Laparoscopic extravesical vesicovaginal fistula repair: our technique and 15-year experience

Abstract

Introduction and hypothesisTwo types of laparoscopic vesicovaginal fistula (VVF) repairs, the traditional transvesical (O’Conor) and extravesical techniques, dominate the literature. We present our 15-year experience of primary and recurrent cases of VVF utilizing an extravesical technique, which we first described in 1999.MethodsAn IRB approved retrospective study revealed 44 female patients with either primary or recurrent VVF. Laparoscopic extravesical repair was performed without an omental flap in the majority of cases. A three-layer closure technique was performed utilizing a double-layer bladder closure and a single-layer vaginal closure followed by bladder testing. A suprapubic catheter was utilized for 2–3 weeks postoperatively for bladder decompression.ResultsA review of our experience reveals a 97 % (32 out of 33) cure for primary VVF and 100 % (11 out of 11) rate for recurrent fistulas, with an overall cure rate of 98 % (43 out of 44) at a mean follow-up of 17.3 months (range 3–64). An omental flap was not utilized in 98 % of patients (43 out of 44), with a success rate of 98 % (42 out of 43). The mean estimated blood loss was 39 mL (range 0–450), mean hospital stay was 1.1 days (range 1–3), and none of the patients suffered any major intra- or postoperative complications. None of the patients required a conversion to open laparotomy.ConclusionsBased upon our experience we believe that performing laparoscopic extravesical VVF repair using a three-layer closure technique without an interposition omentum is a safe, effective, minimally invasive technique with excellent cure rates in an experienced surgeon’s hands.

Laparoscopic Vesicovaginal Fistula Repair with Limited Cystotomy: A Rewarding Treatment Option

“…In our series, we achieved 100 % success rate by using the transabdominal transvesical approach with limited cystotomy. Although transabdominal extravesical repair of VVF has been described which claims the benefit of avoiding cystotomy with reduced operative time and postoperative voiding dysfunction; however, in those studies, the authors described increased fear of injury to ureteric orifices [13][14][15]. Some authors suggest guidance by cystoscopy or vaginoscopy to aid in the dissection of the correct vesicovaginal plane during extravesical approach [14,16].…”

A Simplified Laparoscopic Approach to Repair Vesicovaginal Fistula: The M.S. Ramaiah Technique

“…Although it provides good visualization, it increases the complexity of subsequent laparoscopic suturing and adds significantly to operative duration and possibly also contributes to bladder spasms in the postoperative period. At the other extreme is the total "extravesical approach" as propounded by Miklos and Moore, 12 focusing on a site-specific dissection and repair, without cystotomy or bladder bivalving. The possible disadvantage of this approach is limited visualization of the ureteric orifices, with the risk of ureteric orifice injury during bladder closure, especially if the fistula is located close to the orifices.…”

Robotic vesico-vaginal fistula repair with no omental flap interposition

“…Either laparoscopic or robotic approaches have been described [2]. Surgeons can choose between the traditional transvesical (O'Connor repair) and the extravesical technique [2,3]. Classically, an omental flap is mobilized and interposed between the bladder and the vagina [4,5].…”

“…Classically, an omental flap is mobilized and interposed between the bladder and the vagina [4,5]. Omental interpositioning has never been proven to result in higher cure rates for VVF repair; nevertheless, few authors report no flap mobilization [2,3]. Miklos et al claim a success rate of 98 % without flap interposition over 15 years [2].…”