A vesico-vaginal fistula (VVaF) is an abnormal communication between the bladder and the vagina, which results in urinary incontinence and repeated urinary tract infections.[1] VVaFs cause significant morbidity and have a severe impact on patients mental health, because of permanent leakage of urine.[2] VVaFs can be treated surgically. The aim of this study is to determine the outcome of surgically treated vesico-vaginal fistulae using a transvaginal approach with a Latzko technique.

A retrospective chart study was conducted. Surgical approaches to repair VVaF, from 2014 till September 2020, were selected. Patients who underwent a transvaginal approach were included. The primary objective was fistula closure. Secondary objectives were predictive factors for the outcome of the surgical procedure, e.g. patient characteristics, leakage on cystography two weeks postoperative, and surgery time.

Thirty-one patients had surgery for VVaF. Twenty-five procedures (81%) were performed transvaginally. Thirteen of these (52%) had successful transvaginal closure after first attempt. Of the seven patients who underwent a second transvaginal attempt, four (57%) had successful transvaginal closure. After either one or two attempts with the transvaginal approach, 17 (68%) of the VVaFs were successfully closed. Only few complications were observed. Urinary tract infection was the most common complication (n=4). Five patients with leakage shown on cystography two weeks after surgery had a catheter-in-situ for an extended period of time, independent whether or not the catheter remained in-situ the VVaFs were all persistent. Within the group of patients with successful closure of the VVaF 6 (46%) already underwent a previous attempt in closing the VVaF elsewhere. Of the patients in this study with an unsuccessful closure, 3 (25%) underwent previous VVaF surgery elsewhere.

We analyzed the outcome of vaginal approach of VVaFs. This approach is often chosen because it is a minimally invasive with minimal morbidity. In this study not all recurrent fistulae underwent a second attempt in closing the fistula. If patients who did not yet had a second attempt were taken into account with current success extrapolated, success rates would go up to 79% of the VVaFs successfully closed. Five patients had a cystography that showed leakage and the catheter remained in-situ for an extended period of time to support healing without success. The effect of the catheter remaining in situ therefore seems limited. One can even question the added value of cystography after surgery in this respect. We found that a predicting parameter for success was a previous repair of a VVaF elsewhere, before being admitted to our hospital. This might be coincidental, but at least a previous transvaginal approach elsewhere is not a contra-indication for a second transvaginal attempt.

With few minor complications noted within this cohort, the transvaginal surgical intervention with a Latzko technique remains a good treatment option for VVaFs. The effect of the catheter remaining in situ seems limited, and the cystography two weeks after surgery seems of limited added value to predict whether or not the catheter should remain in-situ to support healing of the VVaF. This study shows that a second attempt in closing the fistula with a transvaginal approach is useful and a previous transvaginal attempt is not a contra-indication for a second transvaginal attempt in closing the VVaF surgically.

Medina, L.G., et al., Robotic uterine-sparing vesicovaginal fistula repair. Int Urogynecol J, 2018. 29(12): p. 1845-1847.
Fujisaki, A., et al., An evaluation of the impact of post-hysterectomy vesicovaginal fistula repair on the mental health of patients in a developed country. Int Urogynecol J, 2019