Diagnostic and Therapeutic Endoscopy taken. Conversion to open was not done in any patient. Blood loss was minimal in all. Intraoperative diﬃculties were noted in the ﬁrst case, which included ﬁxing the bladder to the anterior abdominal wall, pressure of insuﬄation to maintain the pneumovesicum during port insertion and suction, suturing of the vagina and bladder with continuous urine pool, and lastly the small space for instrument movement. These diﬃculties were less in the second and thereafter cases as we were able to overcome these initial discomforts. In the immediate postoperative period no obvious complications were noted, one patient developed upper respiratory tract infection and fever which subsided on its own. Another patient developed prolonged ileus more than 24 hours, which again settled on its own. Three patients were started orally within 24 hours and the patient with ileus was started orally after 48 hours. Patients were allowed to move within 36 hours. All patients had their infant feeding tubes removed on the 7th postoperative day and discharged with urethral catheters. Catheters were removed after 15 days following surgery. Follow-up ranges from 8 months to 17 months in these patients. No recurrence of VVF was noted in any one of them. All the four patients were satisﬁed with the surgical outcome; voiding was near normal in all. The two patients who were sexually active prior to surgery, continued to be having sexual relationship though both experienced some discomfort initially. 4. Discussion There is no “best” approach for all patients with VVF. Although factors such as size, location, and need for adjunctive procedures often have an impact on the choice of approach, the most important factor is commonly the experience of the operating surgeon [2]. Thus, there is no preferred approach for all ﬁstulas, and the optimal approach to the uncomplicated postgynecologic VVF is usually the one that is most successful in the individual surgeon’s hands [7]. Although it has been a long-held belief that gynaecologists prefer to ﬁx VVF transvaginally and urologists prefer a transabdominal approach because of their respective training and experience [8, 9], this diﬀerence is becoming increasingly blurred as urologists gain more experience and comfort operating transvaginally for a number of diﬀerent indications. The majority of VVF’s are amenable to a transvaginal repair. The relative advantages of a transvaginal approach compared with an abdominal approach include shorter operating times, briefer hospital stay, and less blood loss [10]. The principal disadvantages of the transvaginal approach include the relative lack of familiarity of the vaginal cuﬀ anatomy to many urologists; the potential for vaginal short- ening, especially with the Latzko approach; the diﬃculty in exposing high or retracted ﬁstulas near the vaginal cuﬀ, especially in deep, narrow vaginas or those without any apical prolapse, such as that found in nulliparous women [2]. VVF may be repaired transabdominally, and this is the preferred approach in those cases requiring augmentation 3 cystoplasty or ureteral reimplantation. Compared with the vaginal approach, the transabdominal approach to VVF repair is associated with longer recovery time and inpatient hospitalization, greater blood loss, more cosmetic deformity, and in general, greater morbidity [2]. Minimally invasive approaches to VVF repair would be ideal. A number of case reports and small series of laparo- scopic approach have already been published [3–6]. C. H. Nezhat et al. [11] ﬁrst reported laparoscopic repair of a VVF. Von Theobald et al. [3] used an omental J-ﬂap interposition during the laparoscopic repair of VVF. Recurrent VVF was similarly successfully repaired laparoscopically by Miklos et al. [4]. Their patient had previous two failed Latzko partial colpoclesis and closing the vagina and bladder with an interposed omental ﬂap using a laparoscopic approach ultimately repaired the persistent ﬁstula. Similar success with laparoscopic approach was described by a number of other authors [5, 12, 13]. The various authors were of the opinion that laparoscopy oﬀered the patient several advantages which included shorter hospital stay, more rapid postoperative recovery, and better cosmetic appearance than the traditional abdominal approach. The long operative time (>300 minutes) was attributed to diﬃculty in identiﬁcation of the ﬁstulous tract, diﬃcult dissection of the Vesicovaginal space, and need for intracorporeal suturing [6]. Sotelo et al. [14] incorporated concomitant cystoscopy to help guide the bladder incision, facilitating quick access to the VVF, and avoiding unnecessary dissection in the Vesicovaginal space. With our past experience in laparoscopy and intracor- poreal suturing we decided on attempting transvesicoscopic approach. Several laparoscopic surgeons have used this approach in a number of situations such as transvesicoscopic reimplantation of ureters, extraction of huge vesical calculi, and prostatectomy. All our four patients had a solitary, supra- trigonal VVF away from ureteric oriﬁces. Transvesicoscopic approach led us directly over the ﬁstula, making dissection of bladder from vagina easy. The vision was good and the intracorporeal suturing easy. Transvesicoscopic repair of VVF carries all the advantages of laparoscopy including minimal invasiveness, less morbid- ity, shorter hospital stay, early recovery, and better cosmetic appearance. The disadvantages of standard transabdominal laparoscopy, such as injury to other intraperitoneal organs, need for peritoneal drain, prolonged ileus, bleeding, are avoided in this technique. One obvious disadvantage of this procedure would be the inability to interpose healthy tissue such as omentum, in between the bladder and vagina. But with improved experience, articulated instruments, and newer devices, surgeons in future may be able to develop Martius ﬂap and interpose in between the vagina and bladder. 5. Conclusions Transvesicoscopic repair of a Vesicovaginal ﬁstula is feasible, safe and provides good results. It is an additional modiﬁca- tion to the laparoscopic transabdominal approach with all the advantages of laparoscopy.