Vesicovaginal fistula, a robotic approach by Dr. Shakiba and Dr. Petrikovits. This clip demonstrates the initial injury that eventually resulted in a vesicovaginal fistula. Seen here is poor exposure of the pubocervical fascia, leading to an incorrect assessment of anatomical boundaries, therefore leading to bladder injury via thermal damage. Seen here is the real location of the cervical cap, and the proper area of colpotomy is therefore depicted here. The presented patient is a 47-year-old G4, P2, who had a laparoscopic supracervical hysterectomy that was converted to a total laparoscopic hysterectomy because of cervical fibroid. She presented to us complaining of continuous leakage of urine from her vagina seven days post-operatively. Her history is significant for one cesarean delivery and an open myomectomy 10 years ago. CT urogram and office cystoscopy confirmed the diagnosis of vesicovaginal fistula. Patient then received five weeks of continuous Foley without spontaneous closure. Decision was made to then proceed with robotic fistula repair. The following few slides discuss the principles of vesicovaginal fistula repair. Each of these steps will be clearly demonstrated in the following video. Initially vaginoscopy and cannulization were performed, and the fistula tract was identified, located at the right side of the vaginal cuff, thereby allowing for stent passage through the tract cystoscopically. Then the previously passed stent was grasped cystoscopically and pulled through the urethra, thereby creating a loop. Finally, ureteral stents were placed, as seen here. Upon initial entry into the abdominal cavity, a thick omental adhesion was noted attached to the anterior abdominal wall, which was taken down and then attached to the left pelvic sidewall, as seen here. This omental adhesion was later used as the vesicovaginal flap. The initial view of the pelvis demonstrates significant adhesion formations. Seen here is extensive adhesionolysis performed around the vaginal cuff, done in an attempt to restore normal pelvic anatomy. After extensive lysis of adhesions, attention is turned to the vaginal cuff. The EEA sizer is used to push the vagina and rectum cephalad, thereby identifying the vesicovaginal junction. In this example, the bladder was densely adherent to the vaginal cuff, with dense rectal scarring. As seen here, retrofilling of the bladder is recommended to further delineate the complex pelvic anatomy. Visualized here is additional lysis of adhesions, which was performed to free the sigmoid cartilage colon from the vaginal cuff. Now with the bladder clearly identified, intentional cystotomy was performed, and the previously placed fistula stent loop was now identified through the cystotomy. After the fistula tract was identified, the surrounding adhesions from the bowel and bladder were well mobilized. Therefore, approximately 1-2 cm about the radius of the tract was mobilized from adhesions for tension-free closure of the cystotomy and colpotomy to follow later in the repair. Visualized here, the fistula stent loop is cut in half, and the vesicovaginal space is separated approximately 2 cm in depth, with good visualization of the ureter. Thereby mobilizing the surrounding tissue about the fistula tract, and therefore creating a tension-free closure of the tract. Now, the posterior aspect of the vagina surrounding the fistula is mobilized by dissecting it off the rectum, as visualized here. Once the fistula is tension-free and free of adhesions, the cystotomy is closed in two layers. The first layer is the rectum, and the second layer is the fistula. The first layer of the cystotomy is closed using 3-O-Vicryl in a running fashion. It is critical to apply the appropriate amount of tension to the suture to prevent tissue necrosis. The second layer of the cystotomy closure is performed using 2-O-Vicryl in a running fashion, involving the bladder muscularis and the peritoneum. After the second layer is placed, the bladder is backfilled again, thereby a water sealing check is performed to check for the integrity of the closure. After mobilization of the tissue about the colpotomy, closure of the colpotomy was performed using O-Vicryl via multiple figure of 8 sutures, as seen here. The previously created omental flap was now removed from the sidewall and attached within the vesicovaginal space using O-Vicryl and involving the fibromuscular connective tissue of the L-Vag space. Finally, repeat cystoscopy was performed and excellent closure of the fistula was confirmed. Both stents were removed and bilateral ureteral efflux with appropriate force was confirmed. One year postoperatively, patient has been asymptomatic.

robotic approach

vesicovaginal fistula

laparoscopic hysterectomy

urine leakage

vaginoscopy