Vesicovaginal fistulas are a public health issue. In western countries, they are mostly iatrogenic after of pelvic surgeries or radiotherapy. 
Currently, there is no consensus on the best repair technique of those vesicovaginal fistulas. 
The aim of this video is to present a technique of vaginal vesicovaginal fistula repair in prone with a Martius labial interposition flap position.

We present the case of a 67-year-old female, with a poorly compliant neurogenic bladder and intrinsic sphincter deficiency due to spinal cord injury
Following a pubovaginal fascia sling who induced traumatic self-catheterizations, a vesicovaginal fistula occurred with a 2cm diameter orifice located next to the bladder neck.  
A vesicovaginal fistula repair with a Martius labial interposition flap through a vaginal approach was planned. It was decided to use a prone position because the bladder neck and fistula orifice were sticked over the anterior vaginal wall due to the pubovaginal fascia sling making it very challenging to get proper exposure in the lithotomy position.

The operative time was 130 minutes. The procedure begins with an inverted U vaginal  incision. 
During dissection between bladder and vagina, the fascia sling that modify the bladder neck position was visualized and cut. 
The Bladder and vaginal edges of the fistula orifice were  widely excised and the bladder was closed in a vertical axis. 
The Martius flap was harvested in the right labia majora and preserving the inferior pudendal artery to ensure proper bood supply. The Martius flap was then brought and interposed between the bladder and vaginal sutures. 
The anterior vaginal wall was closed longitudinally. A suprapubic and indwelling urethral catheters were placed for three weeks. The hospital stay was three days long. There has been no recurrence of the fistula after 10 months follow-up.

The prone position may be helpful for Vaginal Vesicovaginal fistula repair with a Martius labial flap interposition might be helpful for some urethral or bladder neck fistulas, offering a better visualization and surgical exposure