Robotic surgery for urinary fistulae in females: a narrative review

Abstract

Background and Objective: Fistulae are anomalous communications between two epithelial surfaces. Though with a rare incidence, they impose significant burdens on affected women. Fistulae were initially described in 200 A.D., but management has evolved surgically to include more minimally invasive approaches. Minimally invasive techniques have notably decreased morbidity rates for surgical approaches in the past decades. Robotic surgery was born from the desire to overcome laparoscopy limitations while retaining its advantages. When available, robotic surgery provides surgeons with enhanced dexterity, more precise dissection, easier intracorporeal suturing, a shorter surgical learning curve, elimination of the fulcrum effect, and a three-dimensional (3D) perspective, all while maintaining ergonomic comfort. The main objective of this narrative review was to discuss relevant aspects of the vesicovaginal fistula (VVF), vesicouterine fistula (VUF), and ureterovaginal fistula (UVF) and discuss their robotic repair. Methods: A narrative review was conducted utilizing a comprehensive search to identify studies discussing the robotic management of female urinary fistulae. Data from all types of studies were included without restrictions on article type. Only articles in English and Spanish were considered. Searches were performed on 12/12/2020, 04/25/2023, and 09/10/2023 in the electronic database PubMed (1978 to 2023), using free text terms and keywords. Key Content and Findings: Treatment of genitourinary fistulae depends on the size, location, surgeon preference, and underlying cause. A small subset can resolve with conservative management, but more commonly, fistulae are treated surgically. No matter the type of genitourinary fistulae or the surgical approach, there are general surgical principles essential in ensuring successful surgical repair. These include good visualization, adequate exposure, careful dissection, healthy margins, and watertight closure with suture lines that do not overlap. Conclusions: Surgical management is necessary in complicated cases and when conservative measures fail. When available, robotic surgery can aid in repairing the more difficult and complex fistulae, given its advantages of offering a minimally invasive approach with greater dexterity and a tridimensional view.