Robotic-Assisted Repair of a Vesicovaginal Fistula: Key Considerations and Best Practices

INTRODUCTION: A vesicovaginal fistula (VVF) is an abnormal epithelial connection between the bladder and vagina, typically presenting as continuous urinary leakage. This condition commonly arises from obstetric or gynecological injuries. In developed countries, vesicovaginal most frequently occur as a complication of gynecological surgeries. They are categorized as either simple or complex. Complex cases include those with prior failed repair attempts, a history of radiation therapy, fistulas larger than 2 cm, involvement of the trigone, or concurrent ureteric strictures. Robotic-assisted surgery offers enhanced visualization, also maintaining the benefits of minimally invasive techniques. OBJECTIVE: To illustrate step by step a vesicovaginal fistula repair case with omentum interposition. To exemplify the retrograde catheterization of the fistulous tract from the vagina to the bladder. METHODS: 47-year-old female patient with a history of bleeding uterine fibroids underwent a total laparoscopic hysterectomy. On postoperative day 4, she was re-intervened with an exploratory laparotomy for having an acute surgical abdomen, observing a collection of urine and an incidental lesion in the posterior aspect of the bladder; cystorrhaphy and drainage were performed. Following discharge, the patient reported continuous urinary leakage and experienced recurrent urinary tract infections (UTIs). At 6 weeks post-surgery, a CT urogram identified a 1.5-cm vesicovaginal fistula (VVF). The patient was subsequently scheduled for robotic-assisted VVF repair. The procedure included diagnostic cystoscopy and vaginoscopy to locate and cannulate the fistula tract using a stent, followed by trans-abdominal fistula repair with the interposition of an omental flap to reduce the risk of recurrence. RESULTS: The operative time was 68 minutes with an estimated blood loss of 50 cc. The JP drain was removed on postoperative day 3. The Foley catheter was removed on postoperative day 10. No intraoperative complications were observed. At the 3-month follow-up, the patient remained asymptomatic. CONCLUSIONS: The importance of fistula tract cannulation in accurately identifying the fistula tract during transabdominal repair. The dissection of the surgical planes to obtain a tension-free suture. The convenience of using omentum as interposition tissue to prevent recurrence of the fistula (Figure 1).