V1-07: Robotic-Assisted Extravesical Vesicovaginal Fistula Repair With Omental Flap
Vesicovaginal fistula (VVF) repair involves a transabdominal or transvaginal approach. The open transabdominal approach is limited by its higher morbidity, longer convalescence, and potentially more difficult access depending on anatomy and prior surgical history. The transvaginal approach has multiple advantages, including avoiding a laporotomy, shorter convalescence, and ability to use local interpositional flaps. However, it is limited by potential vaginal shortening and restricted visibility and exposure. The robotic-assisted VVF repair heralds the advantages of the transvaginal approach but is notable for improved visibility, preservation of vaginal length, and success rates reportedly reaching 98.4%.
We present a case of a 43 year old woman who developed a VVF after undergoing a total abdominal hysterectomy for fibroids. Pre-operative CT urogram and office cystoscopy confirmed the diagnosis (image 1). She underwent a robotic-assisted extravesical VVF repair utilizing an omental flap that was mobilized laparoscopically at the start of the case. We demonstrate the technique and feasibility of this approach.
She underwent a successful robotic repair of her VVF with minimal blood loss and was discharged on post-op day #1. A cystogram at 2 weeks post-op revealed no evidence of fistula, and she was dry and satisfied at 3 months post-op.
The robotic extravesical approach to repair a VVF avoids the morbidity of a laparotomy, provides excellent visualization and exposure, and avoids a large cystotomy. It allows the surgeon to maintain vaginal length and allows for significantly better visualization compared to the transvaginal approach. Omental flap interposition can also be used to separate suture lines after VVF repair. Ultimately, the ideal approach to VVF repair is the one the surgeon is most comfortable at performing.