Urethrovaginal fistula (UVF) can result in severe stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD) in some instances. The therapeutic approach can be staged but some authors have reported vaginal UVF repair with concomitant pubovaginal sling insertion. Fistula located at the proximal urethra/bladder neck can be challenging to repair through a vaginal approach. In the present video, we report and describe a new robotic surgical technique aiming to treat concomitantly urethrovaginal fistula and severe SUI due to ISD

We present the case of a 49-year-old female patient with a history of vesicovaginal fistula after hysterectomy for fibroids. After open transvesical vesicovaginal fistula repair she presented a bladder neck stricture along with bilateral ureteral stricture. She underwent an open bilateral ureteral reimplantation. Self-dilation of her bladder neck stricture was initiated and resulted in a UVF. She underwent a vaginal bladder neck reconstruction and UVF repair with Martius flap interposition. Unfortunately, a UVF recurrence was observed at 1 month postoperatively, located at the bladder neck, with severe SUI, a positive cough stress test and a fixed urethra. Several options were discussed with the patient including an ileal conduit.  After discussion, a robotic UVF repair + rectus fascia sling insertion was planned.

Five ports are placed. The Da Vinci Xi robot is docked on the left side of the patient (side docking).   A malleable retractor is inserted in the vagina for vault manipulation. The intervesicovaginal dissection is carried out and difficult due to severe adhesions between the bladder and vaginal walls. The urethrovaginal fistula is intubated with a ureteral catheter and the fistulous orifice is found. The dissection is pursued to separate the bladder neck from the vagina distally, beyond the fistulous orifice to allow tension-free vaginal and bladder neck closure. To facilitate proper visualization of the fistulous orifice the posterior bladder wall is incised on 5 cm medially The vaginal and bladder neck fistulous orifices are excised and specimens ar sent for pathological examination. The vaginal orifice is closed by two V lock running sutures transversally and the bladder is closed longitudinally with two V lock running sutures as well. A passage around the bladder neck for the fascial slign is created by dissecting the vaginal fornices on both sides of the bladder neck, with an assistant’s finger placed in the vagina to put tension on the vaginal wall and facilitate its dissection. 
To harvest rectus fascia sling, a 7 cm suprapubic incision is made and carried down to the rectus fascia. A 10x1.5 cm rectus fascial sling is harvested. The fascia is then closed using two running sutures. The fascial sling is inserted through the 12 mm assistant port and placed around the bladder neck. 
The sling is sutured above the fascia by the assistant An omental flap is then harvested and sutured between the vagina and the bladder neck, below the fascial sling with a V lock. Two tissue layers are then interposed between the bladder and vaginal sutures

The operative time was 290 minutes with estimated blood loss of 100 ml. There was no postoperative complications. The patient was discharged on postoperative day 2. The urethral catheter was removed at day 14 and the patient resumed spontaneous voiding with post-void residual of 20 ml. At 6 months, she is socially continent, wearing 1 pad per day and there has been no UVF recurrence

Robotic urethro-vaginal fistula repair and concomitant fascial sing insertion appears feasible. The technique can be of help in female patients with UVF and SUI due to ISD in case were a vaginal repair is challenging to allow a one-stage surgical treatment.

Continence 2S2 (2022) 100395
DOI: 10.1016/j.cont.2022.100395