Introduction: A fistula is an abnormal communication between two epithelial surfaces (1). A vesicovaginal fistula (VVF) results in a continuous urinary incontinence (2). This condition brings a severe deterioration in middle-aged women´s quality of life (3). Its incidence is underestimated given the associated social stigma (4). Our objective is to describe clinical results, incontinence rates and complications in VF repair with a natural orifice transluminal transurethral endoscopic surgical technique (NOTES). This due to the difficulty in the access through the abdominal or vaginal approach sometimes.
Methods: Previously we presented a case in video of a transurethral VF repair with good outcomes (5), now we present a series of 24 patients taken to VF repair with NOTES technique from 2013 - 2021. Patients taken to VVF, Vesicoperitoneal (VPF) and vesicoenteral (VEF) closure were included. The surgical procedure consists in a transurethral approach, with the use of a resectoscope and Collins loop, the VF hole in the bladder wall is circumcised, then a continuous suture is performed with a bio spiculated suture introduced by the urethral meatus, minor variations between male and female’s techniques are exposed. The surgical technique, complications, outcomes, and clinical follow-up of the patients are described.
Results: A total of 24 patients were included, 95.8% female. The median age was 42 years. 79.1% had VVF. 54.1% had complex VF. The median surgical time was 55 and 77 minutes for simple and complex fistulas, respectively. The rate of intra-surgical complications was anesthesia related in 4.2%. There were no complications = III on the Clavien Dindo scale. 41.6% of the procedures were ambulatory. All patients were released with anticholinergics and bladder catheterizing. 9 of 10 patients with simple VVF reported postoperative clinical improvement. 9 of 13 patients with complex VF had complete resolution of incontinence after removal of the catheter. The median follow-up was 10 months.
Conclusions: NOTES is a minimally invasive technique useful for the initial approach of patients with a VF. It is a reproducible, short-time and potentially ambulatory technique. This approach favors the closure of VVF, VPF and even VEF in non-oncological, oncological and irradiated patients, it is a useful option in patients with previous difficult abdominal approaches without the need to perform open bladder or transabdominal surgery. Multicentric prospective studies are needed for further conclusions