Complex Vesicovaginal Fistula Repair Using Amniotic Allograft: A Case Presentation

INTRODUCTION: Vesicovaginal fistulas (VVFs) are the most common type of acquired genital fistula, with the most common cause being iatrogenic injury after hysterectomy, which accounts for 80% of the annual incidence. Complex VVFs can be further complicated by size, prior radiation, and anatomic position. In addition to traditional interpositional flaps, cryopreserved umbilical cord allograft can serve as an augmentation material to improve tissue healing. OBJECTIVE: We present a case of complex robotic VVF repair augmented with cryopreserved umbilical cord allograft, enhancing the healing environment with an additional regenerative barrier. METHODS: An 80-year-old female with a history of stage IIIC high-grade serous ovarian carcinoma underwent neoadjuvant chemotherapy followed by robotic hysterectomy and bilateral salpingo-oophorectomy complicated by intraoperative cystotomy and proctotomy repair. She subsequently developed complex simultaneous vesicovaginal and rectovaginal fistulas. She was diverted with an end colostomy by colorectal surgery and maintained a Foley catheter without resolution of her recto-vaginal-vesical fistula. After extensive counseling, she elected for surgical repair. The fistula tract was identified cystoscopically at the posterior bladder dome and upper vaginal vault. Robotic dissection was performed between the bladder and vagina to excise the tract and close the remaining healthy tissue. A colovaginal fistula was identified and repaired by colorectal surgery. There was inadequate tissue for an omental flap. Clarix 1K cryopreserved ultra-thick umbilical membrane allograft was bilayered and used to cover the vaginal and cystotomy repairs. Her drain was removed on postoperative day 1, and she was discharged home with a Foley catheter. RESULTS: At her 4-week postoperative follow-up, CT cystogram showed contrast pooling in the vagina, but no definitive fistula tract was seen. The patient maintained her Foley catheter, and additional follow-up imaging at 8 weeks with MRI pelvis confirmed no residual fistula. The patient’s leakage symptoms resolved. CONCLUSIONS: Success rates of conservative management for complex VVFs are poor, and many patients opt for surgical intervention due to their high morbidity and impact on quality of life, affecting not only physical health but also emotional, social, and economic well-being. Umbilical membrane allograft has a wide array of surgical applications due to its regenerative properties. Postoperative outcomes after fistula repairs rely on angiogenesis of healthy tissue and reduction in inflammation, which are regulated by the growth factors and cytokines delivered by the allograft. This biologic allograft serves as an additional treatment option in the repair of complex vesicovaginal fistulas.Figure 1Figure 2