Robotic repair of a branching vesicouterine and vesicovaginal fistula

Introduction and hypothesis We present technical considerations and tips for repairing a complex branching vesicouterine and vesicovaginal fistula via a robotic approach. Methods A 31-year-old female presented with constant urinary leakage following a vaginal birth after prior cesarean section. Evaluation with cystoscopy and cross-sectional imaging demonstrated a branching vesicouterine and vesicovaginal fistula. Repair with robotic-assisted approach was carried out. An intentional cystotomy was made with a tear-drop incision around the fistula tracts. The vesicouterine and vesicovaginal planes were dissected and mobilized. The vaginotomy and cystotomy were closed in a running two-layer fashion with absorbable suture and the uterine defect closed with interrupted absorbable suture. Retrograde bladder filling confirmed a watertight repair. A broad peritoneal flap was created, positioned, and secured with care to ensure it covered past the apex of the fistula closure. Results Following overnight observation she had an uneventful recovery, including catheter removal at 3 weeks after cystogram confirmed resolution of the fistula. At 6 weeks the fistula and her leakage remained resolved, with no de novo voiding or incontinence symptoms. Conclusions A robotic approach to complex branching vesicouterine and vesicovaginal fistula is technically feasible. Careful attention to surgical technique and the use of tissue interposition may improve fistula resolution rates.