Genitourinary fistulas are abnormal communications between the female genital tract and the urinary bladder, ureter or the urethra. Surgery for genitourinary fistulas have evolved over years and the robotic approach has particularly been in vogue lately, for its excellent results and the minimal morbidity it causes. We share our experience of robot assisted laparoscopic repair of genitourinary fistulas and our journey through the different phases of the learning curve.

It is a retrospective analysis of prospectively maintained data of patients who underwent robot assisted laparoscopic repair of genitourinary fistula from March 2018 to March 2022 was done. Preoperative evaluation included a detailed history, cystovaginoscopy and a contrast enhanced cross-sectional imaging. In case of vesicovaginal fistula, vesicocervical fistula and vesicouterine fistulae repair, after placing ureteral catheters in both ureters and feeding tube into fistula , four eight mm ports were placed transperitoneally. After performing adhesiolysis and posterior mini cystotomy, fistula was identified and a plane was created between the bladder and vagina. Vaginal defect  was closed transversely followed by sigmoid epiploicae or omental flap interposition flap placement between the bladder and vagina. Thereafter, bladder closure was done with V lock sutures in a vertical fashion. In case of ureterovaginal fistula (UrVaF) repair, ureter was dissected till the level of fistula and transected. Posterior mini cystotomy was done and ureter was reimplanted into the bladder.

Thirty- five patients of genitourinary fistulas underwent surgery of whom twenty two had vesicovaginal fistula, eight had ureterovaginal fistula, three had vesicocervical fistula and two had vesicouterine fistula . The largest fistula was 3 cm in size. The mean age of patients was 38.33 years. The mean operative time was 178.46 minutes. The mean blood loss was 58.85 ml. The median duration of hospital stay was three days .

Success rate in our study was 85.7% with five failures in complex cases.  All the failure cases had delayed presentation of urinary leakage from fistula site, partly attributed to metabolic concerns (uncontrolled diabetes) in two patients. We identified the different phases of our learning curve based on the level of consciousness and competency, and could retrospectively narrow down our strengths and weaknesses, thus helping others to make our identifiable weakness, their strength.

Robot assisted laparoscopic repair is a feasible and effective method of genitourinary fistula repair with shorter learning curve. The da vinci robot, with its efficient endowrist technology and a highly magnified 3-D vision, helps reach the narrow inaccessible pelvic space easily and perform complex reconstructive surgeries with precision. Our journey through the different phases of learning curve will surely be a pole star for numerous young robotic surgeons embarking on the path of robot assisted repair of genitourinary fistulas.