Extravesical Transabdominal VVF Repair
Extravesical repair approaches a vesicovaginal fistula (VVF) through the vesicovaginal space, avoiding a separate access cystotomy or bladder bivalving. Separating the fistula still creates bladder and vaginal defects that require repair. It is an alternative to O'Conor transvesical exposure, not a proven superior operation.[3][5]
Miklos and colleagues described their laparoscopic variant in 1999; later reports detail the technique and a 44-patient series. Extravesical repair was described before 1999.[2][3]
Choosing the Approach
Extravesical abdominal exposure can be useful for a high cuff fistula, difficult vaginal access, or selected recurrent fistulas. Assess the ureters, bladder capacity, tissue quality, malignancy or radiation history and previous surgery. If concomitant ureterovaginal fistula is suspected, the 2026 EAU guideline weakly recommends contrast-enhanced CT with a late excretory phase and/or MRI.[19] If a malignant fistula or tumor recurrence is suspected, obtain a tissue biopsy before repair.[5]
| Consideration | Implication for planning |
|---|---|
| Accessible high fistula with separable bladder/vaginal planes | Extravesical repair can avoid an additional access cystotomy. |
| Dense scarring or uncertain ureteral relationships | Transvesical exposure may make identification and dissection safer. |
| Trigonal location or associated ureteral injury | Define anatomy carefully. Cystotomy or ureteral reconstruction may be required. |
| Need for reimplantation, augmentation or another abdominal procedure | Plan the combined reconstruction and exposure. These procedures remain possible during an abdominal operation, although a strictly no-access-cystotomy plan may need modification. |
The O'Conor series and ERUS consensus support choosing exposure that permits safe mobilization and closure.[5][7]
Operative Framework
The following describes the published extravesical principles and selected technique variants. Port geometry, dissection extent, sutures and drainage are adapted to the anatomy.
Positioning and ports
Dorsal lithotomy allows simultaneous abdominal and vaginal access. Laparoscopic series used four or five ports; Miklos placed a 10-mm umbilical port by open technique and three further ports under direct vision. Robotic repair uses standard robotic port placement with an assistant port. Adhesiolysis is often needed after prior hysterectomy.[3][5][9][10]
Pneumoperitoneum during conventional laparoscopic repair can be maintained with a Vaseline-soaked vaginal gauze pack and a clamped bladder catheter; a valve-less AirSeal trocar has also been described for this purpose.[17] The AirSeal comparison was conducted in robotic radical prostatectomy.[17]
Identify the fistula and protect the ureters
Perform cystoscopy and establish the number and location of openings. A guidewire, small catheter or ureteral stent passed through the fistula can mark it; in Miklos's technique the fistula-marker stent was removed once the tract was exposed, before excision and closure.[3] A vaginal sizer, sponge stick or end-to-end anastomosis (EEA) sizer supports the vaginal cuff and gives a firm backstop for the dissection between bladder and vagina. It should not be forced through the fistula. The ERUS consensus panel recommends preoperative marking of the fistula with a guidewire or ureteral catheter and a protective ureteral JJ stent.[3][5]
Separate the bladder and vagina
Develop the vesicovaginal space with atraumatic exposure, using sharp dissection with blunt dissection as needed. Identify the marked tract, work around the fistula until the bladder and vagina are separated, and preserve enough vascularized tissue for independent, tension-free closure. Retrograde bladder filling with dye can help confirm the tract. The Miklos technique excised the tract and extended dissection approximately 1–2 cm distally, and other series excised the tract with sharp dissection and trimmed the bladder edge. Lecoanet's robotic series excised the tract in every case. A fixed margin is not a rule, and viable bladder or vaginal tissue is not sacrificed to achieve one.[3][11][13]
Close the defects and test the repair
Miklos described one vaginal layer using 2-0 polyglactin and two bladder layers using 3-0 polyglactin, with interrupted figure-of-eight sutures and testing after each bladder layer. The bladder was filled retrograde with 300–400 mL of dye-tinted fluid; the volume in practice accounts for bladder capacity and avoids overdistension.[3] Miklos performed cystoscopy after each bladder layer.[3] When closure is near a ureteral orifice, confirm ureteral patency.[2] The goal is a watertight, tension-free repair.[3]
Abdel-Karim's series closed the bladder longitudinally and the vagina transversely, with omentum interposed between them. Orienting the closures perpendicular to each other keeps the suture lines from overlapping where the defects allow. The 2015 review associated documented leak testing with success; this is an association, and testing also permits immediate recognition of a leak.[4][10]
Decide on interposition
Vascularized omentum or peritoneum can separate the closures, particularly when tissue quality is compromised. For radiation-associated fistula repair, the 2026 EAU guideline weakly recommends an interposition graft.[19] The choice depends on the available tissue, previous operations and repair complexity. Miklos reported 42/43 closures without omentum in a mostly primary series, and the EAU robotic consensus regards interposition as seemingly beneficial.[3][5] Omental harvest adds operative time.[3][5] A 2024 systematic review included 46 studies of vesicovaginal, urethrovaginal and bladder neck-vaginal fistulas. Six vaginal-route comparisons (n=924) and three abdominal-laparotomy comparisons (n=131) detected no statistically significant improvement in fistula closure with interposition; neither set directly evaluated minimally invasive extravesical repair.[18]
Evans' retrospective abdominal series reported 10/10 benign fistulas healed with interposition versus 12/19 without. The often repeated 12/12 figure combines benign and malignant flap cases.[15]
Giusti used a collagen and fibrin sealant patch (TachoSil) in 16 early post-hysterectomy repairs; Yang reported a peritoneal flap in 15 selected patients. Giusti and Yang provide no comparison of sealant with vascularized tissue or either adjunct's effect on morbidity.[9][12]
Outcomes and Their Limits
| Study | Actual population | Findings and interpretation |
|---|---|---|
| Miklos 2015 | 44 laparoscopic VVFs, including 11 recurrent | Overall closure 43/44 at mean 17.3 months. The abstract reports 42/43 closures without omentum. “15-year experience” describes the accrual period, not 15-year patient follow-up.[3] |
| Abdel-Karim 2011 | 15 supratrigonal VVFs; malignant, radiation-related and recurrent fistulas excluded | All healed at mean 18.9 months after repair with omentum; no control group.[10] |
| Giusti 2018 | 16 early post-hysterectomy repairs with TachoSil | All reported continence at one month and good quality of life at three months; no high-grade complications reported.[9] |
| Tilala 2024 | Prospective nonrandomized comparison: 18 laparoscopic extravesical versus 18 O'Conor repairs of single, simple supratrigonal VVF | Mean operative time was 117 versus 140 min, blood loss 95 versus 210 mL, and stay 3.2 versus 3.9 days. Day-14 cystourethrography found leaks in 1/18 versus 3/18; initial closure was 17/18 versus 15/18 (P=.153), with mean subsequent follow-up of 14.7 versus 12.4 months. Route was surgeon-selected, mean fistula size was 12.8 versus 19.6 mm, and one intended extravesical case crossed to O'Conor and was counted there.[20] |
| Lecoanet 2023 | 22 robotic repairs: 9 extravesical, 13 transvesical | No clinical recurrence at median 15 months. Four postoperative complications occurred, including one major; 20/22 had interposition.[11] |
| Miklos systematic review 2015 | 44 reports, predominantly case reports/series; laparoscopic and robotic repairs | Among patients with a reported repair approach, closure was 100/102 (98.04%) extravesical versus 140/146 (95.89%) transvesical; no significant difference. Heterogeneity prevented a formal statistical meta-analysis. No randomized equivalence inference is warranted.[4] |
| Tavares synthesis 2026 | 14 studies, 206 robotic repairs: 169 transvesical and 37 extravesical | Descriptive overall complication and recurrence rates were 4.37% and 2.91%, with major complications 0.97%. Exploratory comparisons found no significant difference in operative time, complications or recurrence. Blood loss, stay and catheter duration were not statistically compared.[6] |
Tavares performed a descriptive synthesis rather than a formal meta-analysis. Its two comparative studies had moderate and serious risk of bias. Tavares reports recurrence over varying follow-up, without a uniform primary-closure endpoint or direct comparison with transvaginal series.[6]
Wang's 2026 retrospective cohort compared 78 open (31), laparoscopic (31) and robotic (16) transabdominal repairs and did not compare extravesical with transvesical exposure. Closure was assessed at 3 months. Post-hysterectomy fistulas had the highest success (95%), while radiation-induced fistulas (P = 0.031) and trigonal fistulas (32% failure versus 6% non-trigonal, P = 0.004) were associated with poorer outcomes. Approach was not significantly associated with closure at the three-month endpoint in this univariable analysis. Minimally invasive repair was associated with shorter operative time (P = 0.014) and less blood loss (P < 0.001) than open repair, with case complexity differing across groups.[14]
The 2026 Cochrane publication is a review protocol; it contains no completed comparative treatment results.[1]
Operative Parameters in Published Series
| Series | n | Platform | Operative time | Blood loss | Stay |
|---|---|---|---|---|---|
| Miklos 2015[3] | 44 | Laparoscopic | mean 144.8 min | abstract: mean 39 mL; text: mean 51 mL (inconsistent) | abstract: mean 1.1 d; text: mean 1.2 d (inconsistent) |
| Abdel-Karim 2011[10] | 15 | Laparoscopic | mean 171.6 min | mean 110 mL | mean 3 d |
| Abdel-Karim 2011 (LESS)[13] | 5 | Single-site | mean 198 min | mean 90 mL | 2 d |
| Giusti 2018[9] | 16 | Laparoscopic | mean 106 min | not reported in abstract | mean 3.2 d |
| Yang 2025[12] | 15 | Robotic | mean 137 min | mean 14 mL | mean 4.9 d |
| Tavares 2026[6] | 206 | Robotic (pooled) | mean 169 min | 14–90 mL across studies | most under 5 d |
Selected Variants
- Single-site laparoscopy: Abdel-Karim reported five patients with an additional suturing port, omental interposition and urethral drainage for three weeks; all were continent without recurrence at mean eight months. This is feasibility evidence for skilled laparoscopic surgeons.[13]
- Omental interposition demonstration: Watts reports one uncomplicated robotic case with a negative two-week cystogram and no reported incontinence at three months.[8]
- Peritoneal flap: Yang's 15-patient robotic series included seven prior repair failures and reported closure without complications at mean 7.8 months; 14 fistulas were supratrigonal and one was trigonal.[12] The operative report describes bladder opening to locate the fistula and calls the repair a modified O'Conor technique.[12]
- Oncologic treatment interval: Dayan-Schwartz's video case was repaired during a treatment-free interval after conservative treatment failed.[16]
Drainage, Follow-up and Complications
Maintain unobstructed bladder drainage and specify who will assess healing before removal. Miklos initially used both urethral and suprapubic catheters: the urethral catheter was usually removed within 24–72 hours once hematuria resolved, and the suprapubic catheter at 2–3 weeks after cystoscopic, filling and vaginal assessment. ERUS describes urethral drainage for 10–14 days and cystography before removal.[3][5] These schedules are protocol-specific. The 2026 EAU guideline weakly recommends continuous bladder drainage until healing is confirmed; its expert-opinion durations are 10–14 days for simple or postsurgical fistulas and 14–21 days for complex or postradiation fistulas.[19] Cystography before catheter removal can theoretically miss a persistent fistula if no voiding phase is obtained or if the fistula is at the bladder neck.[19] Stent removal depends on its indication, especially if ureteral reconstruction was performed.[3][5]
Miklos reported no major complications and no conversion to laparotomy in 44 laparoscopic repairs, and Tavares reported a 4.37% overall complication rate across robotic repairs.[3][6] Monitor for recurrent leakage, catheter obstruction, infection, bleeding, ureteral injury or obstruction, bowel or rectal injury during deep dissection, inadvertent cystotomy (repaired primarily), ileus after omental harvest and new urinary symptoms. Counsel separately about anatomical closure, continence and sexual recovery. Activity and intercourse restrictions follow healing; cystoscopy and imaging schedules vary.[5][6][11]
See Also
- O'Conor (Transabdominal Transvesical) VVF Repair
- Transvaginal Latzko Repair
- Transvaginal Sims-Simon Multilayered Closure
- Martius Flap for VVF
- Conservative VVF Management
- Endoscopic VVF Management
- Vesicovaginal Fistula (clinical)
- Female Fistula Repair (atlas)
- Omental Flap (foundations)
Videos
References
1. Okada Y, Matsushita T, Hasegawa T, et al. Surgical interventions for treating vesicovaginal fistula in women. Protocol, not a completed review. Cochrane Database Syst Rev. 2026;1:CD015413. doi:10.1002/14651858.CD015413
2. Miklos JR, Moore RD. Laparoscopic transperitoneal extravesical approach to vesicovaginal fistula repair without omental flap: a novel technique. Int Urogynecol J. 2015;26(3):447–448. doi:10.1007/s00192-013-2292-7
3. Miklos JR, Moore RD. Laparoscopic extravesical vesicovaginal fistula repair: our technique and 15-year experience. Int Urogynecol J. 2015;26(3):441–446. doi:10.1007/s00192-014-2458-y
4. 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
5. 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
6. Tavares M, do Carmo Pinto M, Conde Carvalho G, Silva-Ramos M. Vesicovaginal fistula robotics-assisted repair: a systematic review and quantitative synthesis. Int Urogynecol J. 2026. doi:10.1007/s00192-026-06578-8
7. Nesrallah LJ, Srougi M, Gittes RF. The O'Conor technique: the gold standard for supratrigonal vesicovaginal fistula repair. J Urol. 1999;161(2):566–568. doi:10.1016/s0022-5347(01)61951-7
8. Watts KL, Ho R, Ghavamian R, Abraham N. Robot-assisted extravesical vesicovaginal fistula repair utilizing laparoscopically mobilized omental flap interposition. Int Urogynecol J. 2017;28(4):641–644. doi:10.1007/s00192-016-3218-y
9. Giusti G, Lucci Chiarissi M, Abate D, et al. Early repair of post-hysterectomy vesicovaginal fistulae through a laparoscopic transperitoneal extravesical approach: experience of a single center. Urology. 2018;119:44–48. doi:10.1016/j.urology.2018.05.021
10. Abdel-Karim AM, Mousa A, Hasouna M, Elsalmy S. Laparoscopic transperitoneal extravesical repair of vesicovaginal fistula. Int Urogynecol J. 2011;22(6):693–697. doi:10.1007/s00192-010-1334-7
11. Lecoanet P, Madanelo M, Tricard T, et al. Robot-assisted vesicovaginal fistula repair: comparison of the extravesical and transvesical techniques. Int Urogynecol J. 2023;34(10):2479–2485. doi:10.1007/s00192-023-05565-7
12. Yang Y, Chenchen H, Shiliang W, Yuke C, Cheng S. Robot-assisted vesicovaginal fistula repair with "rainbow-shaped" peritoneal flap: a single-center experience. Arch Gynecol Obstet. 2025;311(6):1697–1703. doi:10.1007/s00404-024-07919-y
13. 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
14. 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
15. Evans DH, Madjar S, Politano VA, et al. Interposition flaps in transabdominal vesicovaginal fistula repairs: are they really necessary? Urology. 2001;57(4):670–674. doi:10.1016/s0090-4295(01)00933-5
16. Dayan-Schwartz A, Shachor N, Braverman M, Kogan L. Repair of vesicovaginal fistula in 12 steps using the da Vinci surgical system. J Minim Invasive Gynecol. 2026;33(2):162–163. doi:10.1016/j.jmig.2025.06.015
17. Tenggardjaja CF, Goldman HB. Transabdominal Vesicovaginal and Vesicouterine Fistula Repair. In: Cardozo L, Staskin D, eds. Textbook of Female Urology and Urogynecology. Vol 2: Surgical Perspectives. 5th ed. CRC Press; 2023:1152-1159. doi:10.1201/9781003144243-117
18. Thompson JC, Halder GE, Jeppson PC, et al. "Repair of vesicovaginal fistulae: a systematic review." Obstet Gynecol. 2024;143(2):229–241. doi:10.1097/AOG.0000000000005468
19. Harding CK, Lapitan MC, Arlandis S, et al. "EAU Guidelines on Management of Non-Neurogenic Female Lower Urinary Tract Symptoms." EAU Guidelines. EAU Guidelines Office; 2026. Official 2026 guideline.
20. Tilala YM, Panda S, Paul AS, Mohanty PK, Choudhuri S, Swain S. "Comparative analysis between laparoscopic extravesical repair and laparoscopic O'Connor repair for supratrigonal vesicovaginal fistula." Urol Res Pract. 2024;50(1):58–65. doi:10.5152/tud.2024.23147