The commonest cause of vesicovaginal fistulas (VVF) in North America is abdominal hysterectomy. Controversy still exists regarding the optimal timing of repair and surgical approach, which can be either transvaginal or transabdominal, including laparoscopic or robotic. The role of interpositional flaps is also controversial. We aimed to review our fistula patients with regard to etiology, perioperative parameters, and outcome following transvaginal VVF repair.

Between 1995 and 2022, 83 women with VVFs underwent transvaginal fistula repairs. All data were captured in a database, concurrent with treatment, or from the institutional chart. The data were retrospectively reviewed for etiology, previous repairs and surgery, clinical presentation, location of fistula, surgical parameters, complications, and success rate. The transvaginal approach involved a multi-layer closure with monofilament absorbable sutures and local flap interposition. For the first 40 patients, suprapubic catheters were used and for the remaining 43 patients, urethral foley catheters were used. Catheter drainage was maintained for ~ 4weeks. The outcome was determined by cystogram and symptoms. Success was fistula closure. Institutional ethics board approval was obtained for the study.

Mean patient age was 47 (median 49, range 24 to 81). All patients presented with continuous incontinence with the diagnosis confirmed on cystoscopy and cystogram. Two patients had concomitant ureterovaginal fistulas, one of which was repaired transvaginally simultaneously. 80/83 (96%) had previous pelvic surgery, 20 (24%) prior pelvic malignancies, and 9 had pelvic radiation. Etiology was hysterectomy in 63 patients (76%), childbirth (vaginal or C-section) in 7 (8%), other surgery in 10 (12%), and radiation in 3 (2%). 

Mean time from fistula occurrence to repair was 14.6 mo. (median 7, range 2-276). Mean fistula size was 7.5 mm (median 5, range 2-20). Fistula location was posterior to the trigone in 61 patients (73%), trigone in 13 (16%), and bladder neck in 9 (12%). 26 patients (31%) had had a previous failed repair. 7 (8%) had multiple failed repairs both abdominal and vaginal. 

81/83 fistulas (98%) were successfully closed after 1 transvaginal repair with a follow-up mean of 17 mo. (median 9, range 1-142). The 2 failures were caused by radiation. One had a subsequent successful abdominal repair and the other an ileal conduit. The success for radiation-induced fistulas was lower than for other etiologies (p=0.0009). No difference in outcome was seen with either suprapubic or urethral catheter.

No significant perioperative morbidity was encountered. Mean postoperative hospital stay was 2 days (median 1, range 1-7). 46 (55%) had a hospital stay of 1 day.

Transvaginal VVF repair can be applied successfully and safely in patients after multiple etiologies, except radiation. Despite several prior failed repairs, success could be achieved with minimal morbidity and relatively short hospital stays.

Transvaginal VVF repair is an efficacious treatment for many VVFs. This experience may add to the evidence that due its relative lack of  morbidity and low costs, vaginal repair can be considered first as a surgical option (1).

Dirk J.M.K. De Ridder MD, PhD, FEBU and Tamsin Greenwell MD, PhD Campbell-Walsh-Wein Urology, 129, 2924-2963.e10