










































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2021 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Novel Extravesical Versus Transvesical Technique  
for Abdominal Repair of Vesicovaginal Fistula
Ibrahem Ismail Samaha, Kareem M. Taha, Islam Elbabouly, Maged Ali

Department of Urology, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt 

Abstract

Objectives To compare the transvesical transabdominal repair of vesicovaginal fistula with novel extravesical 
transabdominal repair with respect to operative time, blood loss, hospital stay, catheterization time, postoperative 
lower urinary tract symptoms, urodynamic changes, and recurrence rate.

Methods A prospective randomized controlled study of 94 consecutive female patients who underwent 
transabdominal vesicovaginal fistula (VVF) repair from March 2013 to March 2018 in our center. The patients 
had high vesicovaginal fistula that could not be operated on transvaginally: 47 cases were treated with extravesical 
transabdominal technique, and 47 cases were treated with transvesical transabdominal technique. The primary 
endpoint is the functional outcome regarding postoperative lower urinary tract symptoms (LUTS); secondary 
outcomes are early recovery and success rates. The follow-up period was 3 months for reporting and dealing with any 
complications.

Results There was no significant difference between the groups regarding demographic data. Extravesical repair of 
VVF had significantly higher (106.56±10.46 min) operating time than transvesical repair (95.08±7.6 min) P <0.001. 
There was no significant difference regarding intraoperative blood loss between the extravesical (365.42±81.29 mL) 
and transvesical (353.12±73.9 mL) groups; P = 0.44). The extravesical group had a significant shorter hospital stay 
(62.35±12.25 hours) than the transvesical repair group (85.07±12.0 hours) P < 0.001. Postoperative storage LUTS 6 
weeks assessed by Overactive Bladder Symptom Score was significantly lower for extravesical repair (1.75±0.59) than 
for transvesical repair (6.87±2.24) P = 0.001). This was confirmed by urodynamic evaluation. Two patients (4.2%) in 
the transvesical group but none in the extravesical group experienced fistula recurrence.

Conclusions The extravesical transabdominal approach for repair of vesicovaginal fistula is a novel, successful, and 
versatile technique with reduced hospital stay, reduced postoperative LUTS and possibly fewer recurrences than the 
transvesical technique, and should be considered for all VVF requiring abdominal repair.

Introduction

Vesicovaginal fistula (VVF) is an abnormal communication between the bladder and the vagina resulting in 
continuous leakage of urine[1]. VVF remains a devastating disease with social stigma and psychological strain on 
patients, as well as physical repercussions[2]. Etiology of VVF includes obstetric injury, gynecological and pelvic 
surgeries, radiation therapy, inflammation, and malignancy, but the obstetric complications with prolonged labour 
remain the predominant cause in the developing countries. Inadvertent bladder injury during hysterectomy is the 
most common cause in developed countries with reported rates of 0.3% to 2% after simple hysterectomy and 10% after 
radical hysterectomy[3,4].

This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2021 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Vesicovaginal fistula, transvesical repair, 
lower urinary tract symptoms, overactive 
bladder symptoms score, urodynamic study

None declared. Received on September 17, 2020 
Accepted on January 4, 2021

Soc Int Urol J.2021;2(2):113–119

DOI: https://10.48083/TVYU2515

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Fistula occurs when devascularized tissue is sloughed. 
Leakage of urine through this focus of erosion leads 
to the formation of a tract through fibrotic tissue that 
connects the urinary tract to the bladder. This fistula is 
usually recognized 2 weeks after the trauma[5].

The O’Conor transvesical technique was performed 
via laparotomy for more than 30 years before the first 
laparoscopic case was published in 1994[6]. It was 
not until 1998 that von Theobold described the first 
laparoscopic extravesical VVF repair. Von Theobold 
describes a simple dissection of the bladder away from 
the vagina and a single-layer bladder closure, noting 
“closure of the vagina was not necessary” coupled with 
an omental J flap[7].

The extravesical approach is not a modification of the 
O’Conor technique, as a cystotomy is not required to 
identify the fistula, but it still uses the basic principles of 
fistula repair as cited by Couvelaire in the 1950s[8].

The extravesical approach, first described by Von 
Dittel in 1893[9], focuses on targeted dissection, avoiding 
cystotomy, and preferentially dissecting to the fistulous 
tract via the vesicovaginal plane. The superiority of 
either the transvesical or the extravesical approach has 
not been established in the literature and at the time of 
writing, no study has compared the 2 techniques[10].

The aim of this study was to compare the effectiveness 
of the extravesical technique of transabdominal repair 
with the transvesical technique of transabdominal 
repair for vesicovaginal fistula with respect to operative 
time, blood loss, length of hospital stays, urethral 
catheter time, postoperative lower urinar y tract 
symptoms and recurrence rate. The primary endpoint 
is the functional outcome regarding postoperative lower 
urinary tract symptoms (LUTS); secondary outcomes 
are early recovery and success rates. The follow-up 
period was 3 months for reporting and dealing with any 
complications.

A

C

B

FIGURE 1.

Sagittal section of CT cystogram

3D Format: red arrow shows the high VVF and opacification of the vagina with contrast

Axial section

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Materials and Methods
We undertook a prospective randomized controlled 
study w it h 94 consecutive fema le patients who 
underwent transabdominal vesicovaginal repair from 
March 2013 to March 2018 in our center (Zagazig 
University Hospital). Patients with fistulas close to 
the ureteric orifice and high fistulas that could not 
be accessed through the vagina, as well as those with 
previous recurrent vaginal surgeries that precluded 
vaginal repair were enrolled in this study and underwent 
abdominal repair. Patient consent and institutional 
review board approval were obtained.

Between 2013 and 2018, 94 consecutive female 
patients with high vesicovaginal fistula or previous 
vaginal surgery that precluded transvaginal fistula 
repair were randomized to f istula repair by an 
extravesical transabdominal technique (n = 47) or by a 
transvesical transabdominal technique (n = 47) at our 
center. Preoperative patient evaluation included history, 
physical examination (local vaginal examination, 
inspection with speculum, dye test), and CT cystogram 
(Figure 1). Informed consent was obtained from all 
patients prior to surgery, and institutional review board 
approval was granted.

Operation
Diagnostic cystoscopy was done first to identify the 
fistula tract with stent insertion inside it, A vaginal 
pack was then inserted, and a vertical lower abdominal 
midline incision was made for better exposure and easy 
access for omental flap formation.

All VVF in our series were repaired 3 months after 
the initial trauma to allow edema and inflammation to 
subside and allow better tissue handling and healing. 
The fundamental surgical principles for repair (adequate 
exposure, tension-free approximation of the fistula 
edges, non-overlapping suture lines, good hemostasis, 
watertight closure, and adequate postoperative bladder 
drainage) were achieved.

Transvesical Approach
This is based on the technique described by O’Conor 
and Sokol. After exposure of the pelvic structures, 
mobilization of bladder was obtained[11]. A cystotomy 
(4 to 5 cm) along the sagittal plane near the dome was 
done. The incision was then extended down to the site of 
the fistulous tract. Both ureteral orifices were identified 
before dissection along the tract course and a full-
thickness excision of the tract and the devascularized 
edges, followed by double-layered closure of the bladder 
and vaginal defects with omental f lap interposition. 
The bladder was filled with saline to ensure watertight 
closure. A urethral catheter remained in place for  
2 weeks postoperatively.

Extravesical Approach
This approach focuses on targeted dissection with 
preferential dissection to the fistulous tract via the 
vesicovaginal plane, thereby avoiding cystotomy. The 
fistulous tract was excised. A multilayered closure, with 
non-overlapping suture lines was done. The vaginal 
defect was closed in a double layer, using interrupted 2-0 
absorbable sutures. The bladder defect was repaired in 2 
layers with continuous suturing using a 2-0 absorbable 
suture as shown in Figure 2. Retrograde filling of the 
bladder was done to ensure a watertight seal. An omental 
flap was used as a tissue interposition between bladder 
and vagina. The urethral catheter remained in place for 
5 days postoperatively.

In all patients after both approaches lower urinary 
tract symptoms were evaluated after 6 weeks with the 
Overactive Bladder Symptom Score (OABSS) by filling 
cystometry.

Results
Clinical and Pathologic Characteristics
Ni net y-fou r pat ient s w it h h ig h vesicovag i na l 
fistula underwent transabdominal repair. Patients 
were randomly assigned to receive transvesica l  

Steps of extravesical repair of VVF.
 B - Bladder 

V - Vagina with the yellow omental flap in between

FIGURE 2.

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transabdominal repair (47 patients) or extravesical 
transabdominal VVF repair (47 patients). There was no 
significant difference between the groups with respect to 
age, body mass index (Table 1), or cause of vesicovaginal 
fistula (Table 2).

Clinical Outcomes
The operative time was greater for the extravesical 
approach (106.56±10.46 min) than the transvesical 
approach (95.08±7.6 min) (P < 0.001) due to the more 
delicate dissection to mobilize the posterior bladder 
away from the vagina without cystotomy. Intraoperative 
blood loss was not significantly different for the 
extravesical repair group (365.42±81.29 mL) and for the 
transvesical repair group (353.12±73.9 mL; P = 0.44). 
However, the extravesical group had a significantly 

shorter hospital stay (62.35±12.25 hours) than the 
transvesical repair group (85.07± 12.0 hours) (P < 0.001).

We also compared the functional outcomes for 
both techniques of repair in terms of storage LUTS, 
using the OABSS 6 weeks postoperatively. Extravesical 
repair of VVF caused significantly lower postoperative 
OABSS (1.75±0.59) compared with transvesical repair 
(6.87±2.24) P = 0.001 (Table 3). This was confirmed 
objectively by urodynamic evaluation (Table 5), which 
revealed detrusor overactivity in 14 patients (31.1%) 
in the transvesical group and 5 patients (10.6%) in the 
extravesical group (P = 0.002). Detrusor overactivity 
incontinence was observed in 7 patients (15.5%) in 
the transvesical group and in 2 patients (4.2%) in the 
extravesical group (P = 0.018). This was managed 
with antimuscarinic drug. Post repair stress urinary 
incontinence was observed in 3 patients (6.6%) in the 
transvesical group and 1 patient (2.1%) in the extravesical 
group (P = 0.15). This was managed conservatively.

Fistula recurrence was observed in 2 patients (4.2%) 
within 4 weeks in the transvesical group and none in the 
extravesical group (P = 0.11) (Table 3).

Discussion
Vesicovaginal fistula is one of the most distressing 
complications of obstetric and gynecologic procedures. 
It has a negative impact on life with important 
medicolegal implications. Obstetric VVFs remain a 
major medical problem in many low-resource countries 
with a low standard of antenatal and obstetric care[12].

TABLE 1. 

Age and BMI distribution

Transvesical Extravesical t P

n = 47
(Mean ±SD)

n = 47 
(Mean ±SD)

 

Age 45.16±10.6 47.01±11.26 -1.645 0.074

BMI 29.75±3.37 30.0±3.62 -0.535 0.584

No significant difference between both groups for demographic data

TABLE 2. 

Causes of vesicovaginal fistula

Cause

Group
Total
n(%) χ

2 P
Transvesical

n(%)
Extravesical

n(%)

Cystocele repair 7(14.8) 8(17) 15(19.2) 0.29 0.59

Hysterectomy 21(44.6) 23(49) 44(53.6) 0.26 0.61

Obstructed labour 13(27.6) 10(21.2) 23(20.5) 0.75 0.38

PVS 1(2.1) 2(4.2) 3(0.9) 0.72 0.39

TVT 5(10.6) 4(8.5) 9(5.8) 0.15 0.69

Total 47 47 94

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Transabdominal repair is the preferred approach when 
the fistula is high on the posterior bladder or the fistula 
is complex, or if the vaginal anatomy precludes adequate 
surgical exposure of the defect (retracted defect or 
narrow vagina), or the fistula is closely related to the 
distal ureters[13].

In the present study 53.6% fistulas were secondary to 
gynecological procedures (hysterectomy) and 20.5% 
resulted from obstetric problems, which ref lects the 
findings of the study by Kapoor et al.[14]. In other series, 
however, VVF was reported as predominantly secondary 
to gynecological causes, as shown in Table 4.

We wished to evaluate the outcomes of extravesical 
VVF repair and compare them with the classical 

transvesical technique because we believed that avoiding 
cystostomy could reduce postoperative drawbacks in the 
form of long hospital stay, long catheterization time, and 
high incidence of storage LUTS.

Dolan et al. report that 16.1% of patients experience 
stress urinary incontinence after fistula repair[15]. This 
results from defunctionalization of the detrusor muscle 
because of prolonged VVF exposure[8]. The substantial 
loss of bladder tissue from scarring leads to a smaller 
functional bladder capacity. The bladder then becomes 
stiff and non-compliant leading to stress incontinence 
or de novo urge incontinence. Vaginal scarring and 
shortening of the vagina impair physiologic urethral 
function and prevent adequate urethral coaptation[16]. 
In a study of obstetric fistula in Ethiopia, where 
urodynamic investigation was undertaken after repair, 
55% of patients were incontinent despite successful 
closure of their fistula; stress urinary incontinence was 
most commonly identified abnormality[17]. Another 
study demonstrated stress urinary incontinence in 47% 
of women prior to repair in a series of largely surgical 
fistulae in the United Kingdom. Although in only 3% 
did this persist after repair, these findings are more 
common in obstetric fistula. Detrusor overactivity was 
found in 40% at presentation and persisted in half of 
these at follow-up[18].

We believe that the extravesical technique is a more 
successful, less invasive, and less traumatic repair with 
a lower incidence of detrusor overactivity. The key 
difference is the targeted dissection of the VVF site 
and the layered-closure technique discussed here. In 
contrast, the bivalving of the bladder required with the 
traditional transvesical approach increases the size of the 
bladder defect, which may be responsible for the varied 
success rate (70% to 97%). This rationale is supported 
by fistula experts who have stated that there is a greater 
chance of surgical failure with larger fistulas[16] and 
have advised minimizing the size of the cystotomy  
(<2 cm) during an O’Conor transvesical repair. Others 

TABLE 3. 

Clinical outcomes

Transvesical
n = 47  

Extravesical
n = 47

t P 

Operation time 
(min)

95.08±7.6 106.56±10.46 -8.121 0.001

Blood loss 
(mL)

353.12±73.9 365.42±81.29 -0.684 0.44

Length of 
hospital stay

(hour)
85.07±12.0 62.35±12.25 14.015 < 0.001

Postoperative 
OABSS

6.87±2.24 1.75±0.59 20.988 0.001

Recurrence 2 (4.2%) 0
Fisher

0.11
2.41

TABLE 4. 

Causes of VVF in different studies

Causes
Present 

study

Kapoor 
et al., 
2007

Roy  
et al., 
2006

Kam  
et al., 
2008

 Obstetric 4 4 60 22 25

 Gynecological 23 40 74 70

  Other causes  
(POP repair, continence 
surgeries)

27

TABLE 5. 

Urodynamic evaluation

Procedure

Detrusor 
overactivity

n(%)

Detrusor 
overactivity 

incontinence
n(%)

Stress 
urinary 

incontinence
n(%)

Transvesical (45) 14 (31.1) 7(15.5) 3 (6.6)

Extravesical (47) 5 (10.6) 2 (4.2) 1 (2.1)

P 0.002 0.018 0.15

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have reported great success using the nonbivalving 
extravesical layered-closure technique with and without 
omental flaps[20,21].

It was clear in this series that the success rate with the 
transvesical approach was 95%, with failure in 2 cases, 
compared with extravesical repair, which had a success 
rate of 100%.

We attribute the high success rate to meticulous and 
site-specific dissection as well as a triple-layer closure, 
which included a double-layered bladder closure and 
single vaginal wall closure, as supported by Sokol et 
al.[22], as well as aggressive testing of the bladder’s 
suture line. In a study using a canine model, Sokol et 
al. suggest that a double-layer closure of cystotomy 
is superior to a single-layer closure and may prevent 
fistula. Also good tissue approximation and watertight 
closure are fundamentals for successful VVF repair. 
To determine whether a “watertight seal” had been 
achieved, we undertook retrograde filling of the bladder; 
we then sutured any leaking points in the suture line. 
However, the technique to determine a “watertight seal” 
has never been adequately defined and lacks consistency, 
as suggested in the literature[23].

In this series we fixed omental flap as interpositioning 
layer in all cases, whether transvesical or extravesical, 
to promote healing and better lymphatic drainage, 
although the use of interposition flaps in non-irradiated 
patients has been questioned[24,25].

In a recent retrospective review of 49 patients without 
malignancy or a history of radiation therapy, the 
primary surgeon determined that transvaginal repair 

of benign recurrent VVFs without tissue interposition 
can be as successful as primary repairs without tissue 
interposition[26]. An interposition graft for VVFs 
functions as a barrier and introduces vascularity and, 
theoretically, lymphatics to improve tissue growth and 
maturation.

Decisions about approach, technique, interposition 
grafts, and layers of closure are still debated and must 
be based on the individual surgeon’s experience and 
comfort level. Thus, a surgeon’s decision to approach a 
VVF vaginally, laparoscopically, or via laparotomy is 
based primarily on the individual’s skill, comfort, and 
ability.

To our knowledge, this study is the first to compare 
and discuss the outcomes of transabdominal VVF 
and transvesical repair. We believed that extravesical 
repair of VVF had better outcomes than the traditional 
transvesical repair, and this randomized controlled 
trial provided support for that view. No matter which 
approach decided upon, we believe that the most 
important aspects of VVF repair remain adequate 
dissection, a watertight seal, and good postoperative 
bladder drainage.

Conclusions
The extravesical abdominal approach for repair of 
vesicovaginal fistula is associated with significantly 
reduced hospital stay, significantly reduced postoperative 
overactive bladder symptoms, and a reduced recurrence 
rate compared with the transvesical approach. We 
recommend this technique for closure of VVF that must 
be repaired abdominally.

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