This video's objectives are to demonstrate the techniques and decision process used in the approach to a complex vesicovaginal fistula resulting from obstetric injury, after previous attempts at repair had failed. Our patient was referred from an outside institution to us. At emergent cesarean delivery at 24 weeks, hemoperitoneum, uterine rupture, and placenta percreta were found. During hysterectomy, the right ureter was ligated and the posterior wall of the bladder sustained large cystotomies. Urology repaired the injury, reimplanted the ureter, and placed a right ureteral stent, but the patient developed a vesicovaginal fistula and left ureteral obstruction. Ten months after diagnosis, it was repaired using a robot-assisted laparoscopic approach. This required bilateral ureteral re-implantation and omental flap. Unfortunately, this repair broke down, and testing was concerning for vesicovaginal and left ureterovaginal fistula, high at the vaginal apex. The patient was referred to our institution for our attending surgeon's expertise in fistula repair. Takeaways from this video presentation include: careful delineation of genito-urinary anatomy, vaginal approach, optimization of visualization, wide mobilization of tissue around the defect, watertight closre, meticulous multilayer closure, and aggressive management of infection.