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Endoscopic Management of Vesicovaginal Fistula

Endoscopic management of vesicovaginal fistula (VVF) covers a spectrum of minimally invasive, endoscopy-guided techniques — from purely cystoscopic interventions (fulguration, laser ablation, tissue-adhesive injection) for small fistulae to advanced laparoendoscopic and transvesicoscopic suture repairs for more complex cases.[1][2]

For the underlying clinical evaluation, classification, and decision algorithm, see the vesicovaginal fistula clinical page. For repair-route selection across the female-fistula spectrum, see the Female Fistula Repair atlas.

Cystoscopy in Diagnosis and Preoperative Planning​

Cystoscopy is the cornerstone of VVF evaluation: direct visualization of the bladder-side fistula orifice; assessment of size, location relative to the ureteral orifices and trigone; and evaluation of surrounding-tissue quality. A combined vaginoscopy-cystoscopy technique with simultaneous dual-image (picture-in-picture) display has been described to improve fistula identification and surgical planning in diagnostically challenging cases.[1] The EAU Robotic Urology Section consensus recommends preoperative cystoscopic marking of the fistula with a guidewire or ureteral catheter to guide subsequent repair.[2]

Endoscopic Fulguration (Electrocoagulation)​

A purely endoscopic option reported in selected small VVFs; the best-known series included defects ≤3.5 mm, a study selection limit rather than a validated universal cutoff.[3]

Technique​

  • Cystoscopic insertion of a Bugbee electrode into the fistula tract.
  • Electrocoagulation of the epithelial lining.
  • Continuous Foley drainage 2–3 weeks postoperatively.
  • Anticholinergics to suppress detrusor contraction during healing.

Outcomes​

  • Stovsky series (n = 15, all fistulae ≤3.5 mm): 75% primary-treatment success (9/12) and 2/3 after failed open repair; 11/15 (73%) overall.[3]
  • A five-patient series of defects less than 7 mm reported closure in 4/5; its small uncontrolled sample does not establish a reliable treatment effect.[4]

Best suited as initial treatment for selected very-small fistulae, and as a salvage for small residual fistulae after failed surgical repair.[3]

Laser Ablation / Laser Welding​

ModalitySettingOutcome
Laser welding: one Nd:YAG, seven holmium:YAG casesSingle-center n = 8, mean fistula 3 mm (range 2–4 mm)7/8 dry after catheter removal; mean follow-up 47 months (range 2–110). One procedure was abandoned for bleeding.[5]
Holmium ablation + concurrent vaginal repairSingle case reportCystoscopic laser ablates the bladder-side opening while transvaginal excision addresses the vaginal side.[6]
Laser dissection + pneumovesical laparoscopic closureSingle case after colpectomy in a transmasculine patientDemonstrated feasibility in that anatomy; comparative tissue-injury or efficacy advantages have not been established.[7]

These small reports support feasibility in selected cases, not established safety or effectiveness for every fistula ≤4 mm.[5]

Tissue Adhesive Injection (Fibrin Glue / Cyanoacrylate / PRP)​

ApproachOutcome
Retrograde endoscopic fibrin glue6/8 successes in a mixed urinary-pathology series: seven fistulas of different types (only two VVF) and one caliceal diverticulum. This is not a VVF-specific 75% success rate.[8]
Tissue-adhesive review (84 women; 81 VVF)Fourteen heterogeneous reports, summarized narratively: 12/84 failures/recurrences. Mean follow-up was about 11.5 months; no controlled comparison established superiority of a sealant. Reported complications included septic pelvic thrombosis.[9]
Autologous PRP injection + platelet-rich-fibrin glue interpositionCystoscopic de-epithelialization of the fistula edges, peri-fistula PRP injection, fibrin glue in the tract. 91.7% (11/12) clinical cure at 6 mo.[10]

Sealants and platelet products remain selectively used options with limited evidence. The review included defects of 0.1–3.9 cm; it does not validate a universal 1-cm threshold or establish the preferred treatment for patients at high operative risk.

Transurethral NOTES​

A transurethral endoscopic suture repair using barbed suture has been described for VVFs after hysterectomy for morbidly adherent placenta. In 3 patients, 2 achieved complete resolution; the third had reduction in fistula size and required subsequent laparotomy. This three-case report establishes feasibility only; it does not establish a preferred initial approach.[11]

Transvesicoscopic Repair​

Direct placement of laparoscopic ports into the bladder (vesicoscopy) for intravesical visualization and repair:

  • Combined vaginal + vesicoscopic repair for complex VVF (n = 9): 89% success at median 30 mo. The approach supplements the vaginal route for fistulae not suitable for pure vaginal repair, and pairs the laparoscopic urologist with the vaginal surgeon.[12]
  • Robot-assisted transvesical repair via mini cystotomy has been described, particularly when prior surgical planes have been used in failed repairs.[13]

V-NOTES (Vaginal Natural Orifice Transluminal Endoscopic Surgery)​

For apical VVFs, V-NOTES provides endoscopic visualization through the vaginal route. In a 17-patient modified-technique series, 88.2% success (15/17), with both failures cured on second repair. Mean OR 104 min, EBL 10.5 mL, mean LOS 3.3 d.[14] See vNOTES & Robotic vNOTES for the broader platform context.

Laparoscopic and Robotic-Assisted Endoscopic Repair​

Not purely "cystoscopic" but the most widely adopted endoscopic approaches:

  • Reported 80–100% closure across selected laparoscopic and robotic series; no randomized comparison establishes equivalence to open repair.[15][16]
  • The 2015 review reported 95.9% transvesical and 98.0% extravesical closure across heterogeneous reports, almost entirely case reports/series. These are not randomized comparative rates.[15]
  • LESS (laparoendoscopic single-site surgery) has feasibility reports, including five VVF cases and a mixed GU-fistula cohort. The reported shorter stay/analgesic use does not establish comparative superiority.[17][18]
  • In a 78-patient retrospective abdominal-repair cohort, minimally invasive groups had shorter operations and less blood loss. Prior repair history and timing differed by group; approach was not an independent closure predictor. This is an association within selected groups.[16]

Patient Selection and Limits of the Evidence​

Select the intervention using defect size, tissue quality, ureteral proximity, access, prior radiation/repair and patient goals. Case-series cutoffs do not establish a universal algorithm. A predictor measured after abdominal surgical repair should not be transferred to tiny fistulas treated with fulguration or laser.[2][3][5][16]

The 2026 Cochrane item cited below is a protocol for a future review, not completed comparative evidence. Much of the existing endoscopic literature consists of uncontrolled case reports or small series, so an absence of reported complications or a high closure percentage should not be called established safety or equivalence.[19][20]

Common Principles Across Endoscopic Approaches​

For reconstructive suture repairs, the common goals are:[2][20]

  • Tension-free, watertight closure.
  • Well-vascularized tissue.
  • Adequate mobilization.
  • Protection of the ureteral orifices.
  • Postoperative drainage tailored to the repair and tissue. The ERUS robotic consensus suggested about ten days; small endoscopic series often used two to three weeks. See source-specific drainage guidance.
  • Plan the first attempt carefully and refer when the necessary reconstructive expertise is unavailable; prior failure prompts reassessment rather than an automatic procedure sequence.

See Also​

Videos​

Endoscopic Vesicovaginal Fistula Repair
Preeti Urology & Kidney Hospital (2026)

References​

1. Andreoni C, Bruschini H, Truzzi JC, Simonetti R, Srougi M. Combined vaginoscopy-cystoscopy: a novel simultaneous approach improving vesicovaginal fistula evaluation. J Urol. 2003;170(6 Pt 1):2330–2332. doi:10.1097/01.ju.0000096343.03276.75

2. Randazzo M, Lengauer L, Rochat CH, et al. Best practices in robotic-assisted repair of vesicovaginal fistula: a consensus report from the European Association of Urology Robotic Urology Section Scientific Working Group for Reconstructive Urology. Eur Urol. 2020;78(3):432–442. doi:10.1016/j.eururo.2020.06.029

3. Stovsky MD, Ignatoff JM, Blum MD, et al. Use of electrocoagulation in the treatment of vesicovaginal fistulas. J Urol. 1994;152(5 Pt 1):1443–1444. doi:10.1016/s0022-5347(17)32441-2

4. Shah SJ. Role of day-care vesicovaginal fistula fulguration in small vesicovaginal fistula. J Endourol. 2010;24(10):1659–1660. doi:10.1089/end.2009.0557

5. Dogra PN, Saini AK. Laser welding of vesicovaginal fistula — outcome analysis and long-term outcome: single-centre experience. Int Urogynecol J. 2011;22(8):981–984. doi:10.1007/s00192-011-1389-0

6. Singh R, Schmitt JJ, Knoedler JJ, Occhino JA. Management of a vesicovaginal fistula using holmium laser ablation. Int Urogynecol J. 2016;27(6):969–971. doi:10.1007/s00192-016-3002-z

7. Han G, Zhao R, Liu K, et al. Endoscopic laser dissection combined with laparoscopic pneumovesical repair of vesicovaginal fistula: a novel technique and case report. Urology. 2023;175:223–228. doi:10.1016/j.urology.2023.02.036

8. Sharma SK, Perry KT, Turk TM. Endoscopic injection of fibrin glue for the treatment of urinary-tract pathology. J Endourol. 2005;19(3):419–423. doi:10.1089/end.2005.19.419

9. Bouchard ME, Stairs J, Hickling D, Clancy A, Khalil H. The use of tissue adhesive in management of genitourinary fistulas: a systematic review and case report. Int Urogynecol J. 2023;34(2):445–451. doi:10.1007/s00192-022-05297-0

10. Shirvan MK, Alamdari DH, Ghoreifi A. A novel method for iatrogenic vesicovaginal fistula treatment: autologous platelet-rich plasma injection and platelet-rich fibrin glue interposition. J Urol. 2013;189(6):2125–2129. doi:10.1016/j.juro.2012.12.064

11. Duque-Galán M, Hidalgo-Cardona A, López-Girón MC, Nieto-Calvache AJ. Natural orifice transluminal endoscopic surgery for correction of vesicovaginal fistulas after hysterectomy due to morbidly adherent placenta. J Obstet Gynaecol Can. 2021;43(2):237–241. doi:10.1016/j.jogc.2020.06.029

12. Grange P, Giarenis I, Rouse P, et al. Combined vaginal and vesicoscopic collaborative repair of complex vesicovaginal fistulae. Urology. 2014;84(4):950–954. doi:10.1016/j.urology.2014.06.020

13. Occhino JA, Hokenstad ED, Linder BJ. Robot-assisted vesicovaginal fistula repair via a transvesical approach. Int Urogynecol J. 2019;30(2):327–329. doi:10.1007/s00192-018-3843-8

14. Song X, Jiang C, Lv JW. Transvaginal repair of apical vesicovaginal fistula via vaginal natural orifice transluminal endoscopic surgery (V-NOTES): a modified surgical technique and its outcomes. Sci Rep. 2024;14(1):31095. doi:10.1038/s41598-024-82366-y

15. Miklos JR, Moore RD, Chinthakanan O. Laparoscopic and robotic-assisted vesicovaginal fistula repair: a systematic review of the literature. J Minim Invasive Gynecol. 2015;22(5):727–736. doi:10.1016/j.jmig.2015.03.001

16. Wang Z, Pokhrel G, Yu S, et al. Vesicovaginal fistula repair: comparative analysis of perioperative outcomes and predictors of success in open, laparoscopic, and robotic approaches. Eur J Med Res. 2026. doi:10.1186/s40001-026-03937-5

17. Abdel-Karim A, Elmissiry M, Moussa A, et al. Laparoscopic repair of female genitourinary fistulae: 10-year single-center experience. Int Urogynecol J. 2020;31(7):1357–1362. doi:10.1007/s00192-019-04002-y

18. Abdel-Karim AM, Moussa A, Elsalmy S. Laparoendoscopic single-site surgery extravesical repair of vesicovaginal fistula: early experience. Urology. 2011;78(3):567–571. doi:10.1016/j.urology.2011.05.036

19. Okada Y, Matsushita T, Hasegawa T, et al. Surgical interventions for treating vesicovaginal fistula in women. Cochrane Database Syst Rev. 2026;1:CD015413. Protocol. doi:10.1002/14651858.CD015413

20. Ramphal SR. Laparoscopic approach to vesicovaginal fistulae. Best Pract Res Clin Obstet Gynaecol. 2019;54:49–60. doi:10.1016/j.bpobgyn.2018.06.008