JOURNAL OF ENDOUROLOGY

Volume 22, Number 3, March 2008

Mary Ann Liebert, Inc.
DOI: 10.1089/end.2006.9846

Laparoscopic Repair of Vesicovaginal Fistula*

RODRIGO ARTUR PEREIRA OTSUKA, M.D.,1 JOO LUIZ AMARO, M.D.,1
MILTON TATSUO TANAKA, M.D.,2 EDUARDO EPACAGNAN, M.D.,2
JOS BARBOSA MENDES JR., M.D.,2 PAULO ROBERTO KAWANO, M.D.,1
and OSCAR EDUARDO HIDETOSHI FUGITA, M.D.1

ABSTRACT
Purpose: Vesicovaginal fistula (VVF) is one of the most devastating surgical complications that can occur in
women. The primary cause remains an abdominal hysterectomy. Approach to this condition can be transvaginal or transabdominal. Laparoscopic repair of VVF may be an alternative approach to this treating rare
condition. We present seven cases of VVF treated with transperitoneal laparoscopic technique and our results.
Methods: We retrospectively reviewed the charts of 7 women ranging from 37 to 74 years in age (mean age
52.8 years) at our institution who underwent laparoscopic transperitoneal repair of VVF between February
2004 and March 2006. Etiology of the VVF, surgical technique, operative time, length of hospital stay, and
complications were reviewed.
Results: Six of the seven VVFs we repaired laparoscopically resulted from gynecologic procedures, and one
patient presented with a VVF after a ureterolithotripsy. Mean operative time ranged from 130 to 420 minutes (mean 280 minutes), and mean hospital stay was 7 days. In one patient conversion to open surgery was
necessary due to prolonged operative time. Two complications occurred: a urinary tract infection in one patient and an inferior limb compartment syndrome in another.
Conclusion: Transvaginal laparoscopic repair of VVF is feasible and safe and provides excellent results. It
is a good alternative to the abdominal approach. However, advanced laparoscopic skills are mandatory.

toneal laparoscopic technique for repair of vesicovaginal fistulas and our results.

INTRODUCTION

VESICOVAGINAL FISTULA (VVF) is one of the most

devastating surgical complications that can occur in
women. Abdominal hysterectomy remains the most common
cause of VVF, occurring in 1/1800 hysterectomies1 and accounting for about 85% of cases, while radiation (10%) and obstetric injury (5%) are the other major causes.2 Since Sims report on the successful closure of VVFs in a large series of
female slaves,3 there has been little substantial change in the
basic principles of surgical correction of VVF. For most early
simple fistulas the transvaginal approach is simple and direct.
The abdominal approach may be most suitable after radiation
therapy and for difficult or contaminated fistulas. Since its introduction, laparoscopy has become the first-line approach to
treat many surgical urologic conditions because of its minimal
invasiveness and short convalescence. We present our transperi-

MATERIAL AND METHODS

We retrospectively reviewed the data of seven patients with
VVFs that underwent laparoscopic transperitoneal repair from
2004 to 2006.

Surgical technique
All patients underwent cystoscopy for bilateral urethral
catheterization. A urethral or Foley catheter was placed vaginally through the fistula and pulled out of the bladder. The patient was placed in Trendelenburg position and a primary 10mm port was inserted at the umbilicus, and pneumoperitoneum
was achieved using a Veress needle. Two other ports (5 and 10

1Faculdade de Medicina de BotucatuUniversidade Estadual Paulista, and 2Master Clinica de Cascavel, Botucatu, Brazil.
*Submission to the 2006 Endourological Society Essay Contest.

525

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OTSUKA ET AL.
TABLE 1. DEMOGRAPHIC

AND

FISTULA-RELATED DATA

Patient

Age

Body mass
index

Etiology

Previous treatment
for the fistula

ATOR
CL
IMC
VMP
DB
MVMD
MJSM

37
51
49
46
58
49
74

28.05
30
24.8
28.05
30
23.53
31.96

Endometrial nodule resection

Hysterectomy
Hysterectomy (for malignancy)
Hysterectomy
Hysterectomy (for malignancy)
Hysterectomy
Hysterectomy

No
Yes
No
No
Yes
Yes
No

mm) were placed in the inferior abdominal wall. Placement of

the 10-mm port depends on the fistulas location, and it is placed
on the same side as the fistula. A 5-mm port was also necessary to aid in retracting the bladder during suturing.
In five patients, the posterior bladder wall was vertically incised in the proximity of the fistula and dissection continued
until the catheter could be seen. The incision was carried downward until the fistula tract was excised. At that point the bladder could easily be separated from the vagina, exposing the
sponge retractor in the vaginal orifice of the fistula. The remaining borders of the fistulous tract were excised and viable
tissue margins in both the bladder and vagina were created.
Suturing began at the top of the incision made in the bladder with the initial knot at the outer bladder surface. We used
3-0 polyglactic acid suture in a one-layer running continuous
vertical fashion. The vagina was closed in the same fashion except that the suture was placed transversely. The most inferior
suture in the bladder was also used to anchor an omental flap
interposed between the bladder and the vagina.
In two patients, the initial approach was via the vesicovaginal space. In these cases, the fistulous tract was identified and
excised without opening the bladder. Bladder and vaginal closure were made as previously described.
Two patients concomitantly had a pubovaginal sling added secondary to urinary stress incontinence. The urethral catheter used
during the procedure was removed at the end of the operation, but
an indwelling urethral catheter was placed to allow bladder
drainage. Postoperatively, oral antibiotics were continued and anticholinergics were administered as needed. Patients were instructed to have ambulation as early as possible, to avoid strenuous physical activity, and to avoid sexual intercourse for 2 months.
A voiding cystourethrogram was performed before removal
of the Foley catheter, usually 4 weeks post-surgery.
TABLE 2. SURGICAL
Patient

Operative time
(minutes)

ATOR
CL

130
390

IMC
VMP
DB
MVMD
MJSM

300
180
300
290
420

AND

RESULTS
The seven patients ranged from 37 to 74 years of age (mean
age 52.8 years). In six patients the fistula was the result of gynecologic surgical procedures, and one patient presented with
a VVF after a ureterolithotripsy. Six fistulas occurred after hysterectomy, and one after resection of an endometrioma (Table
1). All fistulas were located above the bladder trigone.
Of the seven patients, three had undergone previous attempts
at surgical fistula repair, including endoscopic fulguration of
the fistulous tract in one patient, and open abdominal repair in
two others.
Operative time ranged from 130 to 420 minutes (mean 280
minutes). In one patient, conversion to open surgery was necessary due to prolonged operative time and difficult dissection
(Table 2). Two complications occurred: a urinary tract infection and an inferior limb compartment syndrome. Two patients
underwent a concomitant procedure to create a pubovaginal
sling secondary to urinary stress incontinence.
Hospital stay ranged from 2 to 20 days (mean 7.2 days). Follow-up ranged from 2 months to 2 years and no patient presented with recurrence of the VVF.

DISCUSSION
The true incidence of vesicovaginal fistulas is unknown, but it
is currently recognized that in developed countries the majority
result from gynecologic surgery.4 The diagnosis of a vesicovaginal fistula is usually straightforward, but some areas of controversy still remain, such as the appropriate timing of fistula repair
and the best surgical approach: transabdominal or transvaginal.
Apparently, there are no differences in terms of results after early
POST-OPERATIVE DATA

Complications
No
Compartment syndrome led to
open procedure
No
No
No
No
Urinary tract infection led to
open procedure

Hospital stay
(days)

Follow-up
(months)

3
20

24
19

5
2
4
3
14

18
7
4
2
2

527

LAPAROSCOPIC REPAIR OF VESICOVAGINAL FISTULA*

or late repair. In both series, including those in whom repairs were
done within 3 months post-injury, and in those in whom the repairs were intentionally delayed, success rates ranged from 86%
to 100%.59 In our series, the time of repair ranged from 7 months
to 3 years after the surgery that caused the VVF.
In terms of the best surgical approach, controversy continues
as to whether the transabdominal or the transvaginal route is more
desirable for repair off VVF. To date there are no significant statistical data that indicate that either approach is superior. The
vaginal approach seems to be simpler, safer, and quicker for most
early simple fistulas,10 while the abdominal approach may be indicated to address supratrigonal vesicovaginal fistulas,11 or more
complex fistulas such as those resulting from radiation therapy
in women with small bladder capacities.12 Laparoscopic repair
of a VVF offers the patient the advantages of a shorter hospital
stay, more rapid postoperative recovery, and better cosmetic results than the traditional abdominal approach. Also, laparoscopy
allows an excellent view and good exposure of pelvic structures,
and provide quick and direct access to the fistula, and relatively
simple fistula resection.
The long operative times for some of our cases (300 minutes) were attributable to difficulty in identification of the fistulous tract, difficult dissection of the vesicovaginal space, and
need for intracorporeal suturing. Three of our seven cases (43%)
had previously undergone an unsuccessful open procedure to
correct the VVF, which made locating the fistulous tract more
difficult secondary to excessive scar tissue. The case with the
shortest operative time (130 minutes) was secondary to resection of an endometriotic lesion in the vaginal dome. The VVF
was located high in the bladder, which allowed the surgeon to
locate the fistulous tract easily. The operative times seen in the
literature for laparoscopic repair of VVF range from 70 to 240
minutes.1316 Sotelo16 and associates incorporated concomitant
cystoscopy to help guide the bladder incision, facilitating quick
access to the VVF, and avoiding unnecessary dissection in the
vesicovaginal space. Laparoscopic freehand intracorporeal suturing, particularly in the pelvis, can be cumbersome, and rigorous training and substantial practice time is mandatory when
performing this type of surgery.
We had one conversion to open surgery, attributable to difficulty with dissection and prolonged operative time, and another patient presented with compartment syndrome of the left
leg, probably caused by inappropriate use of the dorsal lithotomy position and prolonged operative time. Fasciotomy was
performed and the patients recovery was uneventful except for
a prolonged hospital stay (20 days).
All of our patients had effective laparoscopic correction of their
VVFs. The use of an omental flap between the suture lines, particularly when the surrounding tissues are not healthy and wellvascularized, seems to be important in achieving the best result.17
In all of our cases, interposition of the omental flap was easily performed, and may have increased lymphatic drainage and vascularization of the area, promoting excellent surgical results.

tients is a good alternative to the transabdominal approach.

However, advanced laparoscopic skills, particularly with intracorporeal suturing and pelvic surgery, are mandatory.

REFERENCES
1. Miller EA, Webster GD. Current management of vesicovaginal fistulae. Curr Opin Urol 2001;11:417421.
2. Symmonds RE. Incontinence: Vesical and urethral fistulas. Clin
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3. Sims JM. The treatment of vesicovaginal fistula. Am J Med Sci
1852;23:5982.
4. Lee RA, Simmonds RE, Williams T. Current status of genitourinary fistula. Obstet Gynecol 1988;72:313319.
5. Persky L, Herman G, Guerrier K. Nondelay in vesicovaginal fistula repair. Urology 1979;13:273275.
6. Cruikshank SH. Early closure of post hysterectomy vesicovaginal
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10. Goodwin WE, Scardino PT. Vesicovaginal and ureterovaginal fistulas: A summary of 25 years of experience. J Urol 1980;123:370
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1995;153:11101113.
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1994;83:899901.
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1998;105:12161218.
15. Chiber PJ, Shah HN, Jain P. Laparoscopic OConnors repair for
vesicovaginal and vesicouterine fistulae. BJU Int 2005;96:183
186.
16. Sotelo R, Mariano MB, Garcia-Segui A, et al. Laparoscopic repair
of vesicovaginal fistula. J Urol 2005;173:16151618.
17. Evans DH, Madjar S, Politano VA, Bejany DE, Lynne CM, Gousse
AE. Interposition flaps in transabdominal vesicovaginal fistula repairs: Are they really necessary? Urology 2001;57:670674.

Address reprint requests to:

Oscar Eduardo Hidetoshi Fugita, M.D.
Av. Indianopolis, 2244
Planalto Pautista
CEP: 04062-002
So Paulo, SP, Brazil

CONCLUSIONS
ABBREVIATION USED
Transvaginal laparoscopic repair of a vesicovaginal fistula is
feasible, safe, and provides excellent results, and for many pa-

VVF  vesicovaginal fistula.