This video will describe the perioperative management and the procedural steps of a robotic-assisted laparoscopic repair of a vesicovaginal fistula with an omental J-flap interposition. Traditionally, a vesicovaginal fistula is repaired using a vaginal approach. However, there are limitations to this approach, especially in the case of fistulas localized high in the vagina near the vaginal apex. Due to these limitations, high-vesicovaginal fistulas have been traditionally repaired via laparotomy. Laparoscopic approach offers a minimally invasive alternative to these repairs with all its benefits. Laparoscopic repair of a vesicovaginal fistula should be considered if the fistula tract is located high in the vagina and above the interureteric ridge, when the tract is in close proximity to the ureters and in patients with minimal apical vaginal descent. Historically, surgical repair of high-vesicovaginal fistulas has been performed via laparotomy. The urinary bladder can be reached extra or transperitoneally. The excision of the fistula tract and repair can then be performed using transvesicle or extravesicle technique. The transvesicle O'Connor repair warrants large cystotomy to obtain adequate access and visualization. Contrary, extravesicle repair results in significantly smaller bladder defect during the entire repair. The minimally invasive laparoscopic approach to vesicovaginal fistula repairs was introduced in the 1990s. Due to technical challenges of conventional laparoscopy, this approach has not been widely adopted. Robotic-assisted laparoscopy, introduced in the mid-2000s, offers a minimally invasive alternative to the repair of vesicovaginal fistulas while minimizing the shortcomings of conventional laparoscopy. The preoperative workup should be focused on diagnosing and characterizing the complexity of the urogenital fistula, including the evaluation of ureteral involvement. Laparoscopy plays a key role in the preoperative workup. Other diagnostic tests should be used judiciously. The key to the timing of a successful surgical repair is the readiness of the tissues to minimize the risk of recurrence. Factors to consider when deciding on timing of the surgery include etiology of the fistula formation, size of the fistula, and presence or absence of active pelvic infection. Often, the repair is delayed for approximately 6 to 12 weeks after the inciting gynecologic surgery to allow the acute inflammatory reaction of surrounding tissues to subside. The surgery should begin with cystoscopy to identify and mark the fistula's tract. A soft-ended guided wire is cystoscopically introduced through the fistula tract into the vagina and a ureteral axis catheter is passed over the guide wire. This serves to facilitate the identification of a fistula tract and allows for easier dissection when approaching the fistula laparoscopically. We stent the ureters only if the fistula tract lies in close proximity of the ureters. Once the robot is docked, the bladder and vagina are identified with the assistance of a manipulator inserted in the vagina. Distention of the bladder by retrofilling can facilitate identification of its margins. The vesicovaginal space is then dissected and the fistula tract identified with the goal of creating minimal cysto and copotomy. Sufficient separation of the bladder from the vagina to allow a tension-free closure is critical for the success of the repair. The edges of the fistula tract are trimmed to expose healthy bladder wall. The cystotomy is then closed in a traditional two-layer fashion using 3-0 delayed-absorbable running sutures. The first layer is closed with a through-and-through suture that approximates the mucosa. The second layer is a running suture imbricating the bladder muscularis. The bladder should be then retrofilled with fluid to confirm a watertight closure. Copotomy is then closed in one layer with a 2-0 delayed-absorbable running suture, preferably in a perpendicular direction to the bladder closure to minimize overlapping of the suture lines. An omental J-flab can be created with mobilization of the omentum, with placement using reverse Trendelenburg positioning and attachment primarily to the vagina. Alternatives to using the omentum include a peritoneal inlay or using epiploica of the sigmoid colon. Postoperatively, a Foley catheter is left in the bladder for 7 to 14 days to allow continuous drainage of urine to gravity. Prior to removal of the Foley catheter, we always perform a retrograde cystogram to confirm bladder integrity. In this presentation, we have described a robotic-assisted laparoscopic approach to a vascovaginal fistula repair. This approach has been associated with decreased morbidity, decreased blood loss, and a shorter recovery and should be implemented whenever possible compared to the conventional open approach.

perioperative management

robotic-assisted laparoscopic repair

vesicovaginal fistula

omental J-flap interposition

minimally invasive alternative