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Endoscopic Management of Vesicovaginal Fistula

Endoscopic management of vesicovaginal fistula (VVF) covers a spectrum of minimally invasive, endoscopy-guided techniques — from purely cystoscopic interventions (fulguration, laser ablation, tissue-adhesive injection) for small fistulae to advanced laparoendoscopic and transvesicoscopic suture repairs for more complex cases.[1][2]

For the underlying clinical evaluation, classification, and decision algorithm, see the vesicovaginal fistula clinical page. For repair-route selection across the female-fistula spectrum, see the Female Fistula Repair atlas.

Cystoscopy in Diagnosis and Preoperative Planning​

Cystoscopy is the cornerstone of VVF evaluation: direct visualization of the bladder-side fistula orifice; assessment of size, location relative to the ureteral orifices and trigone; and evaluation of surrounding-tissue quality. A combined vaginoscopy-cystoscopy technique with simultaneous dual-image (picture-in-picture) display has been described to improve fistula identification and surgical planning in diagnostically challenging cases.[1] The EAU Robotic Urology Section consensus recommends preoperative cystoscopic marking of the fistula with a guidewire or ureteral catheter to guide subsequent repair.[2]

Endoscopic Fulguration (Electrocoagulation)​

The simplest purely endoscopic option, reserved for small VVFs (≤3.5 mm).[3]

Technique​

  • Cystoscopic insertion of a Bugbee electrode into the fistula tract.
  • Electrocoagulation of the epithelial lining.
  • Continuous Foley drainage 2–3 weeks postoperatively.
  • Anticholinergics to suppress detrusor contraction during healing.

Outcomes​

  • Largest series (n = 15, all fistulae ≤3.5 mm): 73% success as primary treatment (9/12) and 66% (2/3) as salvage after failed open repair.[3]
  • Smaller series of VVFs <3 mm reported up to 80% success.[4]

Best suited as initial treatment for selected very-small fistulae, and as a salvage for small residual fistulae after failed surgical repair.[3]

Laser Ablation / Laser Welding​

ModalitySettingOutcome
Holmium:YAG cystoscopic welding / ablationSingle-center n = 8, mean fistula 3 mm (range 2–4 mm)87.5% (7/8) dry after catheter removal at mean 47-mo follow-up; 1 procedure abandoned for bleeding.[5]
Holmium ablation + concurrent vaginal repairSmall VVFCystoscopic laser ablates the bladder-side opening while transvaginal excision addresses the vaginal side.[6]
Endoscopic laser dissection + pneumovesical laparoscopic closureNovel techniqueLaser provides precise incision and clear plane exposure; pneumovesical lap completes the closure with minimal tissue injury.[7]

Laser welding is considered safe and efficacious for fistulae ≤4 mm.[5]

Tissue Adhesive Injection (Fibrin Glue / Cyanoacrylate / PRP)​

ApproachOutcome
Retrograde endoscopic fibrin glue75% success across various urinary-tract fistulae (some required two injections); no significant complications.[8]
Tissue-adhesive systematic review (n = 84, mean fistula 1.05 cm)Overall failure / recurrence 14.3%. Fibrin glue specifically: only 6.5% recurrence (3/46).[9]
Autologous PRP injection + platelet-rich-fibrin glue interpositionCystoscopic de-epithelialization of the fistula edges, peri-fistula PRP injection, fibrin glue in the tract. 91.7% (11/12) clinical cure at 6 mo.[10]

Most appropriate for small fistulae (≤1 cm) and as an alternative for poor surgical candidates.

Transurethral NOTES​

A transurethral endoscopic suture repair using barbed suture has been described for VVFs after hysterectomy for morbidly adherent placenta. In 3 patients, 2 achieved complete resolution; the third had reduction in fistula size and required subsequent laparotomy. Considered a valid initial minimally invasive option, though experience remains limited.[11]

Transvesicoscopic Repair​

Direct placement of laparoscopic ports into the bladder (vesicoscopy) for intravesical visualization and repair:

  • Combined vaginal + vesicoscopic repair for complex VVF (n = 9): 89% success at median 30 mo. The approach supplements the vaginal route for fistulae not suitable for pure vaginal repair, and pairs the laparoscopic urologist with the vaginal surgeon.[12]
  • Robot-assisted transvesical repair via mini cystotomy has been described, particularly when prior surgical planes have been used in failed repairs.[13]

V-NOTES (Vaginal Natural Orifice Transluminal Endoscopic Surgery)​

For apical VVFs, V-NOTES provides endoscopic visualization through the vaginal route. In a 17-patient modified-technique series, 88.2% success (15/17), with both failures cured on second repair. Mean OR 104 min, EBL 10.5 mL, mean LOS 3.3 d.[14] See vNOTES & Robotic vNOTES for the broader platform context.

Laparoscopic and Robotic-Assisted Endoscopic Repair​

Not purely "cystoscopic" but the most widely adopted endoscopic approaches:

  • Overall 80–100% success across laparoscopic and robotic series, comparable to open.[15][16]
  • Both transvesical (O'Conor) and extravesical approaches work laparoscopically, with success 95.9% and 98.0% respectively.[15]
  • LESS (laparoendoscopic single-site surgery) is feasible with comparable success, shorter LOS (2 d) and fewer analgesics than conventional laparoscopy.[17][18]
  • MIS techniques reduce OR time and EBL vs open, though surgical approach is not an independent predictor of closure rate.[16]

Patient Selection and Predictors of Outcome​

FactorImpact
Fistula size ≤3.5 mmSuitable for fulguration / laser; 73–87.5% success.[1][2]
Fistula size <1 cmCandidate for tissue adhesives.[3]
Prior radiotherapySignificant risk factor for failure (~75% failure rate).[4]
Trigonal locationHigher failure (32% vs 6% non-trigonal).[5]
Post-hysterectomy etiologyHighest success (95%).[5]
Prior failed repairsProgressive decline with each attempt.[6]
Oncologic etiologyIndependent predictor of failure.[4]

Common Principles Across Endoscopic Approaches​

Regardless of technique:[21][2][22]

  • Tension-free, watertight closure.
  • Well-vascularized tissue.
  • Adequate mobilization.
  • Protection of the ureteral orifices.
  • Prolonged postoperative bladder drainage (typically 2–3 weeks).
  • The best chance of success is the first surgical attempt, with an approach the surgeon is experienced in.

See Also​

References​

1. Andreoni C, Bruschini H, Truzzi JC, Simonetti R, Srougi M. Combined vaginoscopy-cystoscopy: a novel simultaneous approach improving vesicovaginal fistula evaluation. J Urol. 2003;170(6 Pt 1):2330–2332. doi:10.1097/01.ju.0000096343.03276.75

2. Randazzo M, Lengauer L, Rochat CH, et al. Best practices in robotic-assisted repair of vesicovaginal fistula: a consensus report from the European Association of Urology Robotic Urology Section Scientific Working Group for Reconstructive Urology. Eur Urol. 2020;78(3):432–442. doi:10.1016/j.eururo.2020.06.029

3. Stovsky MD, Ignatoff JM, Blum MD, et al. Use of electrocoagulation in the treatment of vesicovaginal fistulas. J Urol. 1994;152(5 Pt 1):1443–1444. doi:10.1016/s0022-5347(17)32441-2

4. Shah SJ. Role of day-care vesicovaginal fistula fulguration in small vesicovaginal fistula. J Endourol. 2010;24(10):1659–1660. doi:10.1089/end.2009.0557

5. Dogra PN, Saini AK. Laser welding of vesicovaginal fistula — outcome analysis and long-term outcome: single-centre experience. Int Urogynecol J. 2011;22(8):981–984. doi:10.1007/s00192-011-1389-0

6. Singh R, Schmitt JJ, Knoedler JJ, Occhino JA. Management of a vesicovaginal fistula using holmium laser ablation. Int Urogynecol J. 2016;27(6):969–971. doi:10.1007/s00192-016-3002-z

7. Han G, Zhao R, Liu K, et al. Endoscopic laser dissection combined with laparoscopic pneumovesical repair of vesicovaginal fistula: a novel technique and case report. Urology. 2023;175:223–228. doi:10.1016/j.urology.2023.02.036

8. Sharma SK, Perry KT, Turk TM. Endoscopic injection of fibrin glue for the treatment of urinary-tract pathology. J Endourol. 2005;19(3):419–423. doi:10.1089/end.2005.19.419

9. Bouchard ME, Stairs J, Hickling D, Clancy A, Khalil H. The use of tissue adhesive in management of genitourinary fistulas: a systematic review and case report. Int Urogynecol J. 2023;34(2):445–451. doi:10.1007/s00192-022-05297-0

10. Shirvan MK, Alamdari DH, Ghoreifi A. A novel method for iatrogenic vesicovaginal fistula treatment: autologous platelet-rich plasma injection and platelet-rich fibrin glue interposition. J Urol. 2013;189(6):2125–2129. doi:10.1016/j.juro.2012.12.064

11. Duque-Galán M, Hidalgo-Cardona A, López-Girón MC, Nieto-Calvache AJ. Natural orifice transluminal endoscopic surgery for correction of vesicovaginal fistulas after hysterectomy due to morbidly adherent placenta. J Obstet Gynaecol Can. 2021;43(2):237–241. doi:10.1016/j.jogc.2020.06.029

12. Grange P, Giarenis I, Rouse P, et al. Combined vaginal and vesicoscopic collaborative repair of complex vesicovaginal fistulae. Urology. 2014;84(4):950–954. doi:10.1016/j.urology.2014.06.020

13. Occhino JA, Hokenstad ED, Linder BJ. Robot-assisted vesicovaginal fistula repair via a transvesical approach. Int Urogynecol J. 2019;30(2):327–329. doi:10.1007/s00192-018-3843-8

14. Song X, Jiang C, Lv JW. Transvaginal repair of apical vesicovaginal fistula via vaginal natural orifice transluminal endoscopic surgery (V-NOTES): a modified surgical technique and its outcomes. Sci Rep. 2024;14(1):31095. doi:10.1038/s41598-024-82366-y

15. Miklos JR, Moore RD, Chinthakanan O. Laparoscopic and robotic-assisted vesicovaginal fistula repair: a systematic review of the literature. J Minim Invasive Gynecol. 2015;22(5):727–736. doi:10.1016/j.jmig.2015.03.001

16. Wang Z, Pokhrel G, Yu S, et al. Vesicovaginal fistula repair: comparative analysis of perioperative outcomes and predictors of success in open, laparoscopic, and robotic approaches. Eur J Med Res. 2026. doi:10.1186/s40001-026-03937-5

17. Abdel-Karim A, Elmissiry M, Moussa A, et al. Laparoscopic repair of female genitourinary fistulae: 10-year single-center experience. Int Urogynecol J. 2020;31(7):1357–1362. doi:10.1007/s00192-019-04002-y

18. Abdel-Karim AM, Moussa A, Elsalmy S. Laparoendoscopic single-site surgery extravesical repair of vesicovaginal fistula: early experience. Urology. 2011;78(3):567–571. doi:10.1016/j.urology.2011.05.036

21. Okada Y, Matsushita T, Hasegawa T, et al. Surgical interventions for treating vesicovaginal fistula in women. Cochrane Database Syst Rev. 2026;1:CD015413. doi:10.1002/14651858.CD015413

22. Ramphal SR. Laparoscopic approach to vesicovaginal fistulae. Best Pract Res Clin Obstet Gynaecol. 2019;54:49–60. doi:10.1016/j.bpobgyn.2018.06.008