Robot-Assisted Uterus-Sparing Repair of a Vesicouterine Fistula 26 Years After Cesarean Section: A Case Report and Review of Surgical Techniques

TL;DR

A robot-assisted surgery successfully repaired a rare bladder-uterus connection 26 years after a cesarean section, preserving the uterus.

Contribution

Demonstrates a novel robot-assisted, uterus-sparing technique for repairing vesicouterine fistulas.

Findings

Robot-assisted repair preserved the uterus and achieved successful fistula closure.

Postoperative cystography confirmed no recurrence or defects.

The patient remained asymptomatic after the procedure.

Abstract

This video illustrates the surgical repair of a vesicouterine fistula (VUF) via a transperitoneal, robot-assisted, uterus-sparing approach.

In this video, we present a VUF that occurred after a cesarean section. The patient presented 22 years later with persistent hematuria. She underwent a uterus-sparing, robot-assisted repair via excision of the fistula tract. The uterus and bladder were closed in multiple layers with omental interposition.

The patient tolerated the procedure well. A follow-up cystography confirmed the absence of defects or fistula recurrence. She has remained asymptomatic since the surgery.

Our video demonstrates the feasibility of vesicouterine fistula repair with uterine preservation using an exclusively robot-assisted transperitoneal approach with omental interposition, yielding excellent results.

The online version contains supplementary material available at 10.1007/s00192-025-06304-w.

Full text

Introduction

Vesicouterine fistulas (VUFs) are abnormal communications between the uterus and the bladder, representing a rare subset of urogenital fistulas, accounting for 1% to 4% of cases [1–5]. The increasing global rate of cesarean sections has led to a rise in VUF incidence [3]. Clinically, VUFs present most commonly with cyclic hematuria (menouria), vaginal urinary leakage, or secondary infertility [6]. Although spontaneous closure is rare (approximately 5% of cases [1, 4]), most fistulas require surgical intervention.

This video illustrates the robot-assisted, transperitoneal, uterus-sparing repair of a VUF, highlighting a minimally invasive approach with omental interposition, performed 26 years after the index cesarean section.

Review of Similar Cases and Repair Techniques

The majority of VUFs are diagnosed within months or a few years after cesarean section, with delayed presentations, as in our case, being exceptionally rare [3, 7]. Youssef first described the classic presentation of cyclic hematuria in 1957 [6], whereas others reported variable intervals between cesarean delivery and fistula onset, ranging from months to over a decade [2, 5, 7]. Our case stands out, with a 26-year latency, one of the longest reported in the literature.

Surgical approaches to VUF repair vary:

• Transvaginal approach: suitable for small, low-lying fistulas but limited by access and visualization challenges [8].
• Transvesical–retroperitoneal approach (O'Connor technique): historically considered a standard for complex fistulas, allowing layered closure and omental interposition [9].
• Transperitoneal approach: offers optimal exposure, especially for high or complex fistulas [10]. The robot-assisted technique has gained popularity for its enhanced dexterity, 3D visualization, and precision, particularly in challenging dissections [11].

Key principles of VUF repair include:

• Complete excision of the fistulous tract
• Tension-free multilayered closure of the bladder and uterus
• Interposition of vascularized tissue (typically omentum) to reduce recurrence risk
• Bladder drainage for 10–14 days postoperatively

Our case aligns with these principles.

Case Report

A 48-year-old para 2 woman underwent a primary cesarean section in 1999, complicated by a postoperative hematoma requiring reoperation. A second cesarean section in 2004 revealed moderate adhesions but was otherwise uneventful.

Seventeen years later, she presented with persistent macroscopic hematuria. Cystoscopy revealed a posterior bladder fistulous opening above the trigone. Methylene blue testing was negative, and MRI confirmed a vesicouterine fistula.

Surgical repair was proposed, initially including hysterectomy, but the patient strongly desired uterine preservation.

A robot-assisted, transperitoneal repair was performed:

• Adhesiolysis and dissection of the vesicouterine space
• Excision of the fistulous tract
• Bladder closure in two layers with barbed sutures
• Uterine closure in two layers
• Omental interposition placed in the vesicouterine fold

Bladder integrity was confirmed intraoperatively. The patient was discharged on postoperative day 1 with a catheter. A cystography at day 14 showed no leakage, and she has remained asymptomatic since.

Conclusion

This case highlights the feasibility of robot-assisted, uterus-sparing VUF repair via a transperitoneal approach, even in cases with late presentation, decades after cesarean section. Preservation of the uterus may be considered in selected cases, emphasizing the importance of a multidisciplinary approach.

Our findings support the growing body of literature favoring minimally invasive robot-assisted techniques for VUF repair, which offer excellent outcomes with reduced morbidity.

Supplementary Information

Below is the link to the electronic supplementary material.Supplementary file1 (MP4 64883 KB)