Introduction

Vesicouterine fistula (VUF) was described for the first time in the literature in 1908 [1], while some of its characteristic clinical presentations were defined in 1957 [2]. Options of treatment of VUF vary from conservative follow-up, hormonal therapy and the most commonly used open surgical repair [3].

As a part of recent advances in the field of minimally invasive laparoscopic surgery, laparoscopic VUF repair has been reported [4]. More recently, laparoendoscopic single-site surgery (LESS) has been reported as a valid alternative to the standard conventional laparoscopy for treating many urologic pathologies [5–7]. However, to date, LESS repair of VUF has not been reported yet. In this initial study, we present our experience of LESS repair of VUF and we compare that with conventional laparoscopic transperitoneal extravesical repair of VUF.

Materials and methods

Included in this retrospective study were 11 females with VUF. Six patients with mean age of 32 ± 5 years had conventional laparoscopic extravesical repair, while five patients with mean age of 30 ± 4 years had LESS extravesical repair. After approval of our protocol by the ethical care committee, all patients signed an informed consent including options to convert into laparotomy or conventional laparoscopy in the LESS group. All patients were referred to our institute from different gynecological health care centers. None of these patients had previous repair of VUF. Two patients were diagnosed early and a trial of conservative treatment in the form of urethral catheter for 3 weeks, hormonal therapy and antibiotics was tried and failed. Eleven patients presented with Youssef’s syndrome, while two patients, one in each group, presented with amenorrhea. Pelvic examination, computed tomography, ascending cystography and diagnostic cystoscopy were done for all patients. Diagnostic cystoscopy in one patient revealed a foreign body (gauze) at the fistulas communication that was protruding into the urinary bladder and was removed cystoscopically. However, follow-up of this patient after 3 months showed persistence of her symptoms and presence of the fistula (Fig. 1).

Fig. 1
figure 1

Retrograde cystogram showing fistulous communication between the bladder and the uterus

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Both conventional laparoscopic and LESS repair of VUF were done in all patients by the same surgeon. In both techniques, all patients had general anesthesia and initially placed in lithotomy position where two 5 Fr. ureteric catheters were inserted into both ureters, and a different colored 5 Fr. ureteric catheter was inserted into the fistula, then a Foley’s catheter (20 F) was fixed in the urinary bladder.

Conventional laparoscopic extravesical repair

Patients were placed in supine position and pneumoperitoneum was done through closed technique. An optical 10-mm port was inserted infraumbilically along the midline. Another one 10-mm port and one 5-mm port were inserted midway between the left and right anterior superior iliac spines and the umbilicus, respectively. Two more 5-mm ports were placed in the iliac fossa at both sides. The plane between the uterus and urinary bladder was developed using the scissors and electrocautery where extravesical dissection was continued, being assisted by gentle counter traction and half-filled bladder. The exact site of fistula was identified by the ureteric catheter that was initially inserted into it. Limited cystotomy was made where the fistulas tract was completely excised and the posterior bladder wall was adequately mobilized from the uterus. While doing this, no electrocautery was utilized in order to maintain vitality of the tissues. Trimming of the wall of the urinary bladder was done at the fistula. Then, uterine rent was closed by a single figure of eight 3/0 Vicryl sutures. Two-layer water-tight closure of the urinary bladder was done using 3/0 Vicryl sutures. Then, a flap of omentum was mobilized and inserted between the uterus and the urinary bladder and fixed with two 3/0 vicryl sutures. Hands-free intracorporeal suturing technique was performed in all patients. Finally, tube drain was inserted in all patients.

LESS extravesical repair

About 2-cm incision was done at the lower border of the umbilicus through which an access was made to peritoneal cavity. Both TriPort (four patients) and QuadriPort (one patient) (Olympus, Tokyo, Japan) as well as straight and pre-bent instruments (HiQ LS hand instruments, Olympus, Tokyo, Japan) were used. When QuadriPort was used, skin incision was made to be 2.5 cm. In this group of patients, we used an EndoEYE LTF VP camera (Olympus, Tokyo, Japan). The technique of LESS extravesical repair of VUF was done exactly as with the conventional laparoscopic repair (Figs. 2, 3). As we used straight needle holders, additional 5-mm port was inserted during suturing. This port was inserted midway between the right anterior superior iliac spine and the umbilicus. All suturing in this group were done using used 3/0 Vicryl sutures mounted on 22-mm needle.

Fig. 2
figure 2

Extravesical dissection of VUF during LESS repair being guided by ureteral catheter inside fistula’s tract

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Fig. 3
figure 3

Final view after LESS excision of fistula tract, closure of the bladder and uterus and interposition of an omental flap in between

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Postoperatively, all patients received diclofenac sodium as analgesic and anticholinergics to inhibit bladder spasm. To assess the degree of postoperative pain felt by all patients, VAS was used. Three weeks postoperatively, an ascending cystography was done to check the urinary bladder integrity. Patients were instructed to avoid lifting heavy weights and sexual intercourse for at least three months following the repair.

Statistical analysis

Data of continuous variables are presented as mean ± standard deviation. Mann–Whitney test was used to compare both groups, and P value of <0.05 was regarded statistically significant.

Results

Mean age of patients in both groups was comparable. All patients gave a history of repeated cesarean section (CS). All patients had successful repair without conversion either to open surgery or from LESS to conventional laparoscopic repair. Mean size of VUF was 1.7 ± 0.8 cm (median 1.5 cm). Mean operative time for conventional laparoscopic and LESS repair was 149 ± 18 min (median 150 min) and 144 ± 16 (median 145 min) minutes, respectively. Mean blood loss in conventional laparoscopic and LESS repair was 95 ± 18 c.c. (median 95 c.c.) and 86 ± 15 c.c., (median 80 c.c.), respectively, and no blood transfusion in both groups. In both groups of patients, no intraoperative or postoperative complications were encountered. Mean postoperative hospital stay was 3.1 ± 0.8 days (median 3.0 days) and 2 (median 2.0 days) days, respectively, for both groups of patients, and the difference was statistically significant. None of patients needed morphine as analgesic postoperatively, and parental diclofenac sodium was given only during the postoperative hospital stay. VAS for patients who had conventional laparoscopic repair was 2.8 ± 0.8 (median 2.5), while it was 1.6 ± 0.5 (median 1.5) for patients who had LESS repair, and the difference was statistically significant. In all of our patients, urethral catheter was removed after 3 weeks. After a mean follow-up period of 23.6 ± 8.2 months (median 22 months) and 13.4 ± 1.8 (median 15 months) months for both groups, respectively, all patients were cured.

Discussion

As VUF mainly affect young parous females, it significantly has a social impact. Current reports prove that the occurrence of VUF is increasing over the last two decades with better recognition and reporting of the cases [3, 8, 9]. The current increased rate of CS is the main cause of VUF [9, 10]. In our study, all patients had a history of repeated CS. Clinical presentation of VUF is commonly the classical Youssef’s [2] syndrome that consists of amenorrhea and menouria, or incontinence alone and/or both [11, 12]. The majority of our patients presented with Youssef’s syndrome.

Options for treatment of patients with VUF depend on its onset of presentation, the size of the fistula and the presenting symptoms. Conservative treatment may be successful for small VUF that has been discovered immediately after surgery [13, 14]. However, the reported success rate for conservative treatment is less than 5 % [15]. Although conservative treatment was tried in our group of patients who were discovered early after CS, none of these patients was cured. This is probably due to the relatively large size of the fistula in these patients. Surgical repair is considered as the main treatment option of VUF where transabdominal approach is the most frequently applied and vaginal approach is rarely to be done [3].

Laparoscopic repair of VUF aims for similar success rates with less morbidity compared with transabdominal open surgical repair. Although successful laparoscopic repair of VUF has been reported; however, all of these reports are case reports that included only one to three patients [4, 16–19]. In our study, we report the largest case series of laparoscopic repair of VUF, and to our knowledge, we report for the first time in the literature a series of LESS repair of VUF. The relatively large group of cases in the present study is related to the currently elevated rate of CS which is the principal cause of VUF [9, 10], as all of these patients were referred to our institute from different gynecological health care centers. Available reports show that the overall success rate of laparoscopic repair of VUF is 50–100 % [4, 16–19]. However, reports that presented 50 % success rate were two case reports; each included two patients where conversion to open repair was done in one patient due to technical difficulties and failure to proceed [4, 16]. The success rate of both conventional and LESS repair of VUF in our study is 100 %. This high success rate is probably due to our technique of repair that ensured complete excision of VUF, water-tight closure of the urinary bladder and complete isolation of the bladder and the uterus by a viable flap of omentum and presence of a urethral catheter for 3 weeks. These are the same principles of the open surgical repair [3]. Additional factor that might contribute to high success rate of both conventional and LESS repair of VUF is the cumulative experience of the operating surgeon that was gained from both conventional and LESS repair of vesicovaginal fistula [7, 20].

The reported operative time for laparoscopic repair of VUF in the literature varied between 140 and 220 min, which correlate with our results for both conventional laparoscopic and LESS repair of VUF. Even more, the operative time in patients with LESS repair was less than that with conventional laparoscopic repair, although that was not statistically significant. This indicates the reproducibility of LESS repair of VUF, and with further experience, the operative time could be significantly shorter. However, it is important to mention that LESS group of patients were proceeded by conventional laparoscopic repair which might have contributed to the increasing surgeon’s experience and familiarity with the procedure as the volume of cases increased. The operative time may be attributed to many variables as the cumulative experience of the laparoscopist, surgical skills, surgical approach as well as history of previous surgeries. We used the extravesical approach to achieve our conventional laparoscopic and LESS repair of VUF. This allowed a relatively rapid access with minimal dissection to reach the fistula, being guided by presence of ureteric catheter that was pre-operatively inserted into the fistula. With the extravesical approach, we did a limited cystotomy, which might limit suturing and that could be reflected on the operative time. Also, none of the cases included in our series had previous repair of their VUF.

Recently, LESS has been described for many constructive and complex urologic procedures [7, 21–24]. However, it has been reported that an extra-port was needed in 23 % of LESS patients [25]. In the current group of LESS repair of VUF, we had to add one 5-mm extra-port during suturing which reflects the limitation of currently available instrument ergonomics during intracorporeal hands-free suturing, especially with such difficult reconstructive procedure. Although the 5 cases with LESS repair were done with the same technique, we have noticed a significant decrease in the operative time when we compared the first patient (operative time was 170 min) with the fifth patient (operative time was 130 min), which reflects the familiarity of the technique and improved surgical skills and experience with time. Of course, adding this extra-port while starting the procedure would even save more operative time through helping dissection of the VUF; however, as we describe a novel indication of LESS in urology, we preferred to proceed with the single port only aiming to check the technical feasibility of completing such new procedure with currently available equipments as there is no currently available ideal ports or instruments. As we perform a reconstructive procedure that require many suturing, we preferred to use one 5-mm port instead of a needle-o-scopic accessory port to be able to insert a relatively large-size needle through it to facilitate a full thickness closure of the bladder and uterus. The da Vinci Surgical System has been used to improve the current limitations of LESS; however, it has been found that the current robotic instruments have restricted range of motion, and it has been concluded that robotic LESS is still in its early phase [5, 26].

Prophylactic ureteral catheterization during extravesical approach is helpful to avoid any risk of ureteral injury while doing dissection to reach the fistulous communication as in such cases, extensive adhesions and reaction is expected.

Current studies showed that LESS is either superior or at least comparable to standard conventional laparoscopy [27, 28]. In patients who had conventional laparoscopic repair of their VUF, we used 5 ports; two of them are 10-mm ports. Although the issue of cosmesis may not so appealing for such category of patients who already have a scar of previous CS, LESS repair of VUF was significantly associated with less postoperative pain and shorter postoperative hospital stay, which could be the main advantage of LESS repair of VUF. No intraoperative or postoperative complications were reported in both groups. Also, the blood loss in the LESS group (86 ± 15 c.c.) was relatively less than that of the conventional laparoscopic group (95 ± 18 c.c.). Although this difference in blood loss was not statistically significant, that is, in accordance with other many published comparative studies [29, 30].

Limitations of the current study include the fact that it is a retrospective study that includes a relatively small overall number of patients. However, this study reports for the first time the feasibility of LESS repair of VUF, and compared with other reports, it includes the largest case series of laparoscopic repair of VUF. In the future, we intend to do prospective comparative randomized study to compare conventional laparoscopic and LESS repair of VUF and to try avoiding use of an extra-port during the LESS repair.

Conclusions

Both conventional laparoscopic and LESS extravesical repair of VUF are effective and reproducible procedures that adhere to the same principles of open classical surgical repair. LESS repair of VUF seems to be less morbid than conventional laparoscopic repair; however, the procedure is technically challenging and requires good laparoscopic skills.