion of the procedure should require about 60 to 90 minutes in the absence of significant adhesions. The technique is amenable to a laparoscopic approach, when performed by an appropriately skilled operator.
Final takeaways. Important takeaways to this repair include:
- Stent the fistula to make it easy to find intraoperatively.
- Enter the vagina from above to rapidly locate the fistula tract.
- Use sterile milk to fill the bladder to look for leaks. This works without staining the tissues.
- Minimize tension on the bladder suture line.