Vesicocervical fistula (VCxF) is an extremely rare entity among all the urogenital fistulas. Due to upsurge of caesarean section rate associated with prolonged labor, obstructed labor and rise in instrumental deliveries, cervicovaginal tears and inadvertent vaginal suturing, VCxF is no more limited to text. The differentiation of VCxF from vesicovaginal fistula (VVaF) is crucial as the former requires great skill for repair.

A 31 year, 150cm tall, P2L2 lady had previous 2 lower segment caesarean section (LSCS) 8 years and 4 years ago respectively. Her first caesarean delivery was done for second stage arrest in a private setup. She had spontaneous onset and progress of labor at 38.3 weeks, with total duration of first and second stage of labor  >24 hours. Her operative, immediate and late postoperative period was uneventful following which she had her second pregnancy after a span of four years. Her antenatal period was uncomplicated till she went into spontaneous labor at 37.2 weeks gestation, and opted for trial of labor after caesarean section (TOLAC). She delivered a 2.8kg baby by an emergency LSCS for fetal indication in advanced labor. She had urinary leakage from vagina on postoperative day 7. CT urography showed a 3.1 cm VVaF, while cystovaginoscopy showed two fistulas, VCxF and Vesicouterine (VUtF).
Patient underwent a Robotic VUtF and VCxF repair following which she had delayed urinary incontinence 4 weeks post catheter removal. Cystovaginoscopy showed a small 0.5cm supratrigonal fistula 3cm above the right ureteric orifice communicating with and a 0.5cm right juxtacervical fistula. Patient underwent cystoscopic fulguration with Bugbee cautery  six months after the previous surgery.  Patient again had continuous urinary leakage two months post catheter removal, although the amount was reduced to half.
Patient underwent a repeat cystovaginoscopy revealing same fistula sites in bladder and cervix, confirmed by dye test. Although the complete fistulous tract was not negotiable, the guide wire directed into the vaginal fistulous orifice had a false paracervical tract, the lateral edge of which was in the fistulous tract and was used as a pointer for localisation of cervical end of the tract. Robotic vesicocervical fistula repair with omentum interposition flap was planned. Port placement and docking was done. Peritoneoscopy and adhesiolysis was begun in pelvis. Localisation of exact direction of dissection was guided by the dimple of traction on guide wire partially in the fistulous tract. Mini-cystostomy was done to locate the ureteric orifices and with repeated intermittent traction given by the assistant sitting on vaginal end. Proceeding which, a plane was made between the posterior bladder wall and anterior vagina. The dissection plane was deepened further down posterior to bladder till the guide wire was visible and extended 1cm beyond it. A fistulous tract and its surrounding unhealthy bladder mucosa, extending from the lateral cervical edge to the bladder side wall was excised. After mobilising the bladder well away from the excision site, cervicovaginal layer and bladder was sutured with omental flap interposition. This was followed by placement of drain, and removal of trocars and skin closure.

Patient’s drain was removed on postoperative day two and discharged with catheter for  three weeks. Patient is under regular follow up  and is doing fine.

Vesicocervical fistula repair is one of the most difficult urogenital fistulas for diagnosis and repair. Role of Bugbee cautery in small VCxF did not prove helpful as opposed to its proven role in uncomplicated small VVaF. Robotic route of VCxF repair provides excellent results compared to transvaginal VCxF repair oughing to better dexterity, visualization and ease in identification and repair.

Continence 2S2 (2022) 100398
DOI: 10.1016/j.cont.2022.100398