Introduction Ureteral injury is a known complication of pelvic surgeries, including gynecological, urologic, colorectal, and vascular surgeries. This can occur by transvaginal, laparoscopic, or transabdominal approach [1,2]. Gynecological surgery remains by far the most common means of injury (75%), followed by colorectal surgeries (14%) [3-5], with reports of ureteral injury during gynecologic surgery from 0.35% to 1.5% [4,6]. Total abdominal and laparoscopic hysterectomies are the most common procedures where ureteral injury occurs [1,5]. Injury occurs most often at the level where the ureter courses under the uterine vessels, followed by the ureterovesical junction and the base of the infundibulopelvic ligament [4,7,8]. Many ureteral injuries occur during uncomplicated, routine surgery [8,9]. An abnormal connection between the ureter and vagina, or ureterovaginal fistula, allows for a conduit through which urine can continually leak. This is specific to the combination of ureteral injury and hysterectomy where the urine finds its way to the freshly closed vaginal cuff. Genitourinary fistula formation remains one of the most feared complications of pelvic surgery, with lasting emotional damage, risk for infections, infertility, reoperation, and increased hospital stay [5,10]. Our objective is to present the difficulties encountered in management of our cases and how to rectify them. Materials and Methods A total of four cases of ureterovaginal fistulas were treated at our institution between 2011 and 2017. The average age of our patients was 49 (range 44-58). All ureteral injuries were not recognized at the time of surgery. The etiology of the injury was a laparoscopic assist robotic hysterectomy in three patients, two for gynecological cancer, one for fibroid disease. One patient underwent an open radical hysterectomy for cervical carcinoma, with a concomitant uterosacral vault suspension, retropubic sling, and perineoplasty. Three patients presented 4-6 weeks postoperatively with leakage of urine per vagina. These three patients were diagnosed with CT urogram. One patient presented one month postoperatively with fever, abdominal distention, and acute kidney injury, reporting leakage from vagina since the day of her robotic hysterectomy. She was found to have unrecognized bilateral ureteral injuries, with a right ureterovaginal fistula, diagnosed by retrograde pyelogram. Results The three patients with unilateral ureteral injury with development of ureterovaginal fistula underwent placement of percutaneous nephrostomy tubes. One patient was then treated with ureteral stent placement for a duration of four months, after which, retrograde pyelogram demonstrated resolution of the fistula. Two patients were treated with open neoureterocystotomy with Boari flap and placement of stent. The patient with bilateral ureteral injury was treated with open bilateral neoureterocystotomy, closure of ureterovaginal fistula, and psoas hitch. All patients in our series had renal preservation. Postoperatively, stents were removed in 2-6 weeks, depending if the patient had undergone external beam radiation in the past. Their postop follow up ranges 2 months to 3 years. No patient has required retreatment or intervention to date. We strongly advocate for tension-free anastomosis with absorbable sutures, over a stent, as well as use of omental or peritoneal interposition, if possible.