Robotic Repair of Complicated Vesico-[utero]/Cervicovaginal Fistula after Cesarean Section.

Study Objective: To demonstrate intra- and postoperative steps in a successful management of a complicated vesico-[utero]/cervicovaginal fistula.

Design: Stepwise demonstration of the technique with narrated video footage.

Setting: A urogenital fistula in developed countries mostly occurs after gynecologic surgeries but rarely from obstetric complications. The main treatment of a urogenital fistula is either transvaginal or transabdominal surgical repair. We present a case of a 36-year-old woman, gravida 3 para 3-0-0-3, who developed a complicated large vesico-[utero]/cervicovaginal fistula after an emergent repeat cesarean section. Robotic repair was performed 2 months after the injury using the modified O'Connor method. Blood loss was minimal, and the patient was discharged from the hospital 1 day postoperatively. Follow-up showed complete healing of the fistula with no urine leakage, frequency of urination, or dyspareunia. The patient resumed normal bladder function and menstrual period up to 4 months after the repair procedure.

Interventions: The basic surgical principle of urogenital fistula repair is demonstrated: (1) development of vesicovaginal spaces by dissection of the bladder from the uterus and the vagina, (2) meticulous hemostasis, (3) adequate freshened of the fistula edges, (4) tension-free and watertight closure of the bladder. We also demonstrate some other techniques that have developed though our own practice: (1) facilitating bladder distention by temporarily blocking the fistula, (2) placement of a ureteral catheter to protect the ureters, (3) interposition with omental flap, (4) single layer through and through closure of a cystotomy with 2-0 V-Loc suture (Covidien, Irvington, NJ).

Conclusion: Complicated urogenital fistulas may be repaired successfully using minimally invasive surgery using robotic assistance, enabling less blood loss, faster recovery, shorter hospital stay, and fewer complications, etc.