Study design, materials and methods
A retrospective review of medical records from a single institution over 10 years was conducted. The focus was on patients who underwent VVF repair using a pneumovesical approach with three 5 mm laparoscopic ports. The study evaluated perioperative parameters, postoperative outcomes, and complication rates to assess the efficacy and safety of this surgical method. Cumulative sum (CUSUM) analysis was used to determine the learning curve based on operative time.
Results
Of 26 patients with VVF, 23 (88.5%) had successful fistula closure after the first surgery. One patient required open surgery conversion due to challenges in maintaining pneumovesicum, and two experienced recurrences, although successful repairs were achieved in subsequent surgeries. The average patient age was 47.4 years, with a mean operative time of 99.9 minutes. The postoperative hospital stay averaged 9.1 days, and catheterization lasted about 11 days. The CUSUM chart indicated a learning curve, with fluctuations until the 19th case, followed by a consistent upward pattern.
Interpretation of results
For urologists who may not be familiar with the transvaginal approach, the transabdominal approach can be a preferred alternative in cases of high-lying, inaccessible vaginal fistulas, large fistulas, or coexisting intra-abdominal surgical conditions such as synchronous ureteric involvement. This approach allows wide mobilization of the vaginal wall and bladder, complete excision of the fistula tissue, effective closure of the clean layers without tension, and efficient postoperative bladder drainage. In addition, omental interposition provides tissue support to allow definitive closure of the fistula lesion with an efficient lymph supply, helping in the fast absorption of inflammatory exudates and consequently decreasing the possibility of infected fluid collection. Recently, a transabdominal approach using laparoscopy or robotic surgery has been attempted, providing a clear, magnified surgical view and excellent structural exposure. These approaches offer shorter recovery periods and are less invasive than conventional abdominal surgeries. However, regardless of efforts to reduce postoperative morbidity with laparoscopy or robotic surgery, the relative increase in operative time and the presence of intraperitoneal adhesions caused by previous gynecological surgery make the procedure challenging, whether performed via an extravesical or transvesical approach. Although the transvesical approach has the advantage of better identification and complete excision of the fistula compared with the extravesical approach, it still comes with the risk of morbidity related to a large cystotomy, such as postoperative bladder spasm or dysfunction, as well as potential bleeding and the need for additional sutures.