Abdominal Approach To Vesicovaginal Fistula

A b d o m i n a l A p p ro a c h t o
Ves ic ovaginal F ist u la

Elishia McKay, MDa, Kara Watts, MDb, Nitya Abraham, MDb,*
KEYWORDS
Vesicovaginal fistula Urinary bladder fistula Vaginal fistula Surgical procedures Operative
Robotics Laparoscopy
KEY POINTS
Vesicovaginal fistula (VVF) is a devastating cause of morbidity and can be identified with physical
examination and/or imaging.
The abdominal approach to VVF repair includes a transvesical or extravesical technique.
The same principles of VVF repair apply when using the robot-assisted laparoscopic approach.
Shorter operative times, decreased blood loss, improved visibility, and similar cure rates with the
minimally invasive approach have led to a rise in its popularity.
Video content accompanies this article at https://www.urologic.theclinics.com/.
INTRODUCTION sequelae, radiation therapy, inflammation or infec-

tion, foreign body, and other trauma. Worldwide,
Vesicovaginal fistula (VVF) is an abnormal communi- these fistulas are most commonly related to ob-
cation between the bladder and the vagina resulting stetric complications, with prolonged labor being
in continuous leakage of urine (Fig. 1). The term fis- a predominant contributing factor. In countries
tula was popularized in the sixteenth century. How- with greater access to obstetric care, VVF is
ever, descriptions of these communicative tracts more commonly a complication of pelvic surgery
date back to 1550 BC and were first described in or malignancy treatment, with the former most
relation to obstetric injuries around 950 AD by physi- often preceded by inadvertent bladder injury or
cian and polymath Avicenna.1 This article will briefly ureteral injury during abdominal hysterectomy. In
discuss fundamentals of VVF (etiology, presenta- the United States, the true incidence is not known
tion, evaluation, and diagnosis), followed by focus but has previously been reported to be about 0.3%
on abdominal approaches to VVF repair including to 2%, with some studies reporting an overall inci-
open and minimally invasive techniques. dence of 0.5% after simple hysterectomy and 10%
after radical hysterectomy3,4
EPIDEMIOLOGY AND ETIOLOGY
In general, fistulas occur when devascularized
Despite its long history of recognition, VVF re- tissues become necrotic, leading to subsequent
mains a devastating cause of morbidity for women erosion through the urinary tract and the vaginal
around the world. VVF incites inherent social epithelium, thus allowing urine to escape through
stigma and emotional and psychological strain this channel. This avascularity can be caused by
on its victims, as well as physical repercussions.2 unrecognized intraoperative lacerations, crush
Causes include obstetric injury, postsurgical injury of the bladder wall, suture impingement or
urologic.theclinics.com
Disclosure Statement: None.

a
Department of Obstetrics and Gynecology, Montefiore Medical Center, 1250 Waters Place, Tower 2, Suite
706, Bronx, NY 10461, USA; b Department of Urology, Montefiore Medical Center, 1250 Waters Place, Tower
2, Suite 706, Bronx, NY 10461, USA
* Corresponding author.
E-mail address: [email protected]
Urol Clin N Am 46 (2019) 135–146

https://doi.org/10.1016/j.ucl.2018.08.011
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136 McKay et al
urethrovaginal or VVF. After instillation of the

mixture into the bladder via a Foley catheter, the
examiner inspects the anterior vaginal wall for
leakage while compressing the urethral opening to
avoid incontinence. If no blue-tinged fluid is noted
within the vagina, a tampon may be placed into
the vagina and the patient asked to ambulate for a
short time. The tampon can then be removed and
examined for evidence of blue staining. Staining
on the outlet of the tampon suggests urethral incon-
tinence, whereas staining on the superior aspect of
Fig. 1. Vesicovaginal fistula. (From Rosenman AE. the tampon suggests a vesicovaginal or urethrova-
Chapter 23: pelvic floor disorders: pelvic organ pro- ginal communication. If no dye extravasates, or if
lapse, urinary incontinence, and pelvic floor pain syn- clinical suspicion warrants, the presence of a ureter-
dromes. In: Hacker & Moore’s essentials of obstetrics ovaginal fistula can be tested by the addition of oral
and gynecology. 6th edition. Philadelphia: Elsevier;
phenaozpyridine. The patient should take phenazo-
2016. p. 291–303; with permission.)
pyridine about 30 minutes prior to the office visit. At
kinking injury, electrocautery injury, or with dissec- the office, a tampon can be placed intravaginally,
tion into an incorrect plane in the bladder.5 Although and the patient may ambulate. Orange staining of
it may take weeks for the tissues to break down the tampon will capture ureterovaginal, vesicovagi-
completely and the fistulous tract to fully mature, nal, or urethrovaginal fistulas.
symptoms are classically recognized 1 to 2 weeks Dye studies alone may not be sufficient to
after surgery (in the case of postsurgical etiology). completely evaluate the number and location of
Studies have demonstrated several intraoperative urogenital fistulas. A computed tomography (CT)
risk factors for subsequent VVF at the time of hys- urogram and cystogram of the abdomen and pelvis
terectomy: surgery for benign disease, age less or retrograde pyelogram and cystourethrogram can
than 50 years old, uterus weight greater than be used to evaluate for ureterovaginal and VVFs,
250 g, longer operative times (approximately respectively (Fig. 2). Recent evidence suggests
5 hours or more), and concurrent ureteral injury.6
DIAGNOSIS
A thorough history and physical examination are
the first components of diagnosing a VVF. Women
usually present with constant urinary leakage or
may describe a thin vaginal discharge that began
after their surgery. A high index of suspicion in
this scenario may serve to decrease incorrect or
delayed diagnosis.
Physical examination should commence with an
external genital examination. A cough stress test
should be done to rule out urinary incontinence
from the urethral meatus, which can be a confounder.
Inspection should also include a speculum ex-
amination. Close evaluation of the vaginal wall tis-
sue is imperative. A pinpoint opening on the
anterior vaginal wall or vaginal cuff may be
observed with obvious leakage. In presentations
closer to the date of surgery, one may instead
see a small area of erythema with granulation tis-
sue, which is concerning for a newer fistula. In
this case, a clear opening may not be visible.
If the previously described physical examination
techniques are not diagnostic, a dye test can be
performed. Retrograde filling of the bladder with in-
digo carmine or Methylene blue mixed with sterile Fig. 2. CT cystogram demonstrating an apical VVF that
water or saline will facilitate diagnosis of a could not be clearly visualized on pelvic examination.
Abdominal Approach to Vesicovaginal Fistula 137
that abdominopelvic MRI may also be of value and successful closure. Traditionally, waiting 6 to
may have increased sensitivity compared with CT. 12 weeks was thought to allow granulation tissue
MRI may better help to delineate borders of the to dissipate and thus increase success rates.
bladder, urethra, and vagina, thereby helping with Over the last several years however, earlier clo-
surgical planning.7,8 Finally, cystoscopy should sures, within 1 to 2 weeks of injury, have been
also be performed in order to identify potential described with similar success rates.10,11 Surgical
involvement of the trigone and/or proximity to the intervention must be tailored to the individual cir-
ureters. Vaginoscopy can also be performed if cumstances of each case.
speculum examination is inconclusive.
SURGICAL APPROACH
CLASSIFICATION OF FISTULAS Vaginal Versus Abdominal Approach
Fistulas can be further characterized into simple In general, if either approach is acceptable, then the
and complex based on size and tissue quality. vaginal technique is preferred. Vaginal repair has
The term simple fistula is applied to a single fis- demonstrated significantly shorter operative times,
tula that is small (0.5 cm in diameter) and arising decreased blood loss, and shorter duration of hos-
in nonradiated tissue. The term complex fistula de- pitalization.12 However, certain factors limit the
notes a fistula that has failed a prior repair attempt, feasibility of a vaginal approach in favor of an
is at least 2.5 cm in diameter, or which results from abdominal repair. Most notably, a small introitus,
either chronic inflammatory disease or within radi- high or inaccessible fistulas, complex fistulas, a
ated tissues.3 recurrent fistula after a failed prior repair attempt,
fistulas with significant associated scarring, fistulas
SURGICAL INTERVENTION occurring in irradiated tissues, concomitant involve-
If a simple fistula is diagnosed shortly after sur- ment of the uterus or bowel, or when the relative
gery, conservative and expectant management is position of the ureters is seen as problematic or re-
a reasonable initial therapeutic option. A Foley quires the need for ureteral reimplantation.13
catheter should be placed into the bladder at The following section will focus on open and
time of diagnosis and left in place for 2 to 8 weeks laparoscopic abdominal approaches to VVF repair
with concurrent anticholinergic therapy. This has looking at both transvesical and extravesical ap-
been shown to result in closure of the fistulous proaches. In all cases, early placement of a
tract in approximately 10% of cases.5,9 bladder catheter is recommended. Bilateral ure-
If the patient is further out from surgery or if the teral stents (if required) and a small gauge Foley
defect failed to close with initial conservative man- or ureteral catheter for the fistulous tract can be
agement, then surgical intervention is recommen- placed cystoscopically or through the open
ded. The choice of surgical approach must take bladder, if performing a transvesical approach.
multiple factors into consideration, including the eti-
ology of the fistula, desired timing of surgery, vaginal OPEN ABDOMINAL APPROACH
versus abdominal approach, concomitant proced- Abdominal Incision
ures, excision of the fistulous tract, tissue interposi-
tion, sexual function, and adjuvant treatment.4 As in all open pelvic surgeries, one must first
Surgical techniques to repair VVF have pro- consider the risks and benefits of a lower vertical
gressed over the years since Dr. James Marion versus a transverse (Pfannensteil) abdominal inci-
Sims published the first report of a consistently suc- sion. Benefits of a midline vertical infraumbilical
cessful method of repair in 1852.1 Sims’ emphasis incision include easier access to the upper
on the critical importance of good exposure, contin- abdomen, which facilitates later retrieval of the
uous postoperative bladder drainage, and a omentum for use as an interposition graft, and
tension-free closure remain fundamental to a suc- decreased blood loss. Risks include potentially
cessful repair. Surgeon skill and experience, as worse postoperative pain and a less aesthetically
well as an accurate knowledge of the relevant sur- appealing incision.
gical anatomy of the ureters and the anatomic rela- Alternatively, a low transverse incision limits ac-
tionships of the base of the bladder to the vascular cess to higher abdominal structures but is often
pedicles of the uterus and vagina, are also integral.8 less painful and more easily concealed. If a trans-
verse incision is deemed more appropriate, a
TIMING OF SURGICAL INTERVENTION muscle-splitting incision, such as a Cherney inci-
sion, will assist with increased access to upper
Timing of surgery is based upon the health of the abdominal structures (Fig. 3). Upon entry, expo-
surrounding tissue and optimizing chances of a sure can be further facilitated with the use of
138 McKay et al
Fig. 3. Pfannestiel incision with vertical incision of rectus fascia. (A) Horizontal skin incision (B) Vertical incision of
the rectus fascia (C) illustration of the desired view of the surgical field. (From Mangera A, Chapple C. Case dis-
cussion: vesicovaginal fistula following a total abdominal hysterectomy: the case for abdominal repair. Eur Urol
Focus 2016;2(1):100; with permission.)
self-retaining retractors and packing the bowel up vesicovaginal plane at least 1 to 2 cm beyond
high, out of the pelvis. the fistulous tract. This will decrease tension on
the repair and aid in layered closure for both the
Exposure of the Fistulous Tract vaginal and bladder walls.13
The fistulous tract can be visualized via a transves-
Extravesical Approach
ical or extravesical technique.
The extravesical approach, first described by Von
Transvesical Approach Dittel in 1803,16,17 focuses on targeted dissection,
avoiding cystotomy, and preferentially dissecting
The transvesical approach is based on the tech- to the fistulous tract via the vesicovaginal plane
nique described by O’Conor and Sokol as early (Fig. 6). The superiority of either the transvesical
as the 1950s, which remains a gold standard in or extravesical approach has not been established
the treatment of supratrigonal VVF.14,15 in the literature.17 The authors recommend that
After excellent exposure of the pelvic structures the choice of surgical approach be determined
is obtained, the bladder is mobilized. by surgeon experience and individual fistula
An intentional, 4 to 5 cm high cystotomy is per- characteristics.
formed along the sagittal plane in the extraperito-
neal portion of the bladder near the dome using
Excision of the Fistulous Tract
either cautery or a scalpel13 (Fig. 4).
The bladder incision is then extended down to Classically, excision of the tract was described as an
the level of the fistulous tract. The cystotomy should integral step for a good repair. However, this adage
be long enough to allow a thorough examination, is now debatable.18 Resection of tissue to provide
with visualization of the fistulous tract and identifi- healthy margins was thought to improve success
cation of both ureteral orifices. If excision of the rates.19 However, excision with wide margins may
tract is desired, a separate smaller-gauge Foley or result in a larger defect that ultimately can increase
vessel loop can be used to identify the tract course tension on the repair and risk of recurrence.20 Pres-
and ensure a full-thickness excision (Fig. 5). ently, data suggest excision of the tract is compara-
Regardless of whether tract excision is desired, ble to no excision. Therefore, a decision should be
it is imperative to fully dissect and develop the made on a case-by-case basis.21
Fig. 4. Transvesical approach for VVF Repair (O’Conor technique). (A) Bladder opened and fistula exposed. (B)
Circumferential incision through the vaginal wall. (C) Bladder closed in layers.Vagina closed. (D) Omentum inter-
posed. (From Badlani GH, De Ridder D, et al. Chapter 89: urinary tract fistulae. In: Campbell-Walsh urology. 11th
edition. Philadelphia: Elsevier; 2016. p. 2103–39.e9; with permission.)
To perform a fistulectomy, the surgeon should Vaginal Closure

extend the cystototomy down to the threaded fis-
The vaginal defect can be closed in a single or
tulous tract and circumferentially resect the tract.
double layer using interrupted or running 2-0
Care should be taken to ensure the margins are
absorbable sutures.
well vitalized.
Closure Bladder Closure

A multilayered closure, with nonoverlapping suture The cystotomy should preferentially be repaired in
lines, is generally preferred.13,14,18,22,23 2 layers with either interrupted or continuous
Fig. 5. Foley catheter in VVF to identify tract. (A) Fistulous tract between the bladder and vagina. (B) Foley cath-
eter placed transvaginally into the bladder to visualize fistulous tract. (From Vasavada S. Chapter 65: transperito-
neal vesicovaginal fistula repair. In: Smith JA, Howards SS, Preminger GM, et al, editors. Hinman’s atlas of urologic
surgery. 4th edition. Philadelphia: Elsevier; 2018. p. 484–7; with permission.)
140 McKay et al
(Fig. 7) Use of omental flaps, epiploic appen-

dices of the sigmoid colon, or peritoneal flaps
has been reported. Tissue flaps are thought to
provide another layer of well-vascularized tissue
between the repair and surrounding tissue that
could decrease failure rate. This technique has
been described as early as 1937 and remains
popular among surgeons. In addition to neovas-
cularization of adjacent tissue, omental flaps
are also thought to provide lymphatic drainage
of exudates produced during the healing pro-
cess, thus decreasing risk of infection and fluid
collection.15 However, Miklos and colleagues17
demonstrated that omental interposition grafts
made no difference in cure rates for VVF repairs
compared with their no graft counterparts, mak-
Fig. 6. Extravesical dissection to fistulous tract. (From ing this theoretic benefit unproven in current
Miklos JR, Moor RD, Chinthakanan O. Laparoscopic literature.
and robotic-assisted vesicovaginal fistula repair: a sys- Regarding technique, an omental flap is har-
tematic review of the literature. J Minim Invasive Gy-
vested by mobilizing a section of omentum, usu-
necol 2015;22(5):728; with permission.)
ally supplied by the right gastroepiploic vessels,
suturing using a 3-0 absorbable suture. The au- and suturing this tissue to the anterior vaginal
thors support performing an interval retrograde wall or the posterior bladder wall. Some surgeons
fill of the bladder between the first and second argue that mobilization of the omentum increases
layer of closure to ensure a water-tight seal.13,18 operative time unnecessarily and prefer to use
Some studies suggest ensuring the water-tight the often more proximate fatty sigmoid epiploica24
seal is more important to a successful repair than (Video 1).
the number of layers employed.17,18 Nontissue grafts, such as fibrin glue, have also
been used. However, available data are based
on small sample sizes and, therefore, cannot be
Tissue Interposition
recommended.25
Many surgeons performing repair of VVF support A Foley catheter should remain in place at the
use of a tissue interposition graft. These grafts end of the case to keep the bladder decom-
serve as barriers between the bladder and vaginal pressed and decrease tension on the repair
suture lines. site.
Fig. 7. Omental flap interposition. (A) Repaired vesicovaginal fistula. (B) tissue interposition. (From Vasavada S.
Chapter 65: transperitoneal vesicovaginal fistula repair. In: Smith JA, Howards SS, Preminger GM, et al, editors.
Hinman’s atlas of urologic surgery. 4th edition. Philadelphia: Elsevier; 2018. p. 487; with permission.)
LAPAROSCOPIC AND ROBOT-ASSISTED TROCAR PLACEMENT

LAPAROSCOPIC APPROACH TO
VESICOVAGINAL FISTULA REPAIR The patient should be placed in the dorsal lithot-
omy position. Early cystoscopy and placement of
A laparoscopic approach to VVF repair was first ureteral stents are recommended if the fistula is
described in the early 1990s. The first robot- close to the ureteral orifices.33 Most surgeons
assisted repair was reported in 2005.24,25 These describe placing an open-ended ureteral catheter
techniques employ similar steps to the previ- through the fistulous orifice cystoscopically for
ously described open abdominal practices. identification later (Fig. 8).
Comparable success rates have been demon- Standard laparoscopic trocar placement in-
strated with minimally invasive approaches cludes an infraumbilical port with 3 additional
compared with the open approach but are asso- 5 mm accessory ports,33 although there is no
ciated with decreased blood loss and a shorter standard configuration. In general, trocars should
hospital stay by an average of 2 days.17,24,26–28 be placed to allow optimal visualization and
Cure rates for the laparoscopic approach range greatest range of motion for operating in the
from 75% to 98%, with most studies reporting pelvis.
success greater than 90% for primary repair. In robot-assisted repairs, multiple patterns of
The failure rate for recurrent fistulas is about trocar placement have been described. Several ar-
10%.29–31 ticles describe using the same configuration typi-
Application of robotic assistance to urogyneco- cally used for robot-assisted prostatectomy.25,34
logic procedures is on the rise.24 In regard to VVF, Melamud and colleagues25 describe this
robotic surgery affords more facile lysis of adhe- method in detail. A 12 mm camera port is placed
sions, raising the question of superiority to either in the midline 20 cm from the pubis. The 8 mm
a laparoscopic or an open approach in this robotic arm ports are placed 16 cm from the pu-
setting.26,32 Compared with laparoscopic VVF bis lateral to the rectus muscles bilaterally and
repair, the addition of robotic assistance has at least 10 cm from the midline camera port to
demonstrated multiple benefits. The 3-dimen- avoid robotic arm collision outside the patient.
sional view and magnification improve visibility of A fourth 12 mm port is placed on the right side
the fistula and surrounding structures. The ergo- just above the anterior superior iliac crest.
nomic instruments allow for more accurate and Finally, a 5 mm suction/assistance port is placed
precise movements, facilitating proper dissection 7 cm cephalad and lateral to the midline camera
and development of tissue planes, and aiding in port.
knot tying and achievement of a tension-free Gupta and colleagues report placing a 12 mm
closure.26,27 The most commonly reported disad- camera port in the midline at the level of the umbi-
vantage of robotic surgery is the markedly licus, 2 lateral ports at either side of the pararectus
increased cost compared with laparoscopy location over the spinal umbilical line, and a 5 mm
without robotic assistance.17,26,27 port on the right side 1 inch above and medial to
Notably, the fundamental steps of VVF repair are the anterior superior iliac spine for assistance.
similar in regard to the laparoscopic and the robot- Another 5 mm port is placed on the right side be-
assisted techniques. Therefore the steps are dis- tween the camera and the robotic port for suction.
cussed together with notation made for difference An arch-type configuration and W configuration
in approach. have also been reported (Figs. 9 and 10).
Fig. 8. (A) Supratrigonal fistula visualized cystoscopically. (B) Ureteral catheter placed through fistulous tract.
142 McKay et al
bowel is tucked into the upper abdomen, allow-

ing for adequate visualization of the pelvic
anatomy.
A sponge stick or EEA sizer can be inserted
vaginally for assistance with identification of the
vaginal wall and dissection of the vesicovaginal
plane. Additionally, retrograde filling of the
bladder may aid in identifying the vesicovaginal
reflection17,29
Next, a transvesical (Fig. 11) or extravesical
(Fig. 12) approach to expose the fistula is per-
formed in the same manner as previously
mentioned. Notably, a literature review of 44
studies by Miklos and colleagues demonstrated
success rates of transvesical and extravesical
Fig. 9. Robotic port placement in an inverted U techniques as 80% to 100% and 97.67% to
configuration. (From Badlani GH, De Ridder D, et al. 100%, respectively (relative risk [RR], .98; 95%
Chapter 89: urinary tract fistulae. In: Campbell-Walsh confidence interval [CI], .94-1.02). The previously
urology. 11th edition. Philadelphia: Elsevier; 2016. p. placed fistula catheter will aid in identification of
2103–39.e9; with permission.)
the VVF. The EEA sizer or sponge stick may be
useful in providing a firm surface against which
to dissect the retrovesical region. Upon identifica-
After trocar placement, the patient is placed in tion of the fistula, resection of the tract may be per-
steep Trendelenburg position. The robot is then formed but is not necessary.
docked between the legs or side-docked Miklos and colleagues29 demonstrated that
depending on surgeon preference. The small success rates for single- and double-layer
bladder closures range from 80% to 100% and
93.33% to 100%, respectively (RR, .98; 95% CI,
.94–1.03). The first layer is closed with 3-0 absorb-
able suture in either an interrupted or continuous
fashion (Fig. 13). Similar to the open abdominal
technique, the bladder is retrograde filled to test
for a water-tight seal. A second imbricating
layer is then performed using either 2-0 or 3-0
Fig. 10. Robotic port placement in a W configura-

tion. (From Rosenblum N, Enemchukwu EA. Chapter Fig. 11. Transvesical O’Conor technique used laparos-
64: transvesical repair of vesicovaginal fistula. In: copically. (From Miklos JR, Moor RD, Chinthakanan O.
Smith JA, Howards SS, Preminger GM, et al, editors. Laparoscopic and robotic-assisted vesicovaginal
Hinman’s atlas of urologic surgery. 4th edition. fistula repair: a systematic review of the literature.
Philadelphia: Elsevier; 2018. p. 482; with J Minim Invasive Gynecol 2015;22(5):728; with
permission.) permission.)
Fig. 12. (A) Extravesical dissection to fistulous tract. (B) Dissection of vesicovaginal space.
Fig. 13. Closure of bladder mucosa.
144 McKay et al
Fig. 14. Closure of vaginal opening.
absorbable sutures.33 Stratafix is a barbed sigmoid epiploica or peritoneal tissue may be

absorbable suture that can be used for bladder used, as described previously.
closure that offers the advantage of knotless su- After completion of the repair, a bladder cath-
turing. The vaginal opening is closed using 2- eter is placed to decrease tension on the closure.
0 Vicryl suture in a single layer (Fig. 14). V-lock Foley duration varies by surgeon and ranges
is an absorbable barbed suture that can be from 24 hours to 20 days, with an average of 7 to
used for vaginal closure. 14 days.17,33,35
Next, attention is turned to tissue interposition. A cystogram may be performed prior to catheter
The omentum can be harvested laparoscopically removal to confirm success of the repair.12,35
prior to starting the robotic portion of the case. If
using the Da Vinci Xi platform, the omentum can
SUMMARY
be easily harvested robotically without redocking.
The flap is sutured using interrupted stitches to Since O’Connor first described the open abdom-
the anterior vaginal wall (Fig. 15). Alternatively, inal approach to VVF repair in the 1950s, surgical
Fig. 15. Interposition of omental flap.
techniques have evolved. The principles of an 9. Stamatakos M, Sargedi C, Stasinou T, et al. Vesico-
effective repair include good exposure of the fistu- vaginal fistula: diagnosis and management. Indian J
lous tract, double-layer bladder closure with inter- Surg 2014;76(2):131–6.
vening tissue, retrograde fill of the bladder to 10. Hadley HR. Vesicovaginal fistula. Curr Urol Rep
ensure a water-tight seal, and a tension-free 2002;3(5):401–7.
closure with continuous postoperative bladder 11. Singh O, Gupta SS, Mathur RK. Urogenital fistulas in
drainage. Minimally invasive approaches, particu- women: 5-year experience at a single center. Urol J
larly robot-assisted laparoscopy, have demon- 2010;7(1):35–9.
strated shorter operative times, decreased blood 12. Alan D, Garely MJM Jr. Urogenital tract fistulas in
loss, improved visibility, and similar cure rates women. 2018.
without increased adverse events. These tech- 13. Michael S, Baggish MMMK. Atlas of pelvic anat-
niques are therefore rising in popularity among omy and gynecologic surgery. Elsevier Saunders;
surgeons. Ultimately, surgical the approach to 2006.
VVF repair depends upon the individual character- 14. O’Conor VJ, Sokol JK. Vesicovaginal fistula from the
istics of the patient and fistula and the preference standpoint of the urologist. J Urol 1951;66(4):
and experience of the surgeon. 579–85.
15. Nesrallah LJ, Srougi M, Gittes RF. The O’Conor tech-
ACKNOWLEDGMENTS nique: the gold standard for supratrigonal vesicova-
ginal fistula repair. J Urol 1999;161(2):566–8.
The authors would like to thank the many 16. Dittel LV. Abdominale Blasenscheidenfistel-opera-
women who underwent various forms of this surgi- tion. Wein Klin Wochenschr 1893;6.
cal repair without whom the safe and mostly effica- 17. Miklos JR, Moore RD, Chinthakanan O. Laparo-
cious methods in practice today would not be scopic and robotic-assisted vesicovaginal fistula
available. repair: a systematic review of the literature.
J Minim Invasive Gynecol 2015;22(5):727–36.
SUPPLEMENTARY DATA 18. Neeraj Kohli M, Miklos JR. Meeting the challenge
Supplementary data related to this article can be of vesicovaginal fistula repair: Conservative
found online at https://doi.org/10.1016/j.ucl.2018. and surgical measures. OBG Management 2003;
08.011. 15(8):16–27.
19. McVary KT, MFF. Urinary fistulas. In: Gillenwater JY,
Howards SS, Duckett JW, editors. Adult and pediat-
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Abdominal Approach To Vesicovaginal Fistula

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A b d o m i n a l A p p ro a c h t o

Ves ic ovaginal F ist u la

Video content accompanies this article at https://www.urologic.theclinics.com/.

INTRODUCTION sequelae, radiation therapy, inflammation or infec-

Disclosure Statement: None.

Urol Clin N Am 46 (2019) 135–146

urethrovaginal or VVF. After instillation of the

To perform a fistulectomy, the surgeon should Vaginal Closure

Closure Bladder Closure

(Fig. 7) Use of omental flaps, epiploic appen-

LAPAROSCOPIC AND ROBOT-ASSISTED TROCAR PLACEMENT

bowel is tucked into the upper abdomen, allow-

Fig. 10. Robotic port placement in a W configura-

Fig. 13. Closure of bladder mucosa.

Fig. 14. Closure of vaginal opening.

absorbable sutures.33 Stratafix is a barbed sigmoid epiploica or peritoneal tissue may be

Fig. 15. Interposition of omental flap.

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