Functional Medicine Early Robotic Repair of Vesicouterine Fistula: A Case Report and Literature Review Othman J. Alamoudi * , Mohammed A. AlTheneyan, Naif Aldhaam, Maher Moazin Riyadh, Saudi Arabia article info Article history: Received 22 December 2016 Accepted 11 January 2017 Keywords: Early robotic surgery Vesicouterine fistula repair With frank hematuria abstract As cesarean sections become a more common mode of delivery, they have become the most likely cause of vesicouterine fistula formation. The associated pathology with repeat cesarean deliveries may make repair of these fistulas difficult. Early robotic-surgery offers a 3-dimensional view of the operative field and allows for intricate movements necessary for complex suturing and dissection. These qualities are advantageous in vesicouterine fistula repair. 42 years old female day 12 post-LSCS in author hospital with history of bladder injury and folly’s catheter in place since OR complain of gross hematuria for 8 days. Ó 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Introduction Vesicouterine fistulas are an uncommon phenomenon. Since the first case reported by Knipe in 1908, these fistulas have been esti- mated to account for 1e4% of all genitourinary fistulas. 1,2 During the first half of the century, prolonged labor and vaginal obstetric procedures contributed to the formation of vesicouterine fistulas. In 1957, Youssef reported on the syndrome which now bears his name: bladder injury during cesarean delivery that causes ves- icouterine fistula formation. The classic symptoms of Youssef’s syndrome are amenorrhea and cyclic hematuria coinciding with time of expected menstruation, or menouria. 3 As lower uterine segment cesarean deliveries have increased in popularity, they have become the more common cause of vesicouterine fistula formation. 4 Treatment options include conservative management, such as bladder decompression with indwelling Foley catheter or medical management to induce amenorrhea to aid in fistula healing. Sur- gical removal of the fistulous tract, historically via laparotomy, is also an option. As minimally invasive surgery becomes utilized more frequently in both gynecologic and urologic procedures, laparoscopic and even robotic-assisted laparoscopic repair of ves- icouterine fistulas are viable treatment options. 5e8 We present the case of a robotic-assisted laparoscopic repair of a vesicouterine fistula occurring after a patient’s fourth cesarean delivery. Case report A 42 year old lady P4þ1 she has a history of 3 previous caesarean section and Dilation and Evacuation (D&E), medically free. She was admitted to our hospital in 22/4/2012. She is post-Low Segment Caesarean Section (LSCS) day 12 was done in other hos- pital, she has a history of bladder injury and catheter in place since the operation, we do not know if the patient had a history of voiding problem because she came already with folly catheter, she came to us complain of hematuria it was light since the Operation but it’s start to be frank hematuria with clots before 8 day, she does not define incontinence. On examination the abdomen was soft and lax with mild suprapubic tenderness not radiated, the Patient vital was stable, her lab investigation Na 138 mmol/L, K 3 mmol/L, creatinine 63 mmol/L, urea 6.9 mmol/L, WBC 5.72 Â 10e9/L, HBG 11.1 Â 10e9/L, platelet 397 Â 10e9/L, urinalysis was negative and culture also show no growth, prothrombin time (PT) 10.4 s, INR 0.9. The Patient went to CT scan and shows ureterovesical fistula (Fig. 1). The Patient underwent Robotic Early Vesicouterine Fistula Repair under General Anesthesia, supine position, the procedure was done successfully with minimal blood loss and without any complication. And the sample was send to the histopathological lab for more investigation. The sample shows extensive fibrosis, congestion, acute and chronic inflammation (Fig. 2A, B). After the operation the patient tolerating well orally, moving around the word, she was in mild pain, the urine output (clean) without hematuria passing flatus, the drain was 23 cc/24 hr (hea- moserous) fluid in the first 2 day post-op and in the third it was 19 cc/24 hr. She does not developed fever and the wound was clean, * Corresponding author. E-mail address: dr.otalamoudi@gmail.com (O.J. Alamoudi). Contents lists available at ScienceDirect Urology Case Reports journal homepage: www.elsevier.com/locate/eucr 2214-4420/Ó 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). http://dx.doi.org/10.1016/j.eucr.2017.01.006 Urology Case Reports 11 (2017) 76e78