gms | German Medical Science

Introduction: Vesicovaginal fistula (VVF) formation represents a condition with devastating consequences for the patient and continues to pose a significant challenge to the surgeon. Quick and accurate diagnosis, followed by timely repair is essential to the successful management of these cases. To minimize the morbidity of classical fistula repair, we hereby present a new minimally invasive surgery technique to perfom a fistulae repair of inside closing without transcutaneous, laparoscopic or vaginal incision: transurethral surgery- natural orifice translumenal endoscopic surgery (TUS-NOTES) by using a new small fine needle holder and knot pusher.

Setting: A rigid cystoscope with 30 degree optics is inserted into the patients bladder with CO(2) insufflation. After inspecting the bladder and finding the fistulae orifices the fistulae area is manipulated with an endoscopic hooklet. The bladder segment is excised with electrocautery. First the monocryl 4-0 fibre is put into the needle holder. To fit into the needle is bended. The needle is put loose next to the cystoskope put into the bladder and after touching the wall the fibre is fixed at the end of the needle holder with a clamp. Now by a rotation the whole is at both sides stiched. With a grasp –put through the working channel- the needle is grasped and by loosing the clamp everything can be pulled out. By tying an extracorporal knot and putting an knot pusher over the fibre, the knot is fixed. This procedure is repeated till the whole is closed. The fibres are cutted. Equipment needed:Cystoscope with 30 degree optics, CO(2) insufflation, 1 mm diameter Needle holder (MRSD-Ney), Monocryl 4-0, 0.5 mm diameter Knot pusher, Cystoscopic grasp, Cystoscopic scissor.

Results: The aim of the presentation is to show the TUS-NOTES technique and teach the viewer how to apply this novel intervention to close the fistulae inside of bladder at 6 cases.The mean operative time was 55 min (35 min-110 min), whereas the blood loss was less 10 ml. The patients were discharged 3 days after surgery, and the catheter were removed 10 days after surgery.

Conclusion: To reduce morbidity and prolonged recovery of excision of the VVF, TUS-NOTES technique is efficacious and the preferred method of intervention.

Competing interests: Dr J. Neymeyer was paid for teaching and speaking on behalf of SERAG, AMS and ETHICON. Other authors declare no financial disclosure.