Technical and peri-operative differences between the transvesical and extravesical approach in laparoscopic repair of vesico-vaginal fistula.

In the laparoscopic/robotic repair (L/R R) of Vesico-vaginal Fistulas (VVF) two types of transvesical and extravesical approaches are used.However, no direct comparisons exist between both surgical approaches Moreover, a lack of clinical guidelines is currently ongoing. Therefore, the selection of the type of approach is based on the preferences of the surgeon without considering the characteristics of each case.In order to provide recommendations for the selection of the appropriate technique for each patient, we designed a study that identifies and evaluates differences between the Transvesical and Extravesical approaches in the L/R R of the VVF. A total of 9 patients withVVF were included. Four patients underwent transvesicaltechnique and the rest the Extravesical technique. Thevariables in each group were recorded. Surgical stepswere selected with technical differences to be analyzed(identification of the fistula, dissection of the vesico-vaginalplane, cystotomy, maneuvers of exposure and cystorrhaphy). Short operative times and catheterization times were recorded in the Extravesical approach. Intraoperative blood loss was minimal in both groups, the hospital stay was very similar and no peri and post-operativec omplications were reported. In all cases the fistula was resolved and there have been no recurrences in a mean follow-up of 35 months. Technically, Extravesical approach minimizes the size of the cystotomy, decreases suture time, does not require maneuvers for adequate exposure, and simplifies cystorrhaphy with respect to Transvesical technique, at the expense of requiring further dissection and having a slight difficulty in locating the fistula. Transvesical technique simplifies the locationof the fistula and allows better intravesical visualization. In the L/R R of the VVF, the Extravesicaltechnique offers technical and perioperative advantages,so it must be the technique of choice for most VVFwith indication of abdominal approach. Transvesicaltechnique should be reserved for recurrent, recurrent,inflammatory fistulas, with difficulties identifying the fistulous orifice, close to ureteric orifice and with imminent need for ureteral reimplantation.