Introduction In this surgical film, we present a robot-assisted upper vaginectomy and partial cystectomy for resection of endometrial cancer recurrence at the vaginal cuff involving the bladder. We highlight the use of indocyanine green dye guidance to avoid ureteral injury and review techniques to prevent fistula formation.

Description The patient was taken to the operating room for robot-assisted resection of vaginal cuff tumor. Cystoscopy was performed and revealed no mucosal invasion of the bladder. Bilateral ureteral stents were placed without difficulty and injected with indocyanine green dye for identification of the ureters during dissection. Exploratory laparoscopy revealed no gross carcinomatosis or distant metastasis. The vaginal cuff tumor was noted to be invading into the bladder muscularis posteriorly and partial cystectomy was performed to resect the mass margins in this area. Once the tumor was completely mobilized off the bladder anteriorly and rectum posteriorly, upper vaginectomy was performed with adequate margins. The cystotomy was repaired with a running 3.0 absorbable barbed suture horizontally and the vagina was closed with a running absorbable barbed suture vertically to avoid parallel friction with the cystotomy repair for prevention of fistula formation. A piece of omentum was mobilized and sutured over the vaginal closure as an additional step to prevent future fistula formation.

Conclusion/Implications Locally recurrent vaginal cuff tumors can be safely resected with adequate margins robotically under indocyanine green dye guidance to avoid ureteral injury. Techniques to prevent future fistula formation include avoiding parallel suture friction between bladder, vagina or rectum and using omentum as a friction barrier.