Robotic Vesicovaginal Fistula Repair with Buccal Graft Interposition

Complex vesicovaginal fistulas (VVFs) often require advanced reconstructive strategies. Robotic repair with graft augmentation offers a minimally invasive and durable option for patients with recurrent fistulas or compromised tissue from prior surgery or radiation. We present a case of robotic VVF repair using a buccal mucosa graft and omental flap interposition in a patient with a history of chemoradiation and multiple pelvic surgeries.

A 42-year-old woman with rectal cancer treated with chemoradiation and low anterior resection developed a posterior VVF following hysterectomy complicated by bladder injury and a subsequent colovesical fistula. Despite prolonged urinary diversion, she had persistent continuous leakage. Workup demonstrated a 1-cm posterior VVF and a fixed, shortened vagina. Robotic repair included bilateral ureteral stent placement, bi-valving bladder, wide tissue mobilization, and excision of the fistula tract. Owing to limited vaginal mobility, a 3 × 2 cm buccal mucosal graft was harvested and secured to the vaginal defect. A pedicled omental flap was interposed, with viability confirmed using indocyanine-green fluorescence. The bladder was closed in layers, and 100 units of intravesical onabotulinumtoxinA were administered to reduce postoperative spasms. A Foley catheter remained in place for 4 weeks post operatively with CT cystogram performed prior to removal.

The patient recovered uneventfully and was discharged on postoperative day 2. CT cystogram at 4 weeks confirmed fistula resolution. At 6 weeks, ureteral stents were removed, vaginoscopy demonstrated excellent graft healing, and the patient reported normal voiding without leakage.

This case highlights multiple key principals of complex VVF repair.