Robotic  vesico-vaginal fistula  repair (R-VVF) was described in 2004 with the aim to minimize the morbidity of the abdominal VVF repair. Almost two decades later, the literature on r-VVF remains scant. The objective of this study was to assess the outcomes of R-VVF and to compare the transvesical and extravesical techniques.

The charts of all female patients who underwent a R-VVF from March 2007 to December 2021 at four academic institutions were reviewed retrospectively. All surgeons involved had already a robust robotic surgery experience at the beginning experience (>50 cases) but limited experience with VVF repair. All abdominal VVF repair over the study period were performed using a robotic approach. All centers used a vaginal approach in case of easily accessible vaginal fistulous orifice. The decision to use a vaginal or an abdominal approach was not standardized across centers and left at the surgeons’ discretion. The patients’ characteristics, the surgical technique details (iflap interposition vs. not, transvesical versus extravesical approach, excision of fistulous tract vs not) and peri-operative outcomes were recorded. The success of VVF-R was defined as the absence of clinical recurrence. The outcomes of the extravesical vs transvesical techniques were compared.

Twenty-two patients were included over the study period.  the median age was 43 years (IQR 38-50). The causes of VVF-R were either post-surgical (77.3%), post-obstetrical (18.2%) or post-trauma (4.5%).  Fistulas were supratrigonal and trigonal in 18 and 4 cases respectively. The fistulous tract was systematically excised and an interposition flap was used all but two cases (90.9%%). The transvesical and extravesical techniques were used in 13 and 9 cases respectively. The patient andfistula’s characteristics are presented in table 1. There were more supratrigonal fistula in the extravesical group (100% vs. 69.2%; p=0.11). One intraoperative complication occurred in the extravesical group: an ureteral injury which was immediately sutured (11.1% vs. 0%;p=0.41). The operative time tended to be shorter in the extravesical group (179 vs. 229 minutes;p=0.13). There were only three postoperative complications, all minor: one gross hematuria in the extravesical group (Clavien grade 1), one hematoma requiring blood transfusion and one pyelonephritis  in the  transvesical group (both Clavien grade 2) (11.1% vs. 15.4%; p=0.99). The length f hospital stay did not differ significantly between the to groups (5.1 vs. 4.1 dys; p=0.56). None of the patients had vesico-vaginal fistula recurrence after a median follow-up of 14 months (IQR 3-21).

The present series, one of the largest R-VVF reported to date, is consistent with the few series already published with a 100% cure rate and excellent perioperative outcomes. Systematic excision of the fistulous tract and the high rate of flap interposition may explain the high success rate. The transvesical and extravesical approach yielded similar outcomes but the transvesical approach may allow to treat more complex fistulas (e.g. infratrigonal)

Robotic vesicovaginal fistula repair is feasible with a very high success rate and a low perioperative morbidity. The transvesical and extravesical techniques seem to yield similar outcomes but the transvesical technique may allow to treat more complex cases.

Continence 2S2 (2022) 100268
DOI: 10.1016/j.cont.2022.100268