Vesicovaginal fistula (VVF) is an abnormal epithelized/fibrotic connection between the bladder and vagina, with the consecuence of continuous urinary incontinence, that represents a physical, psychological, sexual, emotional, economical, debilitating, social stigma condition and affects quality of life of women. The true incidence is difficult to know due to underreports (around 0,3-2%); in developed countries it arises mainly as a complication of pelvic-gynecological surgery (80-90%), and from underdeveloped countries the main aetiology is obstetric (>90%). (1)

Although various conservative and non or minimally invasive treatments has been described (bladder drainage alone, electric or laser fistula tract fulguration, fibrin or collagen sealants application, platelet enriched plasma infiltration), the mainstay treatment for VVF is surgical repair, following basic principles such as adequate exposure and identification of structures, wide mobilization, excision of the fistula tract, tension-free closure, interposition flaps, good hemostasis and uninterrupted bladder drainage. Different surgical approaches (transabdominal, tansvaginal, transurethral) are used based on the fistula location (supra or infratrigonal), size (diameter), relation to bladder structures (ureteral meatus, bladder neck, urethra), complexity (uni or multiple), risk factors (radiotherapy), but as there is no best approach, the expertise and training of the surgeons is very important for the decision; in general, simple-infratrigonal fistulas are managed by a vaginal approach, whereas complex-supratrigonal fistulas are either repaired through abdominal or combined approachs. (2)

Among minimally invasive techniques, the NOTES Combined Transurethral-Transvaginal Approach (NOTES-CTTA) represents a good option for the management of VVF; compared to simple transvaginal approach, it could achieve a better exposure of the surgical field to facilitate a successful fistula repair, while compared to the transabdominal approach, NOTES-CTTA only used the natural body cavities (no incisions to the body surface), with the advantages of small surgical injury, minimal bleeding, and rapid recovery. (3)

The aim of our communication, is to show the efficacy and security of the NOTES-CTTA for resection and repair of a VVF, refractory to conservative management.

A 33 years old women without medical antecedents, started with continuous urine leakage through vagina, 1 week after labor assisted with forceps. Cystoscopy identified a <1cm left trigonal orifice (near bladder neck and 2cm from left ureteral meatus). Vaginal exploration (filling bladder with methylene blue), show leakage through a <1cm orifice in anterior vaginal wall. With the diagnosis of simple trigonal VVF, and in consensus with the patient, placement of a 16ch urethral bladder catheter was performed; 6 weeks after (with the catheter 24hours open-connected to bag), cystography and cystography-CT scan demonstrated no contrast from bladder to vagina. Bladder catheter was retired, reappearing immediately continuous incontinence. Cystoscopy and vaginal exploration, showed the persistence of the trigonal VVF, so we decide to perform a NOTES-CTTA. In lithotomy position, under 30º cystoscopic vision, the fistula was tutorized with a guidewire and 3F fogarty balloon (introduced from the vagina into the bladder). Transurethral endoscopic excision was performed with a continuos flow 26ch resector, using Collins-knife electrode with bipolar energy and 0,9% saline irrigation; we were able to precisely surround and excise the fibrotic tissue of the fistula tract. Transvaginal closure of the defect was performed maintaining the lithotomy position, in 3 separate layers: bladder mucosa (continuous 4-0 monocryl), detrusor (continuous 3-0 vicryl), and vaginal mucosa (single 3-0 vicryl). A suprapubic bladder catheter 12ch was placed (due to bad tolerance to previous urethral bladder catheter), and an iodized-vaseline gauze package was left in the vagina. Continuous 0,9% saline bladder irrigation was left for 12 hrs (throuh suprapubic catheter and simple urethral foley).  Transurethral fistula resection time was 10 minutes, vaginal closure time 15 minutes, and total surgery time 50 minutes. The patient was discharged from hospitalization 36hours after surgery, without vaginal package and foley urethral catheher, with the suprapubic catheter open-connected to bag.

None Clavien-Dindo >2 complications were observed. Pathology analysis confirm complete excision of fibrotic VVF. After 1 month with suprapubic bladder catheter 24hours open-connected to bag, cystography, cystoscopy, and physical exploration with methylene blue were performed, showing complete resolution of the fistula; suprapubic bladder catheter was removed, and the patient started with normal micturition without incontinence. With a 3-6 months follow up after surgery, the patient referred a complete reincorporation to normal activities (laboral, social, and sexual), and excellent quality of life.

Although this simple-small VVF was managed initially by conservative treatment with urethral bladder catheter, as no improvement happened, surgical repair was required. Delayed elective surgery was performed 2,5 months after the injury, when local inflammation and edema disappeared, and mucosal membranes became soft for dissection.

Different as described in the publication of Xie et al (3), we decide to perform this technique as a primary surgical indication for VVF;  we did not place ureteral catheters; complete transurethral resection of the fistula scar was performed with the Collins-knife electrode up to the vagina; as the deffect was located on the proximal anterior vaginal wall, we suture it with cystoscopic assistance, without changing the patient to a prone position (saving time for the surgery); postoperatory hospital stay was only 36hrs, and althoug our recommendation was to remove the suprapubic bladder drainage 2 weeks after the surgery, we left it 1 month due to preference of the patient (affraid of recurrence).

In concordance with Xie et al (3), the deffect was closed in 3 layers; one month after the surgery the vaginal exploration showed no leakage when bladder was filled with normal saline stained with methylene blue, and cystography and cystoscopy demonstrated no fistula. During the follow-up period, no urinary leakage or incontinence was observed.

When conservative management of VVF fails, surgery repair must be performed due to personal and social implications it represents for patients, with an impact on quality of life.

In the era of minimal invasive surgery, the NOTES-Combined Transurethral-Transvaginal Approach, has the advantage of small surgical injury with better surgical field exposure, gives the surgeon an excellent view that permits a complete excision of the fistula fibrotic-epithelized tissue with control of the ureteral meatus, selective hemostasis could be performed, and repair of the defect in separate layers with satisfactory anastomosis, always following the basic principles for this kind of surgery, without significants complications and rapid postoperatory recovery.

This technique must be considered as a primary minimally invasive option for the treatment of simple, small, infratrigonal VVF, not only reserved as a rescue surgery after failure of previous surgical procedures.

Shanmugasundaram R et al. Vesicovaginal fistula: Review and recent trends. Indian J Urol. 2019 Oct-Dec; 35(4): 250–258.
Huang WC et al. Surgical repair of vesicovaginal fistulas. Urol Clin North Am. 2002 Aug;29(3):709-23.
Xie M et al. Vesicovaginal fistula repair through combined transurethral and transvaginal approaches: a case series study. J Gynecol Obstet Hum Reprod. 2018 Nov;47(9):487-490.