Repair of Vesicovaginal Fistula in 12 Steps Using the da Vinci Surgical System
To demonstrate the feasibility and effectiveness of a stepwise robotic-assisted vesicovaginal fistula (VVF) repair following oncologic surgery and adjuvant therapy. University teaching hospital. A 60-year-old woman with stage IIIC1, grade 2 endometrial carcinoma developed VVF following total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, sentinel lymph node sampling, and six cycles of carboplatin, paclitaxel, and Dostarlimab. After failed conservative management with Foley catheter and bilateral nephrostomies, the patient underwent robotic-assisted VVF repair. Conservative management was prolonged beyond the typical 6-week trial to allow completion of adjuvant treatment, with continuous bladder drainage and nephrostomies maintained. This approach is supported by literature indicating early postoperative fistulas may close spontaneously with adequate diversion, particularly when small, uninfected, and not radiation-related [1]. However, persistent leakage, failed closure, and impaired quality of life necessitated surgery. Repair was conducted approximately 6 weeks after primary surgery and adjuvant chemotherapy, during a treatment-free interval. This timing was selected to: (1) allow tissue recovery, (2) confirm absence of active disease, and (3) address significant symptoms and quality-of-life burden. This aimed to optimize tissue condition and vascularity for successful closure while minimizing undue delay in cancer treatment. The VVF repair performed in 12 systematic steps, as detailed in the video. The surgery was completed robotically, with removal of the nephrostomy tubes and placement of a Foley catheter, left in place for 14 days. The patient was discharged on postoperative day 1. Follow-up imaging confirmed fistula closure and restored continence. At submission, the patient has 6 months of follow-up with no fistula recurrence, voiding dysfunction, or need for additional urinary diversion. This case illustrates the efficacy of a stepwise robotic VVF repair, offering precise dissection, enhanced visualization, and successful anatomical and functional restoration. VIDEO ABSTRACT.