Vesicovaginal fistula (VVF) is a recognized complication following gynecologic surgeries. In developed countries, 75%–90% of VVFs are attributed to hysterectomy. Other causes include pelvic irradiation, obstetric trauma, malignancy, and infection. The incidence of VVF post-hysterectomy is estimated at 0.1%–2.0%, depending on variables such as the surgeon, patient characteristics, and surgical instruments. The most common symptom is continuous urinary leakage through the vagina. Other symptoms include recurrent urinary tract infections, vaginal irritation, and malodor, which typically present several weeks postoperatively [1].

In cases where the VVF is diagnosed within a few weeks postoperatively and measures ≤5 mm, conservative management with prolonged Foley catheterization may be considered. However, surgical repair is usually required, as epithelialization of the fistulous tract is likely to occur within a few months after the initial injury. Surgical repair is generally delayed 3–6 months post-injury to allow inflammation to subside [2,3].

Traditionally, VVFs have been managed via either a transabdominal or transvaginal approach, with the route determined by the size and location of the fistula. Transvaginal repair is preferred for small, simple, and distal vaginal fistulas, while complex or large fistulas located proximally may necessitate a transabdominal approach [4]. Studies have reported success rates ranging from 75% to 97% for operative VVF repairs. Notably, a systematic review indicated an overall success rate of 96% across various surgical techniques, with vaginal repairs achieving 93.1% success and abdominal approaches reaching 96.3%. Another study highlighted that the success rate for VVF repair can be as high as 85% to 95% when performed by experienced surgeons [5]. However, in clinical practice, success and recurrence rates vary depending on multiple factors such as tissue condition, prior surgeries, degree of adhesions, and anatomical characteristics.

In recent years, robotic surgery has been increasingly utilized across various urologic procedures, including VVF repair, with excellent outcomes. The evolution toward minimally invasive, precise surgery has introduced the single-port (SP) robotic system, which offers superior visualization and precision in confined spaces such as the bladder. We present a case of VVF repair using a SP robot system via a pneumovesical approach, avoiding the peritoneal cavity in a patient with severe adhesions from previous surgeries.

A 57-year-old female presented with persistent urinary leakage per vagina, which had worsened over the past 2 months. She had undergone total hysterectomy with bilateral salpingectomy via a multi-port robotic approach for a large uterine myoma 6 months earlier. Her surgical history included three cesarean sections, spaced 2 years apart approximately 30 years ago. The operative note described severe intra-abdominal and pelvic adhesions.

Initially misdiagnosed as stress urinary incontinence, her symptoms persisted, including continuous leakage during sleep and rest. Cystoscopy revealed a clean, round 7-mm fistula opening located 2 cm left of midline at the trigone-posterior wall junction (Fig. 1). Irrigation fluid was observed draining directly into the vagina. Pelvic MRI confirmed a fistulous tract between the posterior bladder wall and proximal vagina with contrast filling the vaginal cavity (Fig. 2).

Figure 1. Cystoscopy showing a 7 mm round fistula opening located approximately 2 cm left of the midline, near the trigone-posterior wall junction.

Figure 2. Pelvic MRI showing a fistulous tract communicating between the posterior bladder wall and the anterior proximal vagina, with contrast leakage filling the vaginal cavity.

Given the lesion’s location and expected severe adhesions, a transabdominal approach was deemed challenging. Thus, we opted for a transvesical SP robotic repair via a pneumovesical approach, avoiding peritoneal entry.

The patient was placed in lithotomy position and prepped. Cystoscopy was first performed, and bilateral ureteral catheters (5 Fr) were placed to identify the ureteral orifices. A Foley catheter was then inserted. A 3-cm transverse incision was made 2 cm above the symphysis pubis, exposing and opening the Retzius space. The anterior bladder wall was incised transversely (2.5 cm), and a SP access port was installed (Fig. 3).

Figure 3. Incision site for single-port robotic docking. No additional ports were required.

The patient was repositioned to a 13° Trendelenburg, and the SP robot system was docked. A Maryland forceps and a monopolar curved scissors were used on the left and right arms, respectively. Under robotic visualization, careful dissection of the bladder mucosa was performed, maintaining >0.5 cm margin from the fistula opening to avoid ureteral injury. The fistula tract was sharply dissected to separate the bladder mucosa from the vaginal wall while preserving the tract integrity.

The right robotic arm was replaced with a needle holder, and the vaginal wall was sutured using 3-0 barbed suture material. The bladder mucosa was then closed in a watertight manner using the same suture. The port site was closed after undocking, followed by subcutaneous and skin closure (Supplementary Video 1).

The total operative time was 90 minutes with negligible blood loss. Oral intake resumed the next day. The patient was discharged on postoperative day 4 with the Foley catheter in place. A cystogram on postoperative day 7 showed no contrast leakage at either the repair site or the bladder port site, and the Foley catheter was removed (Fig. 4). The patient reported no urinary leakage and resumed normal voiding. Follow-up at 3 months confirmed sustained continence and resolution of symptoms.

Figure 4. Cystography on postoperative day 7 showing no contrast leakage at the fistula repair site or the port insertion site.

VVF is the most common urogenital fistula in women, leading to continuous urinary incontinence and significant quality-of-life deterioration. While conservative treatment is rarely effective, surgical repair remains the gold standard. The primary goal of surgical management is complete excision of the fistula tract and watertight closure, restoring anatomical and functional integrity. Surgical strategy should be individualized based on fistula characteristics, etiology, prior surgical history, and comorbid conditions.

Minimally invasive surgery, including laparoscopic and robotic-assisted techniques, has become increasingly popular. Laparoscopic VVF repair, first reported in the late 1990s, allows for precise dissection with excellent visualization. However, its steep learning curve and technical challenges in cases with severe adhesions or deep pelvic anatomy can limit its utility.

A systematic review of 44 studies published between 1994 and 2014 compared laparoscopic and robotic-assisted VVF repair techniques, focusing on transvesical and extravesical approaches. The review included case reports, case series, and one retrospective cohort study, excluding open and vaginal repairs. Success rates ranged from 80% to 100%, with no significant difference between the transvesical (95.89%) and extravesical (98.04%) techniques. The number of closure layers and use of interposition flaps did not significantly impact outcomes [2].

In patients with dense adhesions or inaccessible fistulas via the peritoneal route, alternative approaches are warranted. Pneumovesical techniques, in which the bladder is insufflated to create a working space, have shown promise. Jeon et al. [6] retrospectively analyzed 26 laparoscopic pneumovesical VVF repairs over 10 years, reporting an 88.5% primary success rate, 99.9-minute operative time, and 11-day catheter duration.

The SP robotic pneumovesical approach offers several advantages for confined-space surgery like VVF repair. Benefits include direct access to the fistula without traversing adhesions, minimal instrument collision, improved dexterity, and superior visualization. It also allows for smaller skin incisions, less postoperative pain, and better cosmetic outcomes. The anatomical fidelity maintained during bladder insufflation facilitates precise dissection and closure.

Our patient experienced significant psychological distress due to persistent urinary leakage following prior surgery. Postoperatively, she reported minimal pain, rapid dietary advancement, and early discharge. At 3 months, she remained symptom-free and fully continent.

Our patient experienced significant psychological distress due to persistent vaginal urinary leakage following prior surgery. However, she expressed high satisfaction postoperatively, reporting minimal pain, rapid dietary advancement, and early discharge. At 3 months, she remained symptom-free and fully continent.

Limitations of this technique include the inability to perform tissue interposition, traditionally used to reduce recurrence. In cases with large or high-risk fistulas, an omental flap via transabdominal approach may still be preferable. Additionally, the high cost of robotic systems remains a consideration.

SP robotic VVF repair via a pneumovesical approach is a simple and effective method that offers reduced operative time and recovery period. It enables precise dissection and suturing, even by less experienced surgeons. This technique may be particularly advantageous in patients with severe adhesions or contraindications to abdominal entry.

All authors have no conflicts of interest to declare.

No external funding was received for this research.

None.

Conceptualization: WBK, YHK. Data curation: WBK. Methodology: WBK, KWL. Project administration: WBK, YHK. Resources: WBK. Software: WBK. Supervision: KWL, YHK. Validation: SWL, JMK. Writing – original draft: WBK. Writing – review & editing: WBK, YHK.

Video 1. This video demonstrates the single-port robot-assisted repair of a vesicovaginal fistula via a pneumovesicum approach using the da Vinci SP robotic platform.