Robotic Approach to Vesicovaginal Fistula Repair Utilizing an Omental Flap

Objectives: This case highlights the surgical technique of a robotic assisted vesicovaginal fistula repair, utilizing an omental flap for tissue interposition

Methods: Our patient is a 29-year-old who underwent repeat cesarean after failed TOLAC due to arrest of descent. Her surgery was complicated by an 8cm cystotomy adjacent to a significantly thinned lower uterine segment. Identification of the surgical planes was challenging but the cystotomy was ultimately closed in two layers with absorbable suture, with an imbricating layer. The patient was discharged on post-operative day 4 with an indwelling catheter.
Patient presented on post-operative day 14 for retrograde cystourethrogram which revealed a small amount of extravasation at the apex of the bladder dome with apparent filling of the endometrial canal raising suspicion for a vesicouterine fistula and decision was made to keep foley in place for additional 2 weeks. Repeat cystourethrogram on post-operative day 28 showed persistent extravasation of contrast. At this time, the decision was made to remove the foley catheter.
Her recovery was ultimately complicated by persistent urinary leakage when supine and with a full bladder. She was seen by Urology where a cystoscopy was performed with posterior bladder wall grossly abnormal, with fistulous tract supratrigonal on the lower posterior aspect of the bladder left of midline and a few cm from the ureteral orifice. Outpatient pelvic examination was unsuccessful in identifying the fistulous tract. Patient was then counseled regarding findings with Urology and Urogynecology and decision made to proceed with surgical correction with a robotic approach.
In this video, we demonstrate a step-wise robotic approach to successfully identify and repair a high vesicovaginal fistula

Clinical Relevance: This case demonstrates how robotic assisted approach to vesicovaginal fistula repair is appropriate and effective when there is a high fistula that is not accessible vaginally, fistulas involving the uterus, and surgeon preference. The video highlights the technique of using an omental flap for interposition to improve tissue healing.