We are presenting a video of a robotic assisted laparoscopic repair of the large vesicovaginal fistula. The patient was a 42-year-old female who had a bladder injury at the time of abdominal hysterectomy. After that, the patient had a vesicovaginal fistula with an unsuccessful transvaginal repair 10 months later. She was referred to our center for a repair of her 4-centimeter fistula up high in the vagina. We started the case with using a 22 French cystoscope with a 30-degree lens. A pancystoscopy was done visualizing the fistula tract. An index finger was placed through the vagina to identify the fistula. The ureteral orifices were identified using a 0.035 glide wire followed by a 5 French ureteral catheter stenting of the right ureter was done without difficulty. This was repeated again on the left side. A vaginoscopy was performed visualizing the fistula tract at the vaginal cuff. We can see the difference between the transitional epithelium of the bladder and the non-keratinized stratified squamous epithelium of the vagina. A 16 French double lumen poly catheter was placed from the vagina into the bladder through the fistula tract. And here we can see the right ureteral orifices and the left ureteral orifices with a catheter in place. Now we are switching to a robotic abdominal view. As we can see, the bladder was distended with a 360 of normal saline as well as an EE assizer was placed in the vaginal cuff. A longitudinal cystotomy using a monopolar scissors starting posteriorly at the bladder down and carried down toward the fistula tract. Here we can see cutting the detrusor muscle and opening the bladder mucosa and we can start seeing the foley bulb. An alternative method of entering the pubocervical space is to cut between the bladder and the vagina. After that, the foley which was coming from the vaginal site was pulled out from the cystotomy site to help with the traction. As we can see, the EE assizer and the vagina as well. The cystotomy incision was extended down toward the tract. After that, mapping of the fistula tract was done in a circumferential fashion. As we can see, the right UO. This mapping was done using the monopolar scissors and was done all around the fistula tract. As we can see, the EE assizer is at the vaginal cuff helping with the traction. After that, using a laparoscopic needle, laparoscopic hydrodistension was done using lidocaine 1% solution with epinephrine. A total of 20 milliliters was used to hydrodissect the space between the bladder and the vagina. As we can see, the blanching of the tissue from the hydrodissection. At that point, sharp dissection and debridement was done of the fistula edges until obtaining a healthy bleeding tissue. And as well, this helped create a tension-free vaginal flap to be re-approximated in the midline and for repair. When dissection was done, it was done without using any energy to preserve the vascularity. As we can see here, the flap was created in all directions and can be easily re-approximated in the midline without any tension. After that, using a 3-O-Vicro suture on a CT2 needle, closure of the vaginal mucosa was done in a longitudinal fashion in a running suture. Care was taken not to interlock the suturing so as not to compromise the vascular supply. The closure was carried down up to the vaginal cuff and the suture was secured with using a PTS Laparotie. Attention was made to the bladder where the closure of the bladder mucosa was done using a 3-O-Vicro suture in a running fashion starting from the right systotomy angle. Bladder closure is done in a transverse fashion not to draw the urethral orifices to the midline and possibly cause urethral obstruction. And this will carry less risk than doing it in the longitudinal fashion. As we can see, the suturing was carried down to the midline from the left side. This was followed by closure of the systotomy starting from the right side and again going toward the midline. Once the two sutures met in the midline, they were tied together securing the first layer of the bladder closure. At that point, a second layer was started using a Laparotie and this was done to imbricate and reinforce the first layer and to obtain a watertight closure. To notice that the Laparotie is placed on the vesicovaginal space not inside the bladder mucosa to prevent any irritation or stone formation. Once the suturing and the imbricating layer was finished, this was secured using a Laparotie. At that point, filling up the bladder with a 300cc of normal saline to assure a watertight closure. As we can see, the vesicovaginal space has an excellent hemostasis as well as we can see that the bladder closure and the vaginal closure are in opposite direction. This will further prevent any recurrence of the fistula. A preferred method of obliterating the space between the vagina and the bladder would have been using a Nomental Flap, however, in our case, this was not possible secondary to prior surgeries. We decided to proceed with the placement of a Repliform Matrix Delmar Graft instead. A 3 ovicles suture was placed at the angle between the vagina and the bladder and a pulley stitch was made. The suture was passed through the Dermis Graft and this was secured into the space without any immobilization. At that point, a Flow Seal Hemostatic Matrix was placed between the graft and the tissue to secure hemostasis. This robotic assisted laparoscopic approach provided us with excellent visualization, easy tissue dissection, and minimal blood loss. Four weeks after surgery, the patient had a Cysto-Urethrogram, revealed no extravasation of the contrast, and four months after surgery, the patient continues to have a urinary continence. These x-rays demonstrate an intact bladder without extravasation of urine in the vagina. Thank you. www.ottobock.com

robotic assisted laparoscopic repair

vesicovaginal fistula

bladder injury

abdominal hysterectomy

transvaginal repair