Robotic Repair of Vesicovaginal Fistula: Step-by-Step Technique for Complex Scenarios

Introduction: Vesicovaginal fistula is a devastating condition often occurring as a complication of surgery or radiotherapy in women. Complex vesicovaginal fistula represents a challenge for repair. It includes fistulas ≥2.5 cm in size, with previous failed attempts at repair, postradiotherapy, involving the bladder trigone, with associated ureteral strictures, or other types of fistulas.1 Materials and Methods: This video shows the step-by-step surgical technique of the robot-assisted repair of vesicovaginal fistula in three different scenarios. The first case occurred after a sacrocolpopexy mesh erosion into the bladder and the vagina in a 60-year-old woman status postrobotic sacrocolpopexy, midurethral sling, and ventral mesh rectopexy who presented at 2 months with continuous urinary leakage per vagina. Cystoscopy showed exposed mesh on the right posterolateral wall. The second case occurred after an emergency hysterectomy with an associated bladder injury in a 33-year-old woman who presented with continuous urinary leakage per vagina. Cystoscopy showed a fistula localized in the trigone, medially to the right ureteral orifice. Surgical history is relevant for two failed attempts at repair, the first an open transabdominal approach and the second an open transabdominal–transvaginal (Martius flap) approach. The third case occurred postradiotherapy and had an associated rectovaginal fistula in a 56-year-old woman with a history of ovarian cancer treated with debulking surgery and chemoradiotherapy, who presented to the clinic because of the persistence of urinary leakage after conservative treatment. Surgical history is relevant for two debulking ovarian surgeries, failed colovaginal fistula repair, sigmoid resection, and urinary plus fecal diversion. Cystoscopy showed a vesicovaginal fistula located posteriorly in the trigone. Vaginoscopy showed a concomitant rectovaginal fistula. Results: All cases had the following steps in common. The patients were placed in the lithotomy position. A cystoscopy was performed to catheterize both ureters and the fistula tract, except for the first case where the mesh obstructed the passage of the wire. Open laparoscopic access was obtained, followed by adhesiolysis and omentum harvesting. In the last case, omentum was unavailable, and a vaginal flap was created. Next, the patient was placed in Trendelenburg position, and posterior cul-de-sac dissection was carried out. Posterior longitudinal cystotomy was made to expose and excise the fistula tract except for the last case where the approach was transvaginal. Subsequent steps for each case are shown in the video. Median perioperative and postoperative data were estimated blood loss 150 (interquartile range [IQR]: 100–225) mL, operative time 3 (IQR: 2.75–6) hours, hospital stay 2 (IQR: 2–5) days, follow-up time 23 (IQR: 13–24) months, no complications were seen, and no fistula recurrence occurred. Conclusions: Robot-assisted laparoscopic repair of vesicovaginal fistula is a safe and feasible management option, even in complex scenarios. No competing financial interests exist. Patient Consent: Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure. Music: www.epidemicsound.com Passing—Jakob Ahlbom (Royalty free) Runtime of video: 9 mins 44 secs