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Chapter 5 Miscellaneous
Step 1: Cystoscopy and catheterisation of the ureters and fistula, port placement
a
The patient is placed in dorsal lithotomy position. Cystoscopy is performed and both ureters are cannulated with 5-F ureteric catheters. The latter manoeuvre facilitates the identification of ureteral orifices and the course of the ureters. A ureteral catheter of a different colour is inserted through the bladder, advanced along the fistu-
b
lous tract into the vagina and retrieved at the introitus. For large fistulae, a Foley catheter instead of a ureteral catheter can be used through the bladder. Port placement follows. A standard five-port transperitoneal approach, similar to that employed in laparoscopic prostatectomy, is used.
Step 2: Creation of omental flap, cystotomy
a
A sponge retractor is inserted into the vagina via the introitus to retract the vagina posteriorly. Once in the abdominal cavity, the first step is to dissect any adhesions. A omental flap is created from the site of the right gastroepiploic artery (Step 2a). The first step to repair the fistula is the dissection of the posterior bladder wall. A vertical
b
bladder incision will be performed, creating a small cystotomy that dissects vertically towards the fistula. Step 2b is a schematic of the cystotomy. It is important to remember that the latter transvesical approach leads to the fistulous tract expeditiously.