Vesicovaginal fistula (VVF) is a rare but serious complication that may occur following a hysterectomy. Recently, the use of robot-assisted approaches to manage VVF has been increasing. These approaches include traditional transvesical techniques and less commonly used extravesical techniques.

We present a case of a 45-year-old woman who presented with de novo medical refractory urinary incontinence for 6 months following laparoscopic hysterectomy for uterine myoma. Cystoscopy revealed a VVF located just proximal to the inter-ureteric ridge and near left ureteral orifice. We planned a robot-assisted extravesical VVF repair with ureteric stenting.

The fistula was identified with cystoscopy, and bilateral ureteric stents were placed. An 8 Fr. Foley catheter was trans-vaginally passed through the fistula tract to outline its course. The robotic surgery was initiated with a standard 3-arm setting for pelvic surgery and one 10-mm accessory port. During the entire procedure, minimal electrocautery was utilized to maintain tissue integrity. The peritoneum was first incised at the vesico-vaginal junction area. The fistular tract was identified, dissected, and then incised to reveal the catheter in tract. The vesico-vaginal plane was dissected to show the intact bladder and vaginal defects. The bladder defect was closed in two layers with 3-0 V-Loc sutures, while the vaginal defect was closed in single layer with 2-0 Vicryl. The interposition of fat or omentum was optional. The bladder was filled with 200ml of normal saline for the watertight test, and one JP drain was placed after closing the peritoneum with running sutures. 

We have performed five cases of robot-assisted extravesical VVF repair with a 100% success rate and a minimum of six months of follow-up. Perioperatively, the mean console time was 77.2 ± 20.3 minutes, and all patients had minimal blood loss and no complications. The mean duration of urethral catheterization was 8.6 ± 2.6 days (range from 7-13 days).

We have demonstrated that robot-assisted extravesical VVF repair is a safe and less invasive option, with rapid recovery and a high success rate.

Continence 7S1 (2023) 101025
DOI: 10.1016/j.cont.2023.101025