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Extravesical Transabdominal VVF Repair

The extravesical transabdominal repair is a transperitoneal approach to vesicovaginal fistula (VVF) without a cystotomy, first described in the late 1990s as a less invasive alternative to the O'Conor transvesical technique. The defining feature is dissection of the vesicovaginal space from outside the bladder, avoiding bladder bivalving. The largest series (Miklos & Moore, n = 44, 15-yr experience) reports 98% success, and across laparoscopic and robotic platforms the extravesical approach is statistically equivalent to the transvesical (98.0% vs 95.9%; RR 0.98, 95% CI 0.94–1.02).[3][4] The EAU Robotic Urology Section consensus recommends that an extravesical approach usually provides a good anatomic view for adequate dissection.[5]

For transvaginal alternatives see Latzko Repair and Sims-Simon Multilayered Closure. For interposition options see Martius Flap for VVF and Omental Flap.

Historical Development​

First described by Miklos and Moore in 1999 as a laparoscopic transperitoneal technique that deliberately avoided the O'Conor bladder-bivalving step.[2][3] Rationale: the O'Conor cystotomy, while providing excellent intravesical visualization, is unnecessarily invasive for many supratrigonal fistulae — it adds bladder tissue loss, prolongs OR time, and requires closure of both the fistula defect and the cystotomy. The extravesical approach was designed to be less invasive while maintaining the same principles of wide vesicovaginal-space dissection, fistula-tract excision, and layered tension-free closure.[1][2]

Now adopted across open, laparoscopic, and robotic platforms, with an increasing trend toward extravesical use in robotic surgery.[6][7]

Principle​

Access the fistula from the peritoneal side of the bladder by dissecting the vesicovaginal space without opening the bladder. Excise the tract; close bladder and vaginal walls as separate layers from the extravesical perspective. Contrasts with the O'Conor, where bivalving the bladder approaches the fistula from inside the lumen.[1][8]

Indications​

Best suited for:[1][9][5]

  • Supratrigonal fistulae with good apical support — the classic indication.[9]
  • Post-hysterectomy VVF at the vaginal cuff — the most common clinical scenario.[10][3]
  • Primary or recurrent fistulae when the ureters are not immediately adjacent and do not require reimplantation.[3]
  • High fistulae difficult to access transvaginally without need for ureteral reimplant or augmentation.[1]
  • Narrow or stenotic vagina precluding transvaginal access.[6]

When to choose transvesical instead​

  • Ureteral reimplantation required — transvesical gives direct intravesical view of orifices.
  • Trigonal fistulae — proximity to ureteral orifices makes intravesical visualization safer.
  • Bladder augmentation required.
  • Very large or complex fistulae needing intravesical assessment of full extent.
  • Multiple fistulae requiring comprehensive intravesical inspection.[1][8][5]

Surgical Technique (Miklos & Moore Laparoscopic Extravesical)​

The most detailed description, based on the 15-year experience (n = 44):[3]

1. Positioning and preparation​

  • Dorsal lithotomy (Allen stirrups) for simultaneous abdominal and vaginal access.
  • Cystoscopy to confirm fistula location, size, and ureteral relationship.
  • Bilateral ureteral catheters or JJ stents for intraoperative protection.[5]
  • Transurethral Foley.
  • Vaginal probe, EEA sizer, or lighted stent through the vagina into the fistula tract for identification from above.

2. Port placement and peritoneal entry​

  • Laparoscopic: 4–5 ports (umbilical camera + working).[11]
  • Robotic: standard robotic port placement with assistant port.[5]
  • Adhesiolysis as needed (often extensive after prior hysterectomy).

3. Identification of the fistula​

  • Identify the posterior bladder wall.
  • Locate the fistula by the vaginal-cuff scar and area of fibrosis / induration.
  • The vaginal probe / EEA sizer tents up the vaginal cuff to identify the fistula site from the peritoneal side.
  • Retrograde bladder filling with methylene blue or indigo carmine helps confirm the tract by visualizing leakage.

4. Vesicovaginal-space dissection (the defining step)​

  • Transverse incision of peritoneum overlying posterior bladder wall, ~2 cm above the fistula.
  • Enter and develop the vesicovaginal space with sharp + blunt dissection.
  • Separate posterior bladder wall from anterior vaginal wall, working circumferentially around the fistula in all directions.
  • Carry dissection at least 2–3 cm beyond fistula margins for tension-free, non-overlapping closure.
  • EAU consensus: adequate and wide dissection of the vesicovaginal space is critical.[5]
  • The vaginal probe / sizer maintains counter-traction.

5. Fistula-tract excision​

  • Sharply circumscribe and excise the tract in its entirety; remove all surrounding fibrotic and scarred tissue.
  • Creates separate bladder and vaginal defects with healthy edges.
  • EAU consensus: careful sharp dissection of fistula edges.[5]
  • The Lecoanet multicenter robotic series excised the tract in all cases.[12]

6. Vaginal-wall closure​

  • Close the vaginal defect first.
  • Running or interrupted 2-0 / 3-0 absorbable, single layer, full-thickness.
  • Close in a transverse direction (perpendicular to the bladder closure) to offset the suture lines.[11]

7. Interposition flap (variable)​

OptionNotes
Omental flapPedicled flap on left or right gastroepiploic; sutured between vaginal and bladder closures.[9][11]
Peritoneal flap"Rainbow-shaped" or standard flap from pelvic peritoneum.[13]
TachoSilTwo layers of collagen-fibrinogen-thrombin patch (4 × 4 cm) — alternative to tissue-flap interposition.[10]
NoneMiklos & Moore — 98% success without omental flap in 43/44 patients.[3]

8. Bladder closure​

Two-layer closure:[3]

  • First layer: running or interrupted 3-0 absorbable, mucosa + submucosa.
  • Second layer: imbricating interrupted or running 3-0 absorbable, detrusor / muscularis.
  • Longitudinal direction (perpendicular to the transverse vaginal closure) to keep suture lines offset.[11]
  • Combined with the vaginal closure this is the three-layer closure described by Miklos & Moore: double-layer bladder + single-layer vagina.

9. Intraoperative integrity testing​

  • Retrograde fill the bladder with 200–300 mL of methylene blue or indigo carmine; inspect for leak.
  • Systematic-review data: a small uplift in success when intraoperative bladder filling is documented.[4]

10. Drainage​

  • Suprapubic catheter preferred by Miklos & Moore (2–3 weeks).[3]
  • Alternative: transurethral Foley alone — EAU recommends ~10 days.[5]
  • Pelvic drain (Jackson-Pratt) optional.

Outcomes​

SeriesnPlatformFlapSuccessKey finding
Miklos & Moore 2015[3]44LaparoscopicNo flap in 98%98% (97% primary, 100% recurrent)15-yr; EBL 39 mL; LOS 1.1 d; no major complications
Abdel-Karim 2011[11]15LaparoscopicOmental in all100%OR 172 min; EBL 110 mL; LOS 3 d; 18.9-mo follow-up
Giusti 2018[10]16LaparoscopicTachoSil in all100%Early repair; OR 106 min; LOS 3.2 d; no high-grade complications
Lecoanet 2023[12]9 (extravesical)RoboticFlap in 90.9% (overall)100%No difference vs transvesical (n = 13); median 15-mo follow-up
Watts 2017[9]Case reportRoboticOmental100%Discharged POD 1; no fistula at 3 mo
Abdel-Karim 2011 (LESS)[14]5LESSOmental100%First LESS extravesical VVF; OR 198 min; 8-mo follow-up
Miklos SR 2015[4]PooledLap / roboticVariable98.0% vs 95.9% transvesicalRR 0.98 (95% CI 0.94–1.02) — no statistical difference
Tavares SR 2026[7]206 (pooled, robotic)RoboticVariable97% overall (2.9% recurrence)No significant difference between transvesical and extravesical

Extravesical vs Transvesical (O'Conor)​

FeatureExtravesicalO'Conor (Transvesical)
CystotomyNoYes (bivalving or shorter cystotomy)
Fistula visualizationIndirect (vesicovaginal space; vaginal probe)Direct intravesical
Ureteral-orifice visualizationCystoscopy requiredDirect via cystotomy
Bladder tissue lossMinimalGreater
InvasivenessLessMore
OR timeGenerally shorterGenerally longer
Blood lossLess (39 mL Miklos)More
Hospital stayShorter (1.1 d Miklos)Longer
Success (lap / robotic)98.0%95.9%
Statistical differenceNone (RR 0.98; 95% CI 0.94–1.02)—
Ureteral reimplantationNot possible without cystotomyPossible
Bladder augmentationNot possiblePossible
Best suited forSupratrigonal with good apical supportTrigonal; reimplant needed; complex anatomy

The Tavares 2026 SR (n = 206 robotic) confirmed no significant differences in OR time, blood loss, complications, or recurrence between approaches.[7] The Lecoanet multicenter robotic comparison (n = 22) found 100% cure in both groups.[12]

The Omental-Flap Debate in Extravesical Repair​

Against routine omental flap​

  • Miklos & Moore 15-yr — 98% success without omental flap in 43/44 patients (only 1 received a flap; success without flap was 98%).[3]
  • Lap / robotic SR — no statistical difference in success with or without interposition.[4]
  • Omental harvest adds OR time and may produce postop abdominal pain and ileus.[1]

For routine flap​

  • Evans 2001 — 100% with flap (12/12) vs 63% without (12/19) for benign transabdominal VVF — recommended interposition in all transabdominal repairs.[16]
  • EAU Robotic Section consensus: interposition seems to be beneficial.[5]
  • Lecoanet robotic series used flaps in 90.9% with 100% success.[12]
  • Abdel-Karim laparoscopic series used omental flap in all 15 patients with 100% success.[11]

Alternative interposition materials​

  • TachoSil — two layers (4 × 4 cm) with 100% success in 16 patients (Giusti); described as "straightforward and atraumatic."[10]
  • "Rainbow-shaped" peritoneal flap — Yang n = 15, robotic, 100% at 7.8-mo follow-up; OR 137 min, EBL 14 mL.[13]

Practice​

Individualize. For simple non-irradiated primary fistulae with well-vascularized tissue, three-layer closure without flap may be sufficient. For recurrent, radiation-induced, or complex fistulae, tissue interposition is recommended.[3][5][16]

Modifications and Variants​

LESS extravesical repair​

Abdel-Karim 2011 — first LESS extravesical VVF in 5 patients via TriPort + prebent instruments through a single umbilical incision (additional 5-mm extraport for suturing). Omental flap in all; OR 198 min, EBL 90 mL, LOS 2 d, 100% at 8-mo follow-up.[14]

Robotic extravesical with rainbow-shaped peritoneal flap​

Yang 2025 — crescent-shaped peritoneal flap from the pelvic sidewall rotated and sutured between the closures. n = 15; OR 137 min; EBL 14 mL; LOS 4.9 d; 100% at 7.8 mo. Avoids omental-harvest morbidity while providing vascularized interposition.[13]

Robotic 12-step technique​

Dayan-Schwartz 2026 — systematic 12-step robotic extravesical approach demonstrated even in a post-oncologic patient on chemo+immunotherapy (carboplatin/paclitaxel/dostarlimab); discharged POD 1; closed at 6 mo.[17]

Early extravesical repair​

Giusti 2018 — extravesical can be safely performed as early repair (within weeks of the inciting event rather than the traditional 3 months). n = 16; OR 106 min; LOS 3.2 d; 100% with no high-grade complications.[10]

Operative Parameters​

SeriesnPlatformOR timeEBLLOSCatheterFollow-up
Miklos & Moore 201544LaparoscopicNR39 mL1.1 d2–3 wk SPC17.3 mo
Abdel-Karim 201115Laparoscopic172 min110 mL3 d3 wk18.9 mo
Giusti 201816Laparoscopic106 minNR3.2 dNR3 mo
Yang 202515Robotic137 min14 mL4.9 dNR7.8 mo
Abdel-Karim 2011 (LESS)5LESS198 min90 mL2 d3 wk8 mo
Tavares SR 2026206 (pooled)Robotic169 min14–90 mL5 dVariableVariable

Complications​

Very low complication rates:[3][7]

  • No major intra- or postoperative complications in the Miklos & Moore 44-patient series.[3]
  • No conversion to open laparotomy in any laparoscopic extravesical series.[3][11]
  • Overall 4.4% complication rate (major 0.97%) across all robotic VVF repairs (both approaches).[7]
  • No significant difference in complication rates between extravesical and transvesical approaches.[7]

Potential complications:

  • Ureteral injury — mitigated by preoperative ureteral catheterization / stenting.
  • Rectal injury — rare; risk during deep vesicovaginal-space dissection.
  • Inadvertent cystotomy during dissection — repaired primarily.
  • Ileus — primarily when omental flap is harvested.
  • Wound complications — reduced with MIS.
  • Recurrence 2.9% overall in the most recent robotic SR.[7]

Predictors of Success​

Wang 2026 — comparative analysis of 78 transabdominal VVF repairs (open, lap, robotic):[15]

  • Post-hysterectomy fistulae had the highest success (95%).
  • Radiation-induced fistulae were associated with significantly poorer outcomes (p = 0.031).
  • Trigonal fistulae had a failure rate of 32% vs 6% non-trigonal (p = 0.004).
  • Surgical approach was not an independent predictor of closure rates.
  • MIS techniques reduced OR time (p = 0.014) and blood loss (p <0.05).

Postoperative Care​

  • Bladder drainage — suprapubic catheter for 2–3 weeks (Miklos & Moore) or transurethral Foley for ~10 days (EAU consensus).
  • Ureteral stents / catheters — removed POD 1–2 (open-ended) or 4–6 wk (JJ stents).
  • Pelvic drain — removed when output minimal (typically 1–3 d).
  • Anticholinergics for bladder spasms.
  • Cystogram at 2–3 weeks to confirm watertight closure before catheter removal.
  • Avoid straining, heavy lifting, intercourse for 6–8 wk.
  • Follow-up cystoscopy at 6 wk to 3 mo.

Advantages​

  • No cystotomy — avoids the morbidity of bivalving and the need to close a large cystotomy.[1][9]
  • Minimizes bladder tissue loss — only the fistula tract is excised.[1]
  • Less invasive — shorter OR time, less blood loss, shorter LOS than transvesical.[3][15]
  • Omental flap may be unnecessary — 98% without flap in the largest series.[3]
  • Maintains vaginal length — no colpocleisis effect.[9]
  • Excellent visualization — particularly with robotic 3D magnification.[5]
  • Applicable to primary and recurrent fistulae — 100% success for recurrent in Miklos & Moore.[3]

Disadvantages and Limitations​

  • No direct intravesical visualization of ureteral orifices — relies on preoperative cystoscopy and ureteral catheterization.[1][8]
  • Cannot perform ureteral reimplantation without converting to a transvesical approach.[1]
  • Cannot perform bladder augmentation.[1]
  • Technically demanding — advanced laparoscopic / robotic suturing skills for deep pelvic dissection.[6]
  • Not suitable for trigonal fistulae — proximity to ureteral orifices makes intravesical visualization safer.[15]
  • Vesicovaginal-space dissection can be challenging in extensive fibrosis or prior radiation.[6]
  • Limited evidence base — no RCTs comparing extravesical to transvesical; all data from retrospective case series.[4][7]

A clear trend toward the extravesical approach in contemporary practice, particularly on the robotic platform:[5][6][7]

  • EAU Robotic Urology Section consensus 2020: extravesical robotic approach usually provides a good anatomic view for adequate dissection.[5]
  • Tavares 2026 SR — no significant differences between transvesical and extravesical robotic approaches across all outcomes.[7]
  • Improved robotic visualization and instrument articulation may obviate the need for cystotomy in many cases previously considered to require it.[6]
  • Novel interposition materials (TachoSil, peritoneal flaps) may further reduce extravesical-approach morbidity by eliminating omental-flap harvest.[10][13]

See Also​

References​

1. Okada Y, Matsushita T, Hasegawa T, et al. Surgical interventions for treating vesicovaginal fistula in women. 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. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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