This patient is a 53-year-old woman that developed a vesicovaginal fistula following an abdominal hysterectomy for uterine fibroids. Her surgical history was significant for three prior cesarean sections. Additionally, at an outside institution, she had previously undergone a transvaginal repair that was unsuccessful, followed by a second repair performed through an abdominal approach including bladder bivalving. Again, the fistula recurred and she was sent to our institution for further evaluation and management. Preoperative office cystoscopy was performed to aid in surgical planning. This revealed a functional right and left ureter. A large cystotomy scar can be seen running between both ureteral orifices and continuing to the dome of the bladder. The fistula is visualized. Note the anatomic distortion of the left ureter, leaving it in close proximity to the fistula as a result of the two prior repairs. Likewise, a CT urogram was performed to rule out concomitant upper tract injury. After discussion with the patient, given her history of two prior failed repairs, we proceeded with a robotic transvesical vesicovaginal fistula repair. The procedure started with cystoscopic placement of double J ureteral stents. The space of retzius was dissected to improve bladder mobility. A cystotomy is made at the dome of the bladder. Inadequate cystotomy is needed to allow for advancing the camera and arms through it without further tearing or stretching the bladder tissues. The suspected fistula site is gently probed to help elicit the exact location. A small incision is made around the fistula for better visualization using electrocautery on cut setting. The fistula seemed to be tracking at a steep angle. Therefore, a .035 guide wire was introduced through the assistant port and inserted through the fistula tract to guide the dissection. The wire is passed to the vagina and a vaginal dilator is inserted. Now that the tract is clearly seen, the fistula is mobilized. It is important to adequately mobilize the different tissue layers in order to properly close and repair the fistula in a tension-free manner. The initial layer closed is the vaginal mucosa and a running 2-O-Vicryl suture is used. During this closure, the guide wire is removed. The muscular layer of the bladder is dissected circumferentially allowing for subsequent tension-free closure. A running 2-O-Maxon suture is used to close this second layer. Particular attention is paid to avoiding obstructing the ureter when placing the suture. Again, mobilization of tissue layers is of utmost importance and the bladder mucosa is freed. The vaginal dilator is removed to relax tension. A 3-O-Maxon suture is used to close this third layer. Care is taken to avoid the left ureteral orifice. Following fistula closure, the ureters are observed for spill. The anterior cystotomy was closed in a standard running 2-layer fashion using absorbable suture. A suprapubic catheter was placed. Four weeks after surgery, CT cystogram revealed no recurrence of fistula. At six weeks, the ureteral stents were removed and cystoscopy revealed a well-heeled bladder. There was no fluid leakage from the vagina on speculum exam. In summary, a 3-layer closure is optimal in repair of a vesicovaginal fistula. It is important to adequately mobilize the tissue layers in order to achieve this multi-layer closure. A robot-assisted transvesical approach to vesicovaginal fistula repair is a useful technique, especially when previous surgical planes have been used in prior repairs and failed, as in this case. It maintains a minimally invasive approach and may avoid complications associated with an open abdominal approach.

vesicovaginal fistula repair

robotic transvesical approach

hysterectomy

double J ureteral stents

bladder mobility