A fistula is defined as an abnormal connection between two internal organs or between an organ and the body surface. Fistulas are named based on the organs they connect.

In developing countries, vesicovaginal fistula (VVF) is most commonly caused by inadequate obstetric care. In developed countries, the leading cause is pelvic or gynecological surgery, with hysterectomy for benign conditions accounting for 60-75% of cases.

VVFs should be classified based on anatomical location, size, and extent. The main clinical manifestations include both daytime and nighttime urinary incontinence or, in cases of small fistulas, painless vaginal discharge.

Diagnosis should be both clinical and imaging-based, including colposcopy with or without a flexible cystoscope to visualize the fistulous opening, cystoscopy to determine its location and distance from the ureteral orifices, cystography, CT urography with cystography, or pelvic MRI.

Conservative treatment with bladder catheterization has shown limited efficacy and is only considered for fistulas smaller than 1 cm. The optimal duration of catheterization remains uncertain, as does the potential role of endoscopic electrocoagulation in small, epithelialized fistulas.

Surgical repair is the gold standard for VVF treatment.

Surgical approaches include vaginal, abdominal laparoscopic, robotic, or combined techniques. The abdominal approach is typically used for supratrigonal fistulas, while the vaginal route is preferred for infratrigonal fistulas. However, the choice of approach often depends on the surgeon's expertise and preference. The vaginal approach requires extensive separation of the bladder and vagina, followed by a tension-free multilayer closure, often reinforced with a vaginal flap, with or without tissue interposition.

Here, we present a step-by-step description of laparoscopic abdominal repair of a vesicovaginal fistula.

We report the case of a 62-year-old woman with a history of abdominal hysterectomy for fibroids three months prior to presentation. She consulted for continuous urinary incontinence, both day and night, unrelated to effort or urgency.

Findings:

24-hour pad test: 552 grams.

Colposcopy: Fistulous opening in the vaginal vault between the 12 and 1 o’clock positions. A vaginal gauze test was performed by instilling methylene blue into the bladder, confirming leakage of dye onto the gauze.

Retrograde cystography: Immediate visualization of a vesicovaginal fistula extending from the mid-posterior bladder wall to the upper vagina.

Cystoscopy: Normal urethral caliber. A fistulous orifice measuring approximately 1 cm was observed in the retrotrigonal region.

We performed laparoscopic intraperitoneal repair using the technique described by Légue and popularized by O’Connor. This involves posterior dissection of the bladder up to the fistulous tract, allowing complete resection and tension-free closure. Additionally, omental interposition is performed to reinforce the repair. Prior to dissection, both ureters were stented with catheters, and the fistulous tract was identified using another catheter to facilitate precise dissection and resection.

The patient had no immediate postoperative complications.

Ureteral catheters were removed after 48 hours.

The patient was discharged with a urinary catheter in place for 21 days.

Before catheter removal, a follow-up cystography confirmed bladder wall integrity, with no contrast leakage or residual fistulous tracts.

Vesicovaginal fistulas should be suspected in patients with prior pelvic surgeries presenting with continuous urinary leakage. The optimal surgical approach should be individualized based on patient characteristics, fistula location, and size. Both vaginal and laparoscopic approaches are valid options, and selection should be tailored to each case.