Robotic repair of vesicovaginal fistulas using fibrin sealant.

INTRODUCTION: Although infrequent, when encountered vesicovaginal fistulas (VVF) are a difficult condition for both patients and physicians alike. After the first robotic repair was described in 2005, this has been an increasingly common treatment modality. At our institution between 2009 and 2014, eleven of these patients were evaluated and treated with robotic repair. However, fibrin sealant was used in place of the traditional tissue flap. Included are six patients who had previously undergone operative repair. MATERIALS AND METHODS: After IRB approval was obtained, a retrospective study was undertaken to identify patients with VVF. Inclusion criteria were operative repair utilizing a da Vinci robotic system; there were no exclusion criteria. A total of eleven patients were identified, and in each case, a robot assisted laparoscopic approach was utilized and Tisseel fibrin sealant was used in lieu of tissue interposition. RESULTS: All patients underwent successful repair of their VVF without evidence of recurrence at a mean follow up of 15.6 months. CONCLUSIONS: Robotic vesicovaginal fistula repair with fibrin sealant seems to be a safe and viable alternative to the traditional repair utilizing a tissue flap.

Analysis of Complications of Pelvic Mesh Excision Surgery Using the Clavien-Dindo Classification System.

PURPOSE: We describe and categorize complications using the Clavien-Dindo classification system in patients who underwent vaginal mesh excision surgery. MATERIALS AND METHODS: With institutional review board approval we retrospectively reviewed the records of 277 patients who underwent vaginal mesh extraction between 2007 and 2015 at a single institution. Surgical complications were stratified using the Clavien-Dindo classification system. Complications were perioperative (prior to discharge) or postoperative (within 90 days). Indications for initial mesh placement, mesh revision procedure, time to resolution and medical comorbidities were assessed. RESULTS: Of the 277 patients 47.3% had at least 1 surgical complication, including multiple complications in 7.2%. A total of 155 complications were identified, which were grade II in 49.0% of cases, grade I in 25.8%, grade IIIb in 18.7%, grade IIIa in 5.2% and grade IVa in 1.3%. No grade IVb or V complications were identified. The indication for initial mesh placement did not significantly affect complication frequency. Patients who underwent combined stress urinary incontinence and pelvic organ prolapse mesh revision surgeries had an increased frequency of complications compared to those treated with mesh revision surgery for pelvic organ prolapse or stress urinary incontinence alone (p = 0.045). Most complications occurred postoperatively and resolved by 90 days. Age, body mass index, smoking status and diabetes were not associated with increased complications. CONCLUSIONS: Despite the complexity of mesh revision surgery most complications are minor. Serious complications may develop, emphasizing the need for proper patient counseling and surgical experience when performing these procedures.

Female Urethral Diverticula in the Contemporary Era: Is the Classic Triad of the "3Ds" Still Relevant?

OBJECTIVE: To evaluate the correlation between signs and symptoms of urethral diverticulum (UD), especially the classic triad of 3Ds including dysuria, dyspareunia, and postvoid dribbling, before and after transvaginal urethral diverticulectomy, in relation to anatomic configuration on imaging. MATERIALS AND METHODS: After IRB approval, records of 54 females who underwent transvaginal urethral diverticulectomy were retrospectively reviewed. Urinary symptoms before and after the procedure were correlated with the anatomical configuration of the UD on magnetic resonance imaging. RESULTS: The median age of the patients was 52 years (range 29-77). Common presenting symptoms were stress urinary incontinence (60%), dyspareunia (60%), and recurrent urinary tract infections (70%). The classic 3Ds were present collectively in only 5% of patients. Dyspareunia was the most common of the 3 "Ds." Twenty-seven percent of patients had none of the classic 3Ds. On physical examination, the most common finding was a tender anterior vaginal wall mass (52%). Presenting signs and symptoms did not correlate with anatomic configuration in terms of radial urethral involvement, size, or length of urethral involvement on preoperative magnetic resonance imaging. After median 14 months of follow-up, no patient reported the classic 3Ds after surgery. CONCLUSION: Recurrent urinary tract infections, stress urinary incontinence, dyspareunia, and vaginal mass are the most common presentations of UD. The classic triad "3Ds" is rarely seen in the individual patient. Preoperative anatomic configuration on imaging is not correlated with the severity or nature of presenting symptoms.

Safe and effective obtainment of access for percutaneous nephrolithotomy by urologists: the Louisiana State University experience.

BACKGROUND AND PURPOSE: Access for percutaneous nephrolithotomy (PCNL) is critical to successful removal of stone burden and is often performed by a specialist other than a urologist. In many regions, however, there is limited availability of such personnel. We reviewed the complication rates that were related to PCNL access when performed at a teaching hospital to establish that access for PCNL may be safely taught to and performed by urology residents. Chief urology residents across the nation were also anonymously surveyed to better understand the current trends and dynamics regarding PCNL access in teaching institutions. PATIENTS AND METHODS: A retrospective chart review was performed of all PCNLs performed at our institution from 1995 to 2009 for any complications that were related to surgery. Patients with access gained at outside institutions or not attempted at the time of surgery by residents were excluded. The complication rate was compared with those of the American College of Radiology. An eight-question survey was also sent by e-mail to all current urology chief residents regarding their experience with PCNL access during residency. RESULTS: A total of 290 patients underwent PCNL with 338 separate access sites gained at the time of surgery under the supervision of nine teaching staff. Access was gained in all cases at the time of surgery. Major complications included: Transfusion in 20 (5.9%) patients, sepsis in 2 (0.6%) patients, pseudoaneurysm necessitating intervention in 2 (0.6%) patients, hydrothorax in 2 (0.6%) patients, pneuomothorax in 1 (0.3%) patient, ureteropelvic junction disruption in 1 (0.3%) patient, and one death (0.3%) after surgery. Minor complications included: Urinary tract infection in five (1.5%) patients, and collecting system injuries in 6 (1.8%) patients necessitating placement of a ureteral stent. Our survey of residents demonstrated that 53% did not routinely gain access for PCNL at their institution. The 94% who did not get instruction on PCNL access, however, thought it would be a valuable addition to their training. CONCLUSION: Our results show that access for PCNL surgery can be safely and successfully obtained by genitourinary residents under the supervision of trained staff at the time of surgery. We think that access for PCNL is a valuable tool that should be in the armamentarium of all urologic surgeons on leaving an accredited urology training program.