Interdisciplinary Approach to Evaluation and Repair of a Complex Post-Cesarean Fistula

INTRODUCTION: Genitourinary fistulae in the postpartum period are a rare complication of cesarean delivery and obstructed labor. Various methods of repair have been described, including abdominal, vaginal, and minimally invasive techniques. Surgical approaches to repair are influenced by fistula type, size, location, and cause. OBJECTIVE: This video presents the diagnostic workup and interdisciplinary planning involving urogynecology, urology, and reproductive endocrinology (REI) for a complex vesico-utero-vaginal fistula following cesarean delivery. A total abdominal hysterectomy and transvesical fistula repair were performed with surgical technique and key anatomic landmarks highlighted in the video. METHODS: A 31-year-old para 1 female presented with continuous large volume urinary incontinence 6 weeks following cesarean delivery and was found to have a large complex vesico-utero-vaginal fistula, confirmed by CT urogram and exam under anesthesia. The cervix was noted to be discontinuous from 10 to 12 o'clock and continuous with the posterior bladder, trigone, and anterior vagina. Interdisciplinary discussions regarding fertility-sparing options and outcomes for future fertility following surgical repair were held between REI, urogynecology, and urology. Ultimately, open abdominal transvesical repair with interposition omental flap and concomitant total abdominal hysterectomy were performed as a co-case with urology and urogynecology at a tertiary hospital. RESULTS: After consultation with REI, the patient decided against a uterine-sparing repair secondary to antepartum risks associated with a uterine-sparing procedure. Due to the complex nature of the fistula, an abdominal transvesical approach was used for fistula repair and total abdominal hysterectomy, which were completed without complication. The video highlights the key steps for successful fistula repair, including dissection and excision of the fistula tract, tension-free watertight, double-layer bladder closure, use of a well-vascularized tissue flap, and postoperative bladder drainage. A CT cystogram was performed 4 weeks postoperatively without demonstration of urinary leakage. The patient was asymptomatic 7 weeks postoperatively. CONCLUSIONS: Genitourinary fistulae are a rare complication of cesarean delivery and obstructed labor. Complex fistulae may require an interdisciplinary approach and evaluation prior to surgical repair. In reproductive-aged patients, counseling about antenatal risks and risk of recurrence with uterine conservation should be reviewed when discussing uterine-sparing repairs.