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O'Conor (Transabdominal Transvesical) VVF Repair

The O'Conor repair is the classic transabdominal transvesical (transperitoneal-transvesical) technique for vesicovaginal fistula (VVF), described by Vincent J. O'Conor Jr. in 1951. It is widely considered the gold standard for supratrigonal VVF. The defining feature is sagittal bivalving of the bladder down to the fistula, providing complete intravesical visualization of the fistula and both ureteral orifices. In the landmark Nesrallah series, 100% of 29 patients (including 9 with prior failed repairs) achieved closure at the first attempt.[1]

For transvaginal alternatives see Latzko Repair and Sims-Simon Multilayered Closure. For the interposition flap typically used with the O'Conor see the omental flap (and for the alternative when transvaginal repair is chosen, see Martius Flap for VVF).

Principle​

O'Conor's 1951 description was a transperitoneal supravesical approach — the bladder is accessed transperitoneally and the fistula approached from within the bladder via a deliberate cystotomy.[2][1] Wide opening of the bladder ("bivalving") provides:[2][1][3]

  • Complete intravesical visualization of the fistula tract.
  • Direct identification and protection of both ureteral orifices.
  • Excision of the entire fistula tract under direct vision.
  • Separate, layered closure of vaginal wall and bladder wall as independent tissue planes.
  • Access for concurrent ureteral reimplantation if needed.

The technique remains the traditional abdominal approach to VVF repair whether performed via open laparotomy, laparoscopy, or robotic assistance.[4][5]

Indications​

When transvaginal repair is precluded by fistula characteristics or patient factors:[2][6]

  • Supratrigonal fistulae that are high and difficult to visualize transvaginally — the classic and most common indication.[1][7]
  • Fistulae near the ureteral orifices requiring ureteral reimplantation (33% of cases in Mondet's series).[3]
  • Need for bladder augmentation.
  • Failed prior transvaginal repair — frequently used as salvage after failed Latzko or other vaginal repairs.[8][1]
  • Concurrent abdominal pathology requiring laparotomy.
  • Narrow or stenotic vagina precluding adequate transvaginal access.[9]
  • Large or complex fistulae with extensive fibrosis.
  • Radiation-induced fistulae where omental interposition is planned.
  • Multiple fistulae requiring comprehensive intravesical assessment.

Contraindications / poor fit​

  • Small, simple, transvaginally accessible fistulae — better managed transvaginally with shorter OR time, less blood loss, less pain, shorter LOS.[2][10]
  • Patients unfit for laparotomy or general anesthesia.
  • Distal / urethral fistulae — better approached transvaginally.

Surgical Technique (Classic O'Conor)​

The classic open technique:[1][8][3][6]

1. Positioning and preparation​

  • Low dorsal lithotomy (Allen stirrups) for simultaneous abdominal and vaginal access.
  • Cystoscopy to confirm fistula location, size, and proximity to ureteral orifices.
  • Bilateral 5 Fr open-ended ureteral catheters placed cystoscopically for intraoperative ureteral protection.[8][11]
  • Transurethral Foley.
  • Vaginal pack or EEA sizer / probe to identify the vaginal cuff / fistula from above.

2. Abdominal incision and peritoneal entry​

  • Midline infraumbilical or Pfannenstiel incision (open).
  • Enter peritoneum; perform adhesiolysis (often extensive after prior hysterectomy).
  • Identify and mobilize the bladder dome.

3. Posterior cystotomy — the defining step​

  • Stay sutures on the bladder dome.
  • Sagittal (midline) cystotomy on the posterior bladder wall, extending from the dome downward toward the fistula.
  • Continue until the fistula tract is directly visualized from inside the bladder.
  • In the classic description, the bladder is essentially bivalved in the sagittal plane down to the fistula, retracting the two halves laterally for wide exposure.
  • Confirm previously placed ureteral catheters at each orifice.[1][8]

4. Fistula-tract excision​

  • Circumscribe and excise the fistula tract in its entirety, including all surrounding fibrotic tissue.
  • Excision through full-thickness bladder wall and into vaginal wall — creating separate bladder and vaginal defects.
  • Critical distinction from the Latzko, which does not excise the tract.[2][1]

5. Vesicovaginal-space dissection​

  • Wide dissection separates posterior bladder wall from anterior vaginal wall.
  • Carry 2–3 cm beyond fistula margins for tension-free, non-overlapping closure.[6]

6. Vaginal-wall closure​

  • Single-layer closure with interrupted or running 2-0 / 3-0 absorbable sutures incorporating full-thickness vaginal wall.
  • In some series the vaginal fistula orifice is intentionally left open to allow drainage (66% of Mondet's cases).[3]

7. Interposition flap​

  • Vascularized tissue interposed between the vaginal and bladder closures.
  • Omental flap is the most commonly used:[2][12]
    • Mobilize the greater omentum off the transverse colon.
    • Pedicled flap based on left or right gastroepiploic artery.
    • Bring into the pelvis and suture over the vaginal closure.
  • Alternatives: peritoneal flap, sigmoid epiploicae, bladder adventitia.[2][13]

8. Bladder closure​

  • Two-layer closure:[6]
    • First layer (mucosa / submucosa) — running or interrupted 3-0 absorbable.
    • Second layer (detrusor / muscularis) — imbricating interrupted 3-0 absorbable.
  • Closure incorporates both the fistula defect and the sagittal cystotomy.
  • Confirm watertight closure with retrograde dye fill (methylene blue or indigo carmine).[6][5]

9. Drainage​

  • Transurethral Foley + often a suprapubic catheter for continuous bladder drainage.
  • Pelvic drain (Jackson-Pratt) near the repair.
  • Maintain catheter drainage 2–3 weeks (mean 15.8 days in Mondet).[7][3]

Modified O'Conor (Dalela)​

Dalela 2006 reduced O'Conor morbidity while preserving its principles:[7]

  • Shorter cystotomy (sagittal or parasagittal) instead of full bladder bivalving — only long enough to see the fistula.
  • No retropubic-space dissection — transperitoneal without entering the space of Retzius.
  • Bladder rotation flaps instead of midline closure when the defect is large.
  • Single-layer continuous interlocking sutures for both bladder and vagina.
  • Universal vascularized tissue interposition (omental or peritoneal flap).

In 26 supratrigonal VVFs (17 primary, 9 recurrent), 100% closure with mean OR time 104 min and insignificant blood loss; 3 required ureteroneocystostomy.[7]

Outcomes​

SeriesnApproachTypeSuccessKey finding
Nesrallah 1999[1]29Open O'ConorSupratrigonal iatrogenic100%34% had prior failed repairs; no bladder dysfunction or capacity loss
Dalela 2006[7]26Modified openSupratrigonal (17 primary, 9 recurrent)100%Mean OR 104 min; 3 reimplants
Mondet 2001[3]28Open transvesicalMixed (47% complex; 40% trigonal)85%33% reimplanted; 38% postop voiding disorders
Evans 2001[12]37Open transabdominalMixed100% with flap, 63% withoutStrong argument for routine flap use
Lecoanet 2023[14]22Robotic (13 transvesical, 9 extravesical)Supratrigonal + trigonal100%No difference between transvesical and extravesical
Tavares 2026[15]206 (pooled)RoboticMixed97% (recurrence 2.91%)No significant difference between transvesical and extravesical

O'Conor (Transvesical) vs Extravesical​

FeatureO'Conor (Transvesical)Extravesical
CystotomyYes (bivalving or shorter)No
Fistula visualizationDirect intravesicalIndirect from vesicovaginal space
Ureteral-orifice visualizationDirectCystoscopy required
Bladder tissue lossGreater (cystotomy + tract excision)Minimal
InvasivenessMoreLess
OR timeLongerShorter
Success (lap / robotic)95.9%98.0%
Statistical differenceNone (RR 0.98; 95% CI 0.94–1.02)—
Best forTrigonal fistulae; need for ureteral reimplantSupratrigonal with good apical support

A systematic review of 44 lap / robotic studies found no statistical difference in success between transvesical (95.9%) and extravesical (98.0%).[5] The most recent robotic SR (n = 206, 14 studies) confirmed no significant differences in OR time, blood loss, complications, or recurrence.[15] EAU Robotic Urology Section 2020 consensus: extravesical usually provides a good anatomic view; transvesical remains essential when direct intravesical visualization of the ureters is needed.[11]

Omental Flap Interposition​

The omental flap is the most commonly used interposition tissue in transabdominal VVF repair and a traditional component of the O'Conor:[2][12]

For routine use

  • Evans 2001 — 100% success with flap (12/12) vs 63% without (12/19) for benign transabdominal VVF repairs; recommended interposition in all transabdominal repairs even for benign fistulae with well-preserved tissue.[12]
  • Dalela modified O'Conor used universal interposition with 100% success.[7]
  • EAU Robotic Section 2020 consensus: tissue interposition seems to be beneficial in robotic VVF repair.[11]

Against routine use

  • Miklos & Moore extravesical — 98% success in >40 patients without omental flap.[4]
  • Lap / robotic VVF repair SR — no statistical difference in success with or without interposition.[5]
  • Omental harvest may produce postop abdominal pain and temporary ileus.[2]

Practice. Most surgeons performing the O'Conor use omental interposition routinely, especially for complex, recurrent, or radiation-induced fistulae. Necessity for simple non-irradiated fistulae remains debated.[2][5][12]

Transabdominal vs Transvaginal​

FeatureTransabdominal (O'Conor)Transvaginal (Latzko / Sims-Simon)
OR timeLongerShorter
Blood lossGreaterLess
Postoperative painMoreLess
Hospital stay2–5 d1–2 d
Complication rateHigherLower
Success85–100%82–100%
Vaginal lengthPreservedShortened (Latzko) or preserved (Sims-Simon)
Ureteral reimplantationPossibleNot possible
Bladder augmentationPossibleNot possible
Sexual function (long term)ComparableComparable
Urinary function (long term)ComparableComparable

A 66-patient comparative study found transvaginal repair achieved 98% success vs 82% abdominal, with significantly shorter OR time, less blood loss, reduced LOS, and lower complication rates (p <0.05) — though the abdominal cohort likely had more complex fistulae.[10] Long-term patient-reported sexual and urinary function are comparable between approaches.[17]

Functional Outcomes and Complications​

  • Bladder function. Nesrallah reported no significant bladder dysfunction or capacity loss after O'Conor.[1] Mondet reported postoperative voiding disorders in 38% of transperitoneal-transvesical patients — functional outcomes are not uniformly excellent.[3]
  • Sexual function. Long-term sexual dysfunction occurs in ~34% regardless of approach. Fistula size and site (not surgical approach) are the main predictors of urinary dysfunction; multiparity is the strongest predictor of sexual dysfunction.[17] One series noted a non-significant trend toward worse sexual function after transabdominal repair and ≥2 prior repairs.[18]
  • Stress urinary incontinence. 3–10% post O'Conor — typically related to pre-existing urethral incompetence rather than the repair itself.[1][7]
  • Approach-specific complications. Ileus (peritoneal entry / omental harvest); wound complications (incisional hernia, infection — reduced with MIS); ureteral injury (mitigated by intraoperative ureteral catheterization); prolonged catheterization 2–3 wk; standard DVT risk.

Evolution to Minimally Invasive​

The O'Conor adapts cleanly to laparoscopic and robotic platforms:[5][9][14][15]

Laparoscopic O'Conor​

First reported in the late 1990s. Bladder bivalved laparoscopically; fistula excised and closed with intracorporeal suturing. Reported success 80–100%.[5][19]

Robotic-assisted O'Conor​

First reported in 2005. The 2026 systematic review (Tavares, n = 206 across 14 studies) reported:[15]

  • Combined mean OR time 169 ± 70 min.
  • Minimal blood loss 14–90 mL.
  • Overall complication rate 4.4% (major 0.97%).
  • Recurrence rate 2.9%.
  • Hospital stay <5 d.[11]

A trend toward the extravesical approach (avoiding cystotomy) has emerged in robotic surgery, since improved visualization and dexterity may obviate the need for bladder bivalving in many cases.[11][14][15]

Postoperative Care​

  • Dual catheter drainage — transurethral Foley + suprapubic — for 2–3 weeks (some protocols use transurethral only).
  • Pelvic drain removal when output minimal (typically 1–3 d).
  • Ureteral stents / catheters removed POD 1–2 (or 4–6 wk for JJ stents).[8][11]
  • Anticholinergics for bladder spasms.
  • Gravity cystogram at 2–3 weeks to confirm watertight closure before catheter removal.[8]
  • Avoid straining, heavy lifting, intercourse for 6–8 wk.
  • Follow-up cystoscopy at 6 wk to 3 mo.
  • EAU robotic consensus recommends indwelling catheter for ~10 days.[11]

See Also​

References​

1. 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

2. 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

3. Mondet F, Chartier-Kastler EJ, Conort P, et al. Anatomic and functional results of transperitoneal-transvesical vesicovaginal fistula repair. Urology. 2001;58(6):882–886. doi:10.1016/s0090-4295(01)01395-4

4. 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

5. 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

6. McKay E, Watts K, Abraham N. Abdominal approach to vesicovaginal fistula. Urol Clin North Am. 2019;46(1):135–146. doi:10.1016/j.ucl.2018.08.011

7. Dalela D, Ranjan P, Sankhwar PL, et al. Supratrigonal VVF repair by modified O'Conor's technique: an experience of 26 cases. Eur Urol. 2006;49(3):551–556. doi:10.1016/j.eururo.2005.12.037

8. Wong C, Lam PN, Lucente VR. Laparoscopic transabdominal transvesical vesicovaginal fistula repair. J Endourol. 2006;20(4):240–243; discussion 243. doi:10.1089/end.2006.20.240

9. 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

10. Shamout S, Anderson K, Baverstock R, Carlson K. Evaluation of surgical approaches for vesicovaginal fistulae repair: the case for transvaginal repair as the gold standard. Int Urogynecol J. 2021;32(9):2429–2435. doi:10.1007/s00192-021-04869-w

11. 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

12. 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

13. Agrawal V, Kucherov V, Bendana E, et al. Robot-assisted laparoscopic repair of vesicovaginal fistula: a single-center experience. Urology. 2015;86(2):276–281. doi:10.1016/j.urology.2015.02.074

14. 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

15. 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

16. Bodner-Adler B, Hanzal E, Pablik E, Koelbl H, Bodner K. Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: a systematic review and meta-analysis. PLoS One. 2017;12(2):e0171554. doi:10.1371/journal.pone.0171554

17. Panaiyadiyan S, Nayyar BU, Nayyar R, et al. Impact of vesicovaginal fistula repair on urinary and sexual function: patient-reported outcomes over long-term follow-up. Int Urogynecol J. 2021;32(9):2521–2528. doi:10.1007/s00192-020-04648-z

18. Lee D, Dillon BE, Lemack GE, Zimmern PE. Long-term functional outcomes following nonradiated vesicovaginal repair. J Urol. 2014;191(1):120–124. doi:10.1016/j.juro.2013.07.004

19. Shah SJ. Laparoscopic transabdominal transvesical vesicovaginal fistula repair. J Endourol. 2009;23(7):1135–1137. doi:10.1089/end.2009.0080