Introduction and Hypothesis <p>Vesicovaginal fistula (VVF) are anomalous communications between the bladder and vagina, often arising as a complication of obstetric injury or gynecologic surgery. Patients typically present with continuous urinary leakage. Successful repair hinges on adherence to core surgical principles of adequate exposure, tension-free multilayer closure, and well-vascularized tissue interposition when needed.</p> Methods <p>This video article demonstrates the application of these principles across three cases performed via transvaginal, robotic, and open abdominal approaches. The three patients featured all had recurrent or complex VVF following previous failed repairs. Each procedure emphasized careful mobilization of the fistula tract, layered watertight closure, and interpositional flap selection tailored to the individual’s prior surgical history and tissue quality.</p> Results <p>All three patients achieved durable closure confirmed by postoperative imaging, with restored continence at follow-up. These outcomes illustrate that the route of repair should be guided by patient anatomy, prior interventions, and surgeon expertise rather than a single preferred approach.</p> Conclusions <p>Successful repair relies on fundamental principles that remain consistent across surgical approaches. When these principles are carefully applied and tailored to individual patient factors, high success rates can be achieved even in challenging or recurrent cases.</p>