A modified transperitoneal laparoscopic approach combined with transvaginal access to repair complex vesicovaginal fistula: our technique and 7-year experience

Objective: To investigate the clinical efficacy of modified transperitoneal laparoscopic approach combined with transvaginal access without omental flap to repair complex vesicovaginal fistula after total hysterectomy. Methods: A total of 68 patients with high-up vesicovaginal fistula were retrospectively reviewed. In 15 cases, the surgery was completed using the laparoscopic transabdominal approach. The number of cases using other approaches included: 18 for open extraperitoneal transvesical approach, 12 for transabdominal approach, and 23 for transvaginal approach. Surgical techniques: In the laparoscopic transabdominal approach, the fistula was dissected under direct visual guidance without opening the bladder. The bladder side of the fistula was closed with a single-layer of continuous suture with 3-0 V-Loc barbed suture. The vagina side of the fistula was closed under a vaginoscope or laparoscope. Omental flap was not used in any of the 15 cases. Surgery under other approaches was conducted as reported previously. Results: In comparison with all other three approaches, the laparoscopic transabdominal approach was associated with shorter operation duration, less blood loss and shorter hospital stay. The incidence of post-surgical infection and urinary incontinence did not differ among the treatments. The rate of overactive bladder syndrome and intestinal obstruction was lower in the patients under laparoscopic transabdominal approach, whereas the rate of surgical success was higher with this approach. Conclusions: For high-up complex vesicovaginal fistula, laparoscopic transabdominal repair is a viable approach. The advantage included direct visual guidance, and therefore more efficiency. Omental flap was not needed under this approach.