Maioli Rafael A, Macedo André R S, Garcia André R L, Almeida Silvio H M de, Rodrigues Marco Aurélio Freitas
Disciplina de Urologia, Departamento de Cirurgia da Universidade Estadual de Londrina. Paraná, PR, Brasil.
Int Braz J Urol. 2015 Sep-Oct;41(5):1030-1. doi: 10.1590/S1677-5538.IBJU.2014.0391.
: The purpose of this video is to present the laparoscopic repair of a VUF in a 42-year-old woman, with gross hematuria, in the immediate postoperative phase following a cesarean delivery. The obstetric team implemented conservative management, including Foley catheter insertion, for 2 weeks. She subsequently developed intermittent hematuria and cystitis. The urology team was consulted 15 days after cesarean delivery. Cystoscopy indicated an ulcerated lesion in the bladder dome of approximately 1.0cm in size. Hysterosalpingography and a pelvic computed tomography scan indicated a fistula.
: Laparoscopic repair was performed 30 days after the cesarean delivery. The patient was placed in the lithotomy position while also in an extreme Trendelenburg position. Pneumoperitoneum was established using a Veress needle in the midline infra-umbilical region, and a primary 11-mm port was inserted. Another 11-mm port was inserted exactly between the left superior iliac spine and the umbilicus. Two other 5-mm ports were established under laparoscopic guidance in the iliac fossa on both sides. The omental adhesions in the pelvis were carefully released and the peritoneum between the bladder and uterus was incised via cautery. Limited cystotomy was performed, and the specific sites of the fistula and the ureteral meatus were identified; thereafter, the posterior bladder wall was adequately mobilized away from the uterus. The uterine rent was then closed using single 3/0Vicryl sutures and two-layer watertight closure of the urinary bladder was achieved by using 3/0Vicryl sutures. An omental flap was mobilized and inserted between the uterus and the urinary bladder, and was fixed using two 3/0Vicryl sutures, followed by tube drain insertion.
: The operative time was 140 min, whereas the blood loss was 100ml. The patient was discharged 3 days after surgery, and the catheter was removed 12 days after surgery.
: Laparoscopy has advantages over open surgery in that it is associated with less pain, shorter length of hospital stay, better cosmesis, quicker recovery, and equal efficacy. Although cases of VUF are rarely noted, the laparoscopic skill obtained through other urological procedures suggest, that laparoscopic repair may be the procedure of choice for such cases (2). The reported operative time for the laparoscopic repair of VUF in the literature varies between 140 and 220 min (3). However, laparoscopic techniques should be considered as a mode of abdominal access and should not influence the method of surgical repair. Surgical success should depend on the adherence to good technique rather than the approach. Hence, this method appears to be a viable alternative for surgeons experienced with laparoscopic suturing techniques.
: Laparoscopic repair appears to be a viable alternative for surgeons experienced with laparoscopic suturing techniques.
本视频旨在展示对一名42岁剖宫产术后即刻出现肉眼血尿的女性进行腹腔镜膀胱阴道瘘修补术的过程。产科团队实施了包括插入Foley导尿管在内的保守治疗，为期2周。随后她出现间歇性血尿和膀胱炎。剖宫产术后15天咨询了泌尿外科团队。膀胱镜检查显示膀胱顶部有一个约1.0cm大小的溃疡病变。子宫输卵管造影和盆腔计算机断层扫描显示存在瘘管。
剖宫产术后30天进行腹腔镜修补术。患者取截石位，同时处于极度头低脚高位。在脐下中线区域使用Veress针建立气腹，并插入一个11mm的主操作孔。在左髂前上棘与脐连线中点处插入另一个11mm的操作孔。在腹腔镜引导下于双侧髂窝各建立两个5mm的操作孔。仔细松解盆腔内的网膜粘连，通过电灼切开膀胱与子宫之间的腹膜。进行有限的膀胱切开术，确定瘘管和输尿管口的具体位置；之后，将膀胱后壁充分游离远离子宫。然后用单根3/0薇乔缝线缝合子宫裂口，并用3/0薇乔缝线对膀胱进行两层水密缝合。游离一块网膜瓣并将其插入子宫与膀胱之间，用两根3/0薇乔缝线固定，随后插入引流管。
手术时间为140分钟，出血量为100ml。患者术后3天出院，术后12天拔除导尿管。
腹腔镜手术相对于开放手术具有优势，因为它疼痛较轻、住院时间较短、美容效果更好、恢复更快且疗效相当。尽管膀胱阴道瘘病例很少见，但通过其他泌尿外科手术获得的腹腔镜技术表明，腹腔镜修补术可能是此类病例的首选手术方式（2）。文献报道的腹腔镜膀胱阴道瘘修补术的手术时间在140至220分钟之间（3）。然而，腹腔镜技术应被视为一种腹部入路方式，不应影响手术修复方法。手术成功应取决于对良好技术的遵循而非手术入路。因此，对于有腹腔镜缝合技术经验的外科医生来说，这种方法似乎是一种可行的选择。
对于有腹腔镜缝合技术经验的外科医生来说，腹腔镜修补术似乎是一种可行的选择。
