The complexity of supratrigonal vesicovaginal fistula (VVF) often hampers clear visualization and precise repair via a transvaginal approach. An alternative technique involves extraperitoneal transvesical repair using transurethral illumination and laparoscopic instruments, presenting a viable solution for supratrigonal VVF. In this video, we focus on a 52-year-old woman who experienced persistent incontinence following an abdominal hysterectomy. She was diagnosed with supratrigonal VVF, which was conservatively managed for six months. This case demonstrates the extraperitoneal transvesical approach for repairing supratrigonal VVF using laparoscopic instruments.

To start the procedure, the supartrigonal VVF was visualized via transurethral cystoscopy. Bilateral ureteral catheters were inserted to prevent injury to the ureteral orifices. A 12mm balloon trocar was then placed and secured at the vaginal opening to prevent air leakage during pneumo-bladder insufflation and also served as an additional working port. The patient was positioned in the lithotomy position, with the operator working between the split legs and the assistant seated next to the patient. Two 5mm ports, placed 2 cm bilaterally from the midline, were inserted near the suprapubic area. To enhance surgical ergonomics, cystoscopy was intermittently replaced with ENT sinuscope during dissection and suturing. Dissection of the vagina and bladder wall was performed using hook dissector and Maryland forceps. Optimal suturing angles were achieved by alternating instruments between the suprapubic and urethral trocars. A leak test was conducted with 100 mL of povidone-iodine mixed with saline, and cystostomy was maintained via the suprapubic trocar until cystography confirmed the resolution of the supratrigonal VVF.

The patient achieved complete continent following the surgery. The follow-up period was 14 months.

Extraperitoneal transvesical repair of supratrigonal VVF using transurethral illumination and laparoscopic instruments is a feasible technique. This approach is particularly suitable for patients with a history of multiple abdominal surgeries, where transabdominal repair may be challenging. We have successfully repaired VVFs up to 2 cm in size, including cases following cancer treatment.