Urinary abnormality successfully treated with robot-assisted surgery

8 September 2008

Robot-assisted laparoscopic surgery has been successfully used to repair abnormal openings between the bladder and vagina known as fistulas, it is reported in the online version of the Journal of Urology.

The procedure was carried out by Dr Ashok Hemal, a urologic surgeon at Wake Forest University Baptist Medical Center, and colleagues. This type of fistula can result in frequent urinary tract infections and the leakage of urine from the vagina and can be mistaken for continence.

All the women patients in the study had previously undergone unsuccessful surgeries to repair the problem. In most cases, the patients in the report would undergo abdominal surgery, requiring a large incision. Instead, centimetre-sized instruments and a small camera were inserted through five small incisions in the abdomen.

“There was less blood loss with this procedure than with conventional surgery and there is the potential for a faster recovery,” said Dr Hemal, director of the Robotic and Minimally Invasive Urologic Surgery Program at Wake Forest Baptist. “The results were outstanding and suggest the robot-assisted surgery is an attractive option for fistulas that would normally require abdominal surgery.”

Robot-assisted surgery has been increasingly used for heart and prostate surgery in recent years and physicians have started using it for other procedures. The da Vinci surgical system has four robotic arms with centimetre-sized instruments attached. The surgeon controls these arms with hand and finger movements while viewing the surgical site on a screen. The tiny instruments and the ability to see the surgical site at tenfold magnification allow for very precise, refined movements.

The type of fistula that the surgeons repaired can occur one to six weeks after gynaecologic or obstetric surgery, such as a hysterectomy. The women in the report had fistulas located in the supratrigonal region, which is at the lower portion of the bladder near the tubes that carry urine from the body.

Fistulas in other areas can often be repaired with a vaginal approach or with laparoscopic surgery, which uses a camera and small incisions — but is not robot-assisted. However, these approaches are not generally used in the supratrigonal region because the physician must work at an extreme angle.

“Robot-assisted surgery has promise to bridge the limitations of laparoscopic surgery and allow more women with fistulas, urinary incontinence or prolapsed pelvic organs to benefit from a minimally invasive approach,” said Hemal.

Hemal had previously published a report in Urology (May, 2006) using robotic-assisted surgery to repair first-time fistulae in women. All the patients in current report had undergone previous failed surgeries — five of the women had at least two failed prior surgeries. With the robot-assisted approach, mean operating time was 141 minutes and mean hospital stay was three days.

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