Robotic-Assisted Simple Peritoneal Flap for Cystostomy Repair After Cesarean Delivery

INTRODUCTION: Cystostomy is the most common genitourinary tract injury during cesarean delivery. One of the principles of bladder repair is watertight closure, which can be achieved by repairing in multiple layers or using a native tissue flap such as the omentum. The peritoneal flap has been widely used in pelvic reconstructive surgery including Davydov peritoneal vaginoplasty, vesicovaginal fistula repair, and radical prostatectomy due to its simple and minimal invasive harvesting technique. OBJECTIVE: This video demonstrates a robotic-assisted cystostomy repair with peritoneal flap due to extremely thin bladder wall after the patient sustained a bladder injury during repeat cesarean delivery. METHODS: We present a clinical case of a 34-year-old G4P4 status post an elective repeat low transverse cesarean delivery complicated by 7-cm bladder injury at the bladder dome. The cystostomy was repaired in two layers with 3-0 polyglactin. The bladder mucosa was noted to be extremely thin intraoperatively. On postoperative day 4, the patient had severe abdominal pain and low urine output. CT abdomen and pelvis showed extensive extravasation of bladder contrast without evidence of bowel obstruction or ileus. After extensive counseling, the patient opted for robotic-assisted cystostomy repair with possible peritoneal flap, cystoscopy, and ureteral stents. The procedure started with bilateral ureteral catheter placement and Indocyanine green (ICG) injection. The bladder was retrogradely filled with 300 cc normal saline. The leakage area was reapproximated with two layers using 3-0 polyglactin in simple interrupted fashion. The third layer closure was performed with 3-0 Vloc in continuous non-locking fashion. The watertight test was positive with methylene blue. The peritoneal flap was performed by mobilizing the peritoneum with adipose tissue overlying the left medial umbilical ligament toward the left round ligament border. Care was taken to avoid injury of the obturator nerve and blood vessels. The peritoneal flap was buttressed over the bladder mucosa with 3-0 polyglactin in simple interrupted fashion. The watertight test was negative. A JP drain was placed in the left lower abdomen. Bilateral ureteral catheters were removed. A ureteric double J stent was placed on the left. RESULTS: The total operative time was 150 min with 20 cc of blood loss. Postoperatively, pain and urine output were improved. She was discharged home on postoperative day seven. The JP drain was removed at her 3 weeks post-op visit after reviewing JP drain output of 20–50 cc daily and normal fluid Cr of 0.9. Fluoroscopy cystogram at 6 weeks post-op showed no contrast extravasation. The Foley catheter was removed. The left ureteral stent was subsequently removed. CONCLUSIONS: The simple lateral peritoneal flap is a viable option to repair bladder injury when there is a need for extra layer closure, and the omental flap is not feasible. It is a minimally invasive technique that can be performed with laparoscopy or open technique. However, care needs to be taken to avoid injuries to obturator nerve and blood vessels.