Vesicovaginal fistula (VVF) formation represents a condition with devastating consequences for the patient and continues to pose a significant challenge to the surgeon. Quick and accurate diagnosis, followed by timely repair is essential to the successful management of these cases.  To minimize the morbidity of classical fistula repair, we hereby present a new minimally invasive surgery technique to perfom a fistulae repair of inside closing without transcutaneous, laparoscopic or vaginal incision: transurethral surgery- natural orifice translumenal endoscopic surgery (TUS-NOTES) by using a new small fine needle holder - minimal suturing device (MSD-Ney) and knot pusher.

Setting: A rigid cystoscope with 30 degree optics is inserted into the patients bladder with CO(2) insufflation. After inspecting the bladder and finding the fistulae orifices the fistulae area is manipulated with an endoscopic hooklet. The bladder segment is excised with electrocautery. First the monocryl 4-0 fibre is put into the needle holder. To fit into the needle is bended. The needle is put loose next to the cystoskope put into the bladder and after touching the wall the fibre is fixed at the end of the needle holder with a clamp. Now by a rotation the whole is at both sides stiched. With a grasp –put through the working channel- the needle is grasped and by loosing the clamp everything can be pulled out. By tying an extracorporal knot and putting an knot pusher over the fibre, the knot is fixed. The roeder sling was preferred as an easy to learn and create extracorporeal knot. This procedure is repeated till the whole is closed. The fibres are cutted.

Equipment needed: Cystoscope with 30 degree optics, CO (2) insufflation, 1mm diameter Needle holder (MSD-Ney), Monocryl 4-0, 0.5 mm diameter Knot pusher, Cystoscopic grasp, Cystoscopic scissor

The aim of the poster is to present the TUS-NOTES technique and teach the viewer how to apply this novel intervention to close the fistulae inside of bladder at 13 cases. The mean operative time was 55 min (35min-110min), whereas the blood loss was less 10ml.  The patients were discharged 3 days after surgery, and the catheter were removed 10 days after surgery. Before removal of the catheter a cystogram was performed. Follow-up examinations were carried out after 2, 6 and 24 weeks by means of  questionnaire, clinical examination, ultrasound and, if necessary, cystoscopy.

The treatment of VVF can either be conservative or surgical. If the fistula occurs after surgery, the condition can be resolved medically by inserting a transurethral or subrapubical catheter. However, most agree that the results of conservative treatment are poor, with only a 5% chance of success. Different approaches can be used for surgical repair, e.g. vaginal, electrocauterization in selected cases, transvesical, transperitoneal, laparoscopic and robotic.

Successful closure of VVF requires accurate diagnostic evaluation, appropriate repair using transurethral approach (TUS-NOTES) that utilize basic surgical principles of careful suturing of tissue. Extakorporale knots simplify the safe knot settlement. The transurethral approach has several advantages. Due to the transurethral suture it is possible to close the VVF at an early stage. It can decrease the risk of blood loss, avoid laparotomy and the opening of the bladder as well as shorter hospital stays and quicker recoveries. The learning curve is low and amounts to 2 interventions.  Evidence indicates that is equally effective as the transvaginal or transabdominal approach.

To reduce morbidity and prolonged recovery of excision of the VVF -  TUS-NOTES technique is efficacious and the preferred method of intervention. Only standard instruments, MSD and the needle holder are used for the procedure. Due to early complication management, patient satisfaction was very high. Long-term studies will confirm the shown results.