The patient, a 46-year-old female, presented to our department with complaints of continuous urinary incontinence. Her medical history included laparoscopic hysterectomy because of uterine myoma 2 months before her visit. Complete blood count, routine biochemistry parameters, urinalysis, urine culture, and urinary system ultrasonography results were all normal. We identified a 5-mm wide fistula between the bladder trigone and the upper part of the vaginal vault with flexible cystoscopy at the outpatient clinic. The patient was catheterized for 3 weeks. The patient who had catheterization failure underwent transvesicoscopic bipolar sealing of the vesicovaginal fistula (TBSF) after 3 months from her primary gynecologic surgery. The patient signed an informed consent form after she was advised on the use of the novel modified surgical procedure.
The operation was conducted with the patient in lithotomy position under spinal anesthesia. A prophylactic antibiotic (second-generation cephalosporin) was given half an hour before the induction. The VVF was identified with a cystoscope using insufflation of gas and it was verified by a guidewire (Fig. 1). The vagina was packed with vaseline-soaked gauze to prevent leakage during bladder filling and escape of CO2 during vesicoscopy. A 5-mm laparoscopic port was placed into the bladder under cystoscopic guidance in the lateral of the midline, halfway between the umbilicus and symphysis pubis. The second 5-mm port was placed into the bladder laterally at the midline and inferior to the first port (Fig. 2). A cystoscope was used as a transurethral camera for vesicoscopy. Bladder mucosa and muscular layer were gripped with a forceps and raised up for a multilayer closure. The fistula tract was grasped and sealed by an EBVS (LigaSure  5 mm blunt tip 37 cm sealer; Medtronic, Inc., Dublin, Ireland) (Fig. 3). An 18F Ryle's tube was kept in the bladder as a cystostomy through one of the existent ports. The bladder was also catheterized.
The operative time was 65 minutes. Blood loss was minimal and could not be measured in the case. There were no intraoperative or postoperative complications. The patient was allowed oral intake within 3 hours, to move within 12 hours postoperatively, and was discharged after removal of the cystostomy on the first postoperative day. The Foley catheter was kept in place for 3 weeks. An oral anticholinergic was given until the removal of the Foley catheter. The patient was instructed to return to our office 3 weeks after surgery for urethral Foley catheter removal and subsequent cystoscopic and vaginal inspection to confirm VVF repair (Fig. 4). During a 3-month follow-up, the patient remained continent, and the laboratory results were within normal range.