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1Obstet. Gynecol. Dpt., GUH and Charles Univ.,,Prague, Czech Republic, 2Charles Univ. in Prague, Gen.Univ. H, Prague, Czech Republic, 3Urology Dpt., GUH andCharles Univ.,, Prague, Czech Republic, 4Dpt. of Obstet.and Gynecol., 1st Faculty of Med., Prague, Czech Republic.

Objective: Vesicovaginalfistulas are rare complications of gynaecological surgery. Theymostly occur following abdominal hysterectomy. The efficacy ofsurgical repair is reported to be between 75% to 97%. For fistularepair transvaginal, abdominal, laparoscopy or robotics approachcould be used. The aim of this video is to provide a step-by-stepdescription of our approach to laparoscopical vesicovaginal fistulasurgical repair.

Methods: Case description A41-year-old woman was referred to our department with increasing“urgency incontinence” which was refractory to solifenacintreatment. Incontinence developed following abdominal hysterectomywith urinary bladder resection (6/2014) due to endometriosis of thebladder after previous caesarian sections (2006, 2008) accompanied bysevere urgency, urgency incontinence and pelvic pain related tobladder filling and voiding, increasing during menstrual bleeding.Despite urinary leakage the patient was satisfied with the result ofthe hysterectomy due to easing of the pain and severe urgency. Basicclinical exam in specula revealed urine leakage localized in thevaginal apex. Cystoscopy exam proved presence of vesicovaginalfistula. Due to localization of the fistula we offered the patientlaparoscopical extravesical fistula repair. Surgical procedureCystoscopy was performed and ureteral stents were bilaterallyinserted. Afterwards the wire guide was inserted to the vesicovaginalfistula. Laparoscopy was performed, using a 10 mm port inserted ininferior edge of the umbilicus to accommodate the laparoscope andthree other ports (one 10 mm and two 5 mm). To provide properdissection of the vesicovaginal space and identification of thefistula tract, dissection was performed above the endopelvic fascia.The endopelvic fascia was identified after peritoneum dissectionabove the vaginal cuff, far from the scar tissue. Afterwardsdissection of the vesicovaginal space around the fistula tract wasperformed. The vesicovaginal fistula was dissected, and the fistulatract was completely excised. Dissection was continued approximately2-3 cm below the fistula to provide complete separation of the vaginaand the bladder wall. A two-layer suture of the bladder wall wasperformed using 2-0 Vicryl running suture, following single layersuture of the vaginal wall. Bladder suture line integrity was testedwith retrograded filling of the urinary bladder to 300 ml with“Patent blue” diluted in sterile saline. Interposition of thegraft was performed using omental flap, which was attached to vaginawith two stitches. Postoperative course The postoperative course wasuneventful. An indwelling Foley catheter was left for two weeks. Thepatient was discharged from hospital on the third day after surgery.The patient returned two weeks after surgery, the urinary bladder wasfilled to 300 ml of sterile saline, the Foley catheter was removedand cystoscopy was performed; this established the successful healingof the fistula. In follow-up visits 3 and 6 months after surgery thepatient was continent; she had slightly increased daily frequency (8)with no other symptoms of OAB.

Clinical relevance Theextravesical approach seems to be effective for surgical repair ofvesicovaginal fistulas. This technique is less invasive thantransvesical repairs, there is no need for cystotomy or bivalving ofthe bladder. One of the most important steps in this procedure isseparation of the vaginal wall and urinary bladder and watertightsuture of the bladder, with possibility of graft interposition.Interposition of the omental flap is discussed; according to some ofthe literature there is no evidence of improvement in healing usingthis technique.