Vesicovaginal fistula (VVF) is an abnormal communication between the bladder and the vagina. VVF is more commonly a complication of pelvic surgery or malignancy treatment, with the former most often preceded by inadvertent bladder injury or ureteral injury during abdominal hysterectomy. Women usually present with constant urinary leakage. Cure rates for the laparoscopic approach range from 75% to 98%. This video shows a laparoscopic transperitoneal approach following the principles of abdominal VVF repair: good exposure of the fistulous tract, double-layer bladder closure, retrograde fill of the bladder to ensure a water-tight seal, tension-free closure and continuous postoperative bladder drainage.

We describe step by step fundamentals of VVF repair. A laparoscopic extravesical transperitoneal approach was performed.  
Case report
A 45-year-old female with no previous medical or surgical history, who underwent a laparoscopic hysterectomy for multiple benign uterine myoma. Constant urinary leakage per vagina began after surgery. 
Physical examination: continuous urine leakage per vagina with a negative stress cough test. Speculum examination, no pinpoint opening on vaginal wall or vaginal cuff.
Cystoscopy: < 5mm opening on the bladder posterior wall.
Computed tomography (CT) urography of the abdomen and pelvis: VVF at the vaginal cuff and a right complete duplex collecting system. 
Surgery: Considering that the patient had a complete right duplex collecting system, first we performed a cystoscopy in order to place a guide wire through the fistulous orifice, identify proximity to the ureters and intubate them prior to surgery. The initial laparoscopic extravesical approach included an infraumbilical port and 3 additional 5 mm accessory ports.

The intraoperative blood loss was < 300 cc, operative time of three hours and 30 minutes, length of stay was 6 days, the urinary catheter was removed on day 14 after surgery.

Minimally invasive approaches, following the principals of abdominal VVF repair, have demonstrated shorter operative times, decreased blood loss, improved visibility, and high cure rates without increased adverse events. Ultimately, surgical the approach to VVF repair depends upon the individual characteristics of the patient and fistula and the preference and experience of the surgeon.

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Gedik A., Deliktas H., Celik N., et al: Which surgical technique should be preferred to repair benign, primary vesicovaginal fistulas? Urol J 2015; 12: pp. 2422-2427