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O'Conor (Transabdominal Transvesical) VVF Repair

The O'Conor repair is a transabdominal transvesical approach that opens the bladder toward the fistula to expose the defect and ureteral orifices. O'Conor and Sokol published their report in 1951. Nesrallah later reported closure in all 29 selected supratrigonal iatrogenic cases, including nine with prior repair attempts; that uncontrolled series does not establish a universal “gold standard” over vaginal or extravesical repair.[1][20]

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​

In the classic transperitoneal transvesical approach, a deliberate cystotomy exposes the fistula from within the bladder.[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]

Direct intravesical exposure can facilitate tract excision, but the extent of tissue removal still depends on viability and what is needed for closure. Do not sacrifice useful tissue simply to remove every area of fibrosis.[2][11]

Abdominal vesicovaginal fistula approachesOriginal schematic · v2026-09-11 · Clinical review pending

Extravesical dissection approaches the fistula without bivalving the bladder. O'Conor access opens the bladder toward the fistula. Bladder and vaginal defects are closed separately. Extravesical repair still opens the bladder defect; route and interposition depend on fistula and tissue quality. Related: extravesical. (Original WARWIKI schematic; see the figure source record and review limits.)

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 the tract under direct vision and remove nonviable tissue/foreign material as indicated. Individualize excision, preserving viable tissue needed for a tension-free closure.
  • 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.
  • Mobilize sufficiently for a tension-free closure without unnecessary dissection near the ureters; the required distance depends on the defect.[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 described a modification intended to limit tissue disruption; its uncontrolled series did not establish comparative morbidity reduction:[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%Nine had prior repair attempts; the abstract’s accompanying 34% is arithmetically inconsistent with 29 patients
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]37 overall; 29 benignOpen transabdominalBenign/malignantBenign subgroup: 10/10 with flap versus 12/19 withoutNonrandomized; cannot establish causal flap benefit
Lecoanet 2023[14]22Robotic (13 transvesical, 9 extravesical)Supratrigonal + trigonalNo recurrence at median 15 monthsSmall nonrandomized comparison does not establish equivalence
Tavares 2026[15]206 across 14 studiesRobotic, both routesMixedReported recurrence 2.91%; this is not a separately established primary-closure rateNo significant route difference; heterogeneous observational data

O'Conor (Transvesical) vs Extravesical​

FeatureTransvesicalExtravesical
AccessSeparate cystotomy, bivalving or a shorter openingDissection through the vesicovaginal space without a separate access cystotomy
Bladder openingAccess cystotomy and fistula defect require closureThe fistula defect still opens into the bladder and requires closure
Ureteral protectionDirect intravesical view, with catheters/stents as indicatedCystoscopic identification and protection as indicated
SelectionUseful when intravesical exposure or associated reconstruction is neededUseful when extravesical mobilization safely exposes the defect

The 2015 review reported 95.9% transvesical and 98.0% extravesical closure across mostly case reports/series; it did not perform a conventional meta-analysis because of heterogeneity. The 2026 robotic synthesis also found no significant route difference. Neither establishes equivalence or universal advantages in blood loss, operative time, tissue loss or morbidity.[5][15]

Omental Flap Interposition​

Omentum can provide vascularized separation between organ repairs, particularly in a compromised tissue bed. Routine use in every uncomplicated abdominal VVF remains unsupported by high-level evidence.[11][19]

  • Evans's retrospective series included 29 benign fistulas: 10/10 closed with a flap versus 12/19 without. The additional two successful flap cases were malignant fistulas, so 12/12 is not the benign-group denominator. Selection and other confounding prevent a causal comparison.[12]
  • Dalela used interposition in all 26 cases; Miklos reported selected extravesical repairs without omentum. Neither one-arm experience proves whether the flap is necessary.[4][7]
  • The ERUS robotic consensus favored considering interposition, while reviews found no statistically significant closure advantage across heterogeneous reports. Individualize tissue choice, reach and harvest morbidity.[5][11]

Transabdominal vs Transvaginal​

Use vaginal access when it provides adequate exposure and reconstruction; abdominal access may be needed for an inaccessible defect or associated ureteral/bladder reconstruction. Fistula complexity, tissue condition and surgical expertise affect selection.[6][19]

Shamout's retrospective series included 49 vaginal and 17 abdominal repairs, with 98% and 82% success respectively and better perioperative measures in the vaginal group. This is not randomized evidence that one route is intrinsically superior. Patient-reported follow-up studies also suggest both routes can restore function, but small responder groups and selection limit equivalence claims.[10][16][17]

Functional Outcomes and Complications​

  • Bladder function: Nesrallah reported no significant capacity loss in 29 selected cases, whereas Mondet reported postoperative voiding disorders in 38% of a different 28-patient cohort. Neither describes the expected outcome for every O'Conor repair.[1][3]
  • Sexual and urinary symptoms: Studies after successful closure show persistent symptoms in some women. Panaiyadiyan enrolled 81 women with successful repairs; sexual-function outcomes used an assessed subset. Lee's FSFI response rate was only 33%. Such data cannot establish a universal 34% dysfunction rate or guarantee equal function after each route.[16][17]
  • Stress incontinence: One patient in each of the Nesrallah and Dalela series had residual SUI. Anatomical fistula closure should not be reported as complete continence.[1][7]
  • Operative complications: Counsel about infection, bleeding, bowel/ureteral injury, ileus and wound morbidity according to the chosen exposure and associated reconstruction. Interposition and minimally invasive access do not eliminate these risks.[6][13]

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][18]

Robotic-assisted O'Conor​

Robotic VVF repair was reported from 2005. The 2026 review (Tavares, 206 patients across 14 studies) combined transvesical and extravesical repairs, so these are not O'Conor-specific estimates:[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%.
  • Most studies reported hospital stays less than five days.[15]

An extravesical approach avoids a separate access cystotomy and bladder bivalving, but the fistula-related bladder defect still requires closure. Select the route for exposure and associated reconstruction.[11][14][15]

Postoperative Care​

Provide unobstructed bladder drainage; a second catheter and a pelvic drain are selected according to the reconstruction. Catheter and stent removal depend on the repair, ureteral reconstruction and leakage assessment, not a universal postoperative-day rule.[6][11]

Wong's two-patient laparoscopic report removed ureteral catheters on days one and two and used a gravity cystogram at three weeks. That is a described protocol, not evidence that all O'Conor repairs require the same schedule. EAU expert guidance suggests 10–14 days of bladder drainage for simple/postsurgical and 14–21 days for complex/radiation repair, with source-specific differences summarized in fistula principles.[8][19]

Assess persistent leakage, emptying and symptoms, and choose dye testing, cystography or cystoscopy for the clinical question. Routine follow-up cystoscopy at six weeks to three months is not established for every uncomplicated repair. Discuss activity and intercourse as tissue healing permits.

The 2026 Cochrane item below is a protocol, not completed comparative evidence.[2]

See Also​

Videos​

Robotic Transvesical Vesicovaginal Fistula Repair
AUA University (2024)

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. Protocol. 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. 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

17. 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

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

19. European Association of Urology. Non-neurogenic Female LUTS guideline, section 4.8: urinary fistula. 2026 edition. Full guideline section.

20. O'Conor VJ, Sokol JK. Vesicovaginal fistula from the standpoint of the urologist. J Urol. 1951;66:579–585. PubMed record.