Minimally Invasive Management of Genitourinary Fistula: Intravesical Versus Extravesical Approach

Editor: Since description of the O'Conor technique in the early 1970s, for the past 50 years, it is still the most-common approach for surgical management of genitourinary (GU) fistulae. ¹

When using this technique, adequate exposure, dissection, and repair of a fistula requires complete bivalving of the bladder. In contrast to this classic approach—which is associated with a large cystotomy—the concept of “site-specific dissection” or an extravesical approach was developed in the late 1990s to minimize/obviate the need for a large cystotomy during GU fistula repair. ²

Recently, Giusti et al. reported successful outcomes in 16 patients who underwent laparoscopic vesicovaginal fistula (VVF) repair via a retrovesical approach. ³ Despite an emerging interest in the use of laparoscopic/robotic approaches for minimally invasive management of GU fistulae, the extravesical technique has not yet been well-acknowledged. ⁴ Intuitively, laparoscopic magnification and visualization provide adequate exposure to the otherwise poorly accessible retrovesical space. ⁵ This could explain why the advent, development, and implications of extravesical dissection were synchronized with the application of laparoscopy for GU fistulae repair. ¹

Not only is minimizing cystotomy during GU fistula repair a step toward a less-invasive procedure, it could theoretically improve the surgical success rate.^1,4,5 Giusti et al. should be commended for their study, in which they described the extravesical approach for VVF repair clearly, as many previous reports have not discriminated between intravesical versus extravesical approaches.^1,3,4 Giusti et al., in their study, interposed absorbable fibrin sealant between the bladder and vaginal cuff in each patient to reduce the chance of recurrence. ³

While the extravesical approach for dissection of both a VVF and a vesicouterine fistula (VUF) has been described,^1,3–5 understandably, access to—and exposure of—a VVF with an intact bladder can be more challenging, compared to a VUF. A VVF is usually located deep in the pelvis, and the bladder contour encases the vaginal cuff completely. In contrast, a VUF is a “high-up” fistula, and, with the uterus in place, the anatomy of the bladder and its relation to the genital organs can be preserved. Technically, for extravesical exposure of a VVF, the surgeon might need to identify, mobilize, and “lift-up” the posterior bladder wall adequately to expose the vaginal cuff and proceed with dissection in the vesicovaginal plane.

Although interposing a tissue flap after fistula repair has been a common practice for decades—as Miklos et al. critically reviewed this practice—it has never been proven to improve the success rate.^1,4 Successful repairs of even recurrent fistulae without tissue interposition flaps have been reported.^1,3 Furthermore, intraoperative findings in patients with recurrent VVFs showed neither improved tissue vascularity nor viability/presence of the previously interposed omental flaps.^1,4 With these new concepts and observations, interposing bioabsorbable sealant materials requires further justifications.

Minimally invasive management of GU fistulas, including the retrovesical approach or the use of laparoscopic/robotic techniques, continues to be rewarding. However, studies designed to compare the potential advantages of these modifications are highly advisable.^1,4,5