Minimally invasive surgical approaches have become highly popular in line with technological advancements. In vesicovaginal fistula (VVF) repair, numerous minimally invasive surgical techniques, namely laparoscopic, robotic, and transvaginal techniques, are used. However, these techniques require invasion though minimally. In this report, we present a patient with iatrogenic VVF in whom we applied a novel “zero-invasion” technique, Natural Orifice Transurethral Endoscopic Vesicovaginal Fistula (NOTE-VVF) Treatment, to repair the fistula tract by advancing the laparoscopic trocar through a natural orifice, i.e. urethra.

Case 
A 45-year-old female patient was admitted to our clinic with the complaint of continuous urinary incontinence that started immediately after total abdominal hysterectomy that was performed due to uterine myoma in another center about three weeks earlier. Patient history indicated that she had no complaint of urinary incontinence prior to hysterectomy. 
Urogynecological examination indicated urine leakage from the vagina, not from the urethra. Serum creatinine level, complete urinalysis, urinary culture, and urinary ultrasonography were normal. Due to a suspicion of VVF, a 14 Fr urethral catheter was inserted in the bladder and the methylene blue test revealed urinary leakage from the vagina. The diagnosis of VVF was confirmed by the visualization of a fistula tract approximately 5 mm in diameter in the bladder trigone region on cystoscopy which was performed on an outpatient basis . Elective surgery was planned for the fistula repair.
Following preoperative preparation, the patient was placed in the lithotomy position at operation room under spinal anesthesia. After cleaning and draping, the location and width of the fistula tract was determined by entering the bladder with the cystoscopy. An optical lens (for imaging) and a 5mm laparoscopic trocar (working trocar) were carefully inserted into the bladder through the female urethra. Subsequently, the VVF line was sutured at 1-2 mm intervals and the bladder side was closed using 4/0 absorbable sutures that were advanced into the bladder through the working trocar. The procedure was completed after inserting a 14 Fr urethral catheter in the bladder.

In this case, VVF repair was performed with the NOTE-VVF repair technique and the patient was discharged 24 hours after surgery (total operative time, 23 min). On day 10 after surgery, the patient had no urinary incontinence and no methylene blue leakage from the vagina following the Valsalva maneuver and thus the urethral catheter was removed. No urinary incontinence was present at later follow-up visits, and the cystoscopy performed at month 3 showed complete closure of the fistula tract. No peri- or post-operative complication occurred in the patient.

NOTE-VVF technique introduced in the present study, which can be applied by entering the bladder through the urethra only by using 5 mm laparoscopic trocar and a thin optical lens, can be successfully used in the treatment of small, non-complicated, acute-stage, iatrogenic VVFs.

Continence 2S2 (2022) 100397
DOI: 10.1016/j.cont.2022.100397