Vesicocervical fistula repair. We do not have anything to disclose. Our patient is a 28-year-old G1P1, status post a primary low transfer C-section, secondary to arrest of dilation and failure of descent. She presented to our clinic with urinary incontinence after her C-section. A blue dye test was positive, as well as a cystoscopy with a fistula seen 4 centimeters above the left ureteral orifice and slightly to the midline. During the pelvic exam, there was a fistula straggled in the cervix at the 11 o'clock position, which was communicating with the bladder. This type of fistula is most often seen after a caesarean delivery and represents 1 to 4% of the urogenital fistulas. In this video, we illustrate the surgical steps needed to repair a vesicocervical fistula. Omental adhesions are separated from the anterior wall of the uterus using short bursts of caudary interaction. The omentum is completely separated from the uterus. The bladder peritoneum is incised, separating the bladder from the vagina, cervix, and anterior wall of the uterus. A vaginal probe is inserted to assist in peritoneal dissection. The third robotic arm is used for traction. This allows a surgeon to utilize the other two robotic arms for dissection, traction, and counter-traction. The bladder is then mobilized away from the cervix using short bursts of caudary interaction. The fistula's tract is identified. Good exposure is essential for excision of the fistula's tract. The bladder is gently mobilized away from the anterior vaginal wall The bladder is gently mobilized away from the anterior vaginal wall, cervix, and anterior uterine wall. This process is done with care to ensure a safe dissection without injury to the bladder. The edges of the fistula's tract are excised and removed. The bladder, anterior vaginal wall, and anterior uterine wall of the fistula's tract is identified. The anterior vaginal wall is separated from the bladder. Adequate hemostasis, traction, and counter-traction is used throughout the dissection. The dissection is continued with adequate margins are seen between the bladder and vaginal wall. One to two centimeter margins are seen after the dissection is completed. The ureters are identified. The edges of the bladder fistula's tract are excised and removed. Caution is taken not to injure the ureters in the process. The end result of the dissection is shown here. The bladder submucosis is re-approximated using 3-O-Vicrol in a running fashion. Adequate approximation of the bladder submucosis Adequate approximation of the bladder submucosis is an essential step in the repair. A second layer closure of the bladder defect in a running fashion is shown here. The bladder is filled with 300 cc's of saline to ensure water-tight closure. A 3-O-Vicrol is used for the third layer closure of the bladder wall defect. All knots are tied intracorporeally with robotic assistance. The end result of the three-layer closure and repair of the bladder is shown here. A 2-O-PDS with a leprothyte is used to reconstruct the endocervical canal up to the level of the anterior uterine wall. A 2-O-PDS with a leprothyte is used to reconstruct the endocervical canal up to the level of the anterior uterine wall. A leprothyte is applied after the repair is completed. The vaginal wall defect is then closed with 2-O-PDS with a leprothyte. A leprothyte is applied to the end of the suture. The end result of the repair is shown here. The omentum is then gently grasped, mobilized, and gently placed over the anterior uterine wall and vaginal wall. The omentum is then tucked into the vesicovaginal space and fixed in place with 3-O-Vicrol sutures. Three more sutures are used to anchor the omentum on both sides of the vesicovaginal space. The end result of the omental flap is shown here. Cystoscopy is done and both ureters are noted to be patent and functioning. For more information visit www.osho.com OSHO is a registered Trademark of OSHO International Foundation

surgical repair

vesicocervical fistula

urinary incontinence

C-section

bladder peritoneum