Robotic-Assisted Laparoscopic Repair of Post-Hysterectomy Vesicovaginal Fistula Using Omental Interposition Flap

STUDY OBJECTIVE: To demonstrate, via robotic-assisted laparoscopy, a transperitoneal technique for repair of post-hysterectomy vesicovaginal fistula (VVF) using an omental interposition flap. DESIGN: Video article. SETTING: University Hospital and referral center for Gynaecological disease. PATIENTS OR PARTICIPANTS: A 52-year-old woman with VVF after laparoscopic hysterectomy. INTERVENTIONS: Repair of post-hysterectomy VVF with omental flap interposition. MEASUREMENTS AND MAIN RESULTS: A 52-year-old woman with a history of menorrhagia refractory to medical treatment underwent a total laparoscopic hysterectomy and bilateral salpingectomy. Histology of the uterus showed multiple uterine fibroids and adenomyosis. Twelve days following the hysterectomy, she developed leakage of urine per vagina. Computed tomography scan and cystourethrogram demonstrated normal ureters and presence of a vesicovaginal fistula. An indwelling catheter was inserted to rest the bladder and allow the acute inflammation surrounding the fistula to subside prior to definitive surgical repair six weeks later. The repair consisted of seven steps: 1. Restoration of anatomy; 2.. Opening the vaginal vault; 3.. Identification of fistula defect; 4.. Resection of fistula tract; 5.. Dissection of vesicovaginal space; 6.. Closure of vesical and vaginal defects; 7.. Interposition of omental graft: The patient was discharged 48 hours after surgery. The indwelling catheter was maintained for 14 days. Cystourethrogram was carried out to confirm the integrity of the bladder prior to catheter removal. There was no further vaginal loss. Clinical follow up at six weeks and three months post-repair showed no bladder or vaginal dysfunction. CONCLUSION: Robotic-assisted laparoscopy is a feasible approach for repair of VVF, which can be performed systematically using seven steps. This technology lends itself well to procedures requiring intricate dissection and multi-layered suturing as demonstrated in this case.