Vesicouterine fistulas are uncommon in comparison to other urogenital tract fistulas in women, accounting for 1-4% of cases. Risk factors include cesarean delivery, dehiscence of uterine closure after repair, placenta percreta, and intrauterine device-associated injury. Presenting symptoms include leakage of urine per vagina, cyclic hematuria (Youssef’s syndrome), or, amenorrhea. Diagnosis of a vesicouterine fistula includes a high degree of suspicion based on history, physical examination, cystoscopy at the time of menses and MRI imaging. Other modalities such as cystogram or hysteroscopy can be utilized as well. In this video, we demonstrate a robotic-assisted laparoscopic approach to repair of a vesicouterine fistula.

The patient presented is a 33-year-old woman, G4P4 (4 cesarean sections), who noticed blood in her urine after her last cesarean section 4 years prior to presentation to our clinic. She was told that she may be having urinary tract infections and was treated with antibiotics. After several years, she realized that the hematuria was cyclic and associated with her period. She additionally noted occasional urine leakage per vagina. Given this history, she underwent MRI urogram and cystoscopy at the time of menses in our clinic. MRI demonstrated tethering of the urinary bladder to the c-section scar and endometrium abutting the urinary bladder lumen, concerning for a vesicouterine fistula. Cystoscopy at the time of menses demonstrated a fistulous opening at the dome/posterior bladder wall with blood emanating from the opening. She was counseled on proceeding with robotic-assisted laparoscopic repair of vesicouterine fistula and an informed consent for the procedure and video recording was obtained.

The patient was given pre-operative broad-spectrum antibiotics and placed in the dorsal lithotomy position, after induction of general anesthesia. Pneumoperitoneum was created via Veress needle and 5 ports were placed in a straight line (RIGHT: 12mm Air seal port, 5mm assistant port, 8mm robotic port; LEFT: 8mm camera port, 8mm robotic ports x 2). Da Vinci Xi robot was docked after patient was placed in steep Trendelenburg position. Monopolar scissors were placed in the right arm, bipolar forceps in the left arm, and prograsp for the assistant “fourth arm”. The procedure is detailed in the video with the following steps: (1) Dissection of vesicouterine space and identification of fistula (2) Closure of uterus (3) Pre-placement of omental tacking sutures (4) Closure of bladder and peritoneum (5) Omental flap interposition.

The patient was discharged on POD1 with a large bore urethral catheter for 2 weeks and oral contraception for 3 months to prevent menstruation and allow our repair to heal appropriately. Patient did well at short term follow-up with no complications. She additionally denied leakage of urine per vagina. Once removed from oral contraception, she will be evaluated for persistent bleeding with history and cystoscopy. This video details a step-by-step, minimally invasive approach to repair of a vesicouterine fistula and elucidates important anatomic considerations. 

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