Robotic fistula repair of multiple vesicovaginal fistulas using sigmoid epiploica: case report

Urogenital fistulas most commonly result from gynecologic surgery in well-resourced countries, with the most common surgery being a hysterectomy. These can be treated conservatively with catheterization or repaired transvaginally or transabdominally using open, laparoscopic, or robotic-assisted approaches. Most commonly, an omental flap is used to separate bladder and vaginal suture lines. However, in patients with significant omental adhesions, the sigmoid epiploica can be used. We present a case of a robotic-assisted repair of two vesicovaginal fistulas (VVFs) using interposition of sigmoid epiploica, with intraoperative identification of the fistulous tracts using ureteral stents. A 39-year-old female presented with new-onset urinary leakage for three months status-post a total laparoscopic hysterectomy and bilateral salpingo-oophorectomy for endometriosis. Cystourethrogram revealed a VVF. We completed a robotic repair of two VVFs using the sigmoid epiploica. This case is unique because we used the sigmoid epiploica to separate bladder and vaginal suture lines and used ureteral stents to assist in the identification of the fistulous tracts. Post-operative cystourethrogram revealed no persistent fistulas. Use of sigmoid epiploica is an excellent alternative to omental flap use in patients with extensive abdominal surgery or history of endometriosis who may be at risk for significant omental adhesions that would preclude the use of the omentum. Ureteral stents are an effective method of fistula identification in robotic surgery.