To demonstrate the steps involved in the vaginal repair of a large neobladder to vagina fistula.

A 56 y old woman underwent a neobladder reconstruction after radical cystectomy. Despite an uneventful recovery, she developed severe post-operative urinary incontinence not controlled by an indwelling urinary catheter. A definitive repair was offered transvaginally.

Fistula exposure can be obtained with a Lonestar retractor and headlights. Following catheterization of the fistula with a large council-tip catheter over a guide wire, the edges of the fistula were circumscribed. Vaginal flaps were raised, including posteriorly in search for the omentum which had been brought down at the time of the cystectomy. An omental flap was identified and fully mobilized. The fistula was closed with running absorbable sutures starting at each corner, with a final knot at the midpoint once the guidewire was removed. The watertightness of the repair was checked by filling the neobladder via a large 22 Fr urethral catheter (to allow mucus drainage secondarily). Then the omental flap was advanced as tissue interposition. The vaginal flaps were then re-approximated over the underlying repair with running and interrupted reinforcing absorbable sutures. The vagina was packed and belladonna and opium suppository was administered to minimize postoperative spasms. 

At 4 weeks post-repair, a cystogram was obtained to confirm neobladder integrity and definitive repair of the fistula. Patient resumed voiding efforts. At 8 months post-operatively, no recurrence has been noted. Patient has resumed sexual activity and her recent CT scan indicates no pelvic recurrence.

Vaginal repair of a neobladder to vagina fistula can be attempted. Following the principles of fistula closure, a tension free repair can be obtained followed by tissue interposition. A satisfactory outcome can be attained, obviating the need for a more morbid open repair.