This is a case of a 44-year-old female who underwent total abdominal hysterectomy, left salpingo-oophorectomy, and right salpingectomy for a 10 cm leiomyoma. Post-operatively, she developed a vesicovaginal fistula located adjacent to the left ureteral orifice, which significantly affected her quality of life with persistent urinary leakage through the vaginal canal. Given the high risk of a ureteral injury when repairing a fistula in close proximity with the ureteral orifice, a decision to perform a transabdominal vesicovaginal repair combined with a non-transecting ureteroneocystostomy was made, highlighting the importance of a multi-disciplinary approach in complex surgical cases.

The procedure began with a cystoscopy that confirmed the defect (Figures 1 and 2). Bilateral open-ended ureteral stents were easily placed, and retrograde pyelography showed no ureteral fistula or obstruction. A midline incision was done and was carried down to the peritoneal cavity. The bladder was identified and opened. The fistulous tract was excised transvesically before debriding the area. The defect in the vaginal septum was closed using absorbable sutures. An omental flap was mobilized and brought down to cover the fistula site (Figure 3). The ureter was identified extravesically. With minimal dissection, a side-to-side non-transecting ureteroneocystostomy was performed to “create” a neo-orifice at the level of the bladder dome, minimizing risks of devascularization, fibrosis and subsequent obstruction. This was done by performing a ventral ureterotomy at the level of the middle ureter and a posterior cystotomy. No attempt was made to completely mobilize the distal ureter. The side to side anastomosis between the bladder and ureter was performed using interrupted vicryl 4-0 sutures. The bladder was closed in two layers—from seromuscular to mucosal—to ensure a watertight seal. Double J stents were placed. To maintain bladder drainage, a French 20 suprapubic catheter and a French 24 urethral catheter were inserted. Total operative time was 4 hrs. The ureteroneocystostomy per se only took 1 hour.

The patient was discharged on the 7th postoperative day, with antimuscarinics to prevent bladder spasms. One month postoperatively, the patient reported no more leakage. A repeat cystogram did not show the previously noted fistula. The urethral catheter was removed, and the suprapubic catheter was clamped after discontinuation of anti-muscarinic medication. The patient was able to void freely without any signs of incontinence. A repeat cystoscopy 6 months postoperatively, showed a completely healed repair site. A retrograde pyelogram was performed at the ureteroneocystostomy site, revealing no leaks and confirming that the native ureter was patent (Figure 4). Stents were removed.

In conclusion, the non-transecting ureteroneocystostomy technique is a promising alternative for ureteral re-implantation, aiming to preserve the blood supply and potentially reduce recurrence rates of strictures, or in this case, provide an easier way to perform a prophylactic ureteral reimplantation to avoid any injury while performing a transvesical repair of a vesicovaginal fistula. Studies have shown successful outcomes with minimal complications, making it a feasible and effective approach over the standard transecting ureteronocystostomy. The reported success rates of 87.5% to 93.8% at short to medium-term follow-up indicate its potential as a novel management strategy for distal ureteral strictures and other case such as a supplementary management in vesicovaginal fistula repair. Further research and long-term follow-up are necessary to establish its widespread adoption and refine its application in clinical practice.