When to consider a transvesical approach for vesicovaginal fistula repair

Cleveland Clinic urologists have reported good outcomes in recent cases that have utilized the single-port (SP) robotic system to gain transvesical access for vesicovaginal fistula (VVF) repair. While vaginal or abdominal access is the mainstay for VVF repair, in select cases the transvesical approach, which means directly through the bladder, is a possible alternative.

In many patients, closing the fistula through the vaginal route is successful. However, some patients with complex or recurrent fistulae may be better suited for an abdominal approach, which may include open, laparoscopic or robot-assisted surgery, all of which can utilize the omentum flap to close the fistula hole and create a barrier between the bladder and vagina to reduce the risk of recurrent malformation.

Challenges associated with previous abdominal surgeries

In a recent case, female pelvic medicine and reconstructive surgeon Sandip Vasavada, MD, was faced with a challenge. The patient had a complicated abdomen and no omentum flap as a result of previous abdominal surgeries. Proceeding with limited flap options could have led to an increased likelihood of postoperative morbidity.

Vaginal access was also not an option because of clinical indications and patient preference. The team and the patient decided to proceed using the single-port robot with the transvesical approach to access the VVF.

Dr. Vasavada, who collaborated with Mohamed Eltemamy, MD, a staff member in the section of Urology/Advanced Urological Robotic & Laparoscopy on this case, says this approach is rarely warranted for VVF repair. But given the patient-specific challenges, it was an ideal choice.

A closer look at the interposed flap using the SP robot

In the intraoperative video below, the surgeons separate the hole or “the communication between the bladder and the vagina.” Then they raise the flap tissue around it and close it sequentially side-by-side.

Click for video

Outcomes and indications

“The patient had no complications and was discharged the same day. It’s not going to be like this case every time, but it’s appropriate to consider this approach in extreme circumstances like hers.”

Results were similar in a different case with a patient who had a complicated abdomen and had previously failed two vaginal surgeries. “It was a difficult situation, and success rates decline after each attempt; but, we decided if we can access it from inside the bladder, we will. And that’s where the utility of the single-port robotic approach really comes into play,” Dr. Vasavada notes.

While indications are still evolving, patients with complicated abdomens, limited interposing flap options, an otherwise satisfactory bladder capacity, and no need for radiation after surgery may be candidates for this approach.