Robotic Repair of Complex Vesicovaginal Fistula with Cervical Reconstruction

Objectives: To demonstrate a unique case presentation of a successful repair of a complex vesicovaginal fistula repair using a robotic-assisted approach with a concurrent anterior cervical lip reconstruction. The cervical defect was a noted sequela of a prior cesarean section injury.

Methods: We present a video of a 31-year-old para G3PA0 who presented to our institution for evaluation and management of a complex vesicovaginal fistula noted at the apex just anterior to the anterior cervical lip. A 3cm anterior lip cervical defect was also noted on exam under anesthesia which required repair. The patient’s past surgical history was notable for three prior cesarean sections; the last of which occurred four months prior to her presentation and was significant for a hysterotomy extension into the lower uterine segment down to the level of the anterior cervix. The patient initially presented to an outside facility on post-operative day ten after her cesarean section for leakage of urine per vagina, at which time her vesicovaginal fistula was confirmed on CT Urogram.
The surgery began with cystoscopic evaluation of the fistula, which was noted to be approximately 3cm in diameter and located on the posterior dome of the bladder just superior to the trigone. The right and left ureteral orifices were noted to be 3cm distal to the fistula and both were stented cystoscopically using 5 Fr open ureteral catheters. The surgery continued using a robotic-assisted approach. Dense adhesions between the uterus, bladder and anterior abdominal wall were lysed, followed by robotic dissection of adhesions between the bladder, vagina and cervix. This was continued until the level of the vesicovaginal fistula was reached. A small anterior colpotomy was made to aid in visualization of the fistula. Once delineated, the vesicovaginal fistula was mobilized and edges were excised. The edges of the fistula were repaired in two layers robotically in a running non-locked fashion with water-tight seal confirmed. The cervical defect was then repaired robotically in a running non-locked fashion, followed lastly by closure of the anterior colpotomy in a running non-locked fashion. Hemostasis of the surgical field was noted throughout the case. The patient was ultimately discharged on post-operative day one with a foley catheter in place. A post-operative CT Urogram was obtained on post-operative day 15 noting negative bladder leak, and the patient’s foley catheter was removed.

Clinical Relevance: This case demonstrates a feasible and successful minimally invasive approach to repairing an unusual presentation of a complex vesicovaginal fistula with concomitant cervical reconstruction.