The openings, known as vesicouterine fistulas, can be the result of cesarean section surgery as well as prolonged obstructed labor. The main symptoms are menstruation through the bladder, known as cyclical hematuria, with or without urinary incontinence.
In the June issue of Urologia Internationalis, Hemal, a professor of urology, reports on three patients whose fistulas were repaired with robot-assisted surgery, a minimally invasive option that requires only five small incisions. In one case, a hysterectomy was also performed in addition to repairing the fistula. Hemal has previously reported his experience using the technology to repair other types of fistulas.
"Robotic repair was successful in all cases with mean operative time of 175.5 minutes and all patients being discharged on the third day after surgery," said Hemal in an interview. "Robot-assisted surgery allows surgeons to offer a minimally invasive approach for a variety of reconstructive procedures."
Treatment for the vesicouterine fistulas depends on the size of the opening and the symptoms. Options include hormone treatment to shrink the uterus to its pre-pregnancy size and surgery to repair the opening. At one time, the only surgical option was to open the abdomen with a large incision. A newer approach is laparoscopic surgery, a minimally invasive approach in which procedures are performed through small incisions. This option has been shown to decrease pain, length of hospitalization and scarring and offers a quicker recovery, said Hemal.
Robot-assisted surgery is a type of laparoscopic surgery in which the surgeon controls four robotic arms with hand and finger movements while viewing the surgical site on a screen. The instruments are modeled after the human wrist and allow for full dexterity. The tiny instruments - as well as the ability to see the surgical site at tenfold magnification - allow for very precise, refined movements.
Hemal said robot-assisted surgery can be easier to learn than pure laparoscopic surgery because it increases the surgeon's dexterity.
"Robot-assisted technology makes it easier to perform complex surgeries and allows us to offer the benefits of laparoscopic surgery for difficult and rare fistulae," he said. Hemal is a pioneer in robot-assisted surgery and helped develop many of the surgical protocols in use today. At Wake Forest Baptist, he and colleagues in the Department of Urology use the technology for surgeries of the prostate, kidney and bladder as well as for female pelvic organs. Hemal has the world's most extensive experience using the technology to repair fistulas between the bladder and vagina and is also a world leader using robot-assisted and laparoscopic surgery to manage cancer.
Hemal is director of the Robotic and Minimally Invasive Urologic Surgery Program at Wake Forest Baptist. He is a fellow in the International College of Surgeons and the American College of Surgeons.