Recurrent Urethro vaginal fistula(UVF) is an uncommon condition. It is usually following prolonged labour and following episiotomy. It occurs following  third degree perineal tear. UV fistula can also be secondary to other causes like urethral diverticulectomy, sling procedures, pelvic trauma .
The Aim of the study was to consider a  reliable procedure and suggest a good alternative  technique for repair of recurrent  urethrovaginal fistula and restore Quality of Life.

We present a case of a thirty one  year old lady with urinary and faecal iincontinence. Initial management was a colostomy. and repair of urethrovaginal fistula in a remote hospital.. Following  catheter removal after one week, she complained of leak per vagina and was also voiding  per urethra . She also had raised postvoid residual.
On presentation to our tertiary centre, she was evaluated.
CT Abdomen and pelvis with contrast  revealed a  urethrovaginal fistula.
Examination and Urethrocystoscopy showed a large defect in the vagina and upto proximal urethra. Bladder neck involvement was suspicious .
Vagina was cicatrised due to previous repair.

In view of the above findings, we proceeded with a gracilis muscle flap.separate incision was made in the mid thigh. Gracilis muscle, tendon identified. Adequate length of the flap was taken . It was tunneled subcutaneous , groin, labia minora to the area of defect upto bladder neck.and positioned well with absorbable sutures.
 Patient had urethral and suprapubic catheter post op. 
Suprapubic catheter was removed after six weeks and  Urethral Catheter was removed after eight weeks post op.

Patient was voiding well with alpha blocker and short term muscle relaxant. Initially , she carried out Clean intermittent  self catheterisation  until post void residual was satisfactory.

Martius flap ,buccal mucosa graft  were also  considered. Gracilis flap may carry comorbidity due to large  and separate incisions in thigh but the outcome of the repair is more successful in recurrent urethrovaginal fistula.The technical challenge was to create a space for the gracilis flap with atretic vagina. Inspite of this  technical challenge , it is a good option.

In view of the large defect and the recurrence of the urethrovaginal fistula, the decision was taken to proceed with gracilis muscle flap.
 Gracilis flap also provided good vascularity,  adequate coverage ,cushion and sling effect for the large defect and at the bladder neck. 
Continence procedure was not considered in view of the high postvoid residual and no SUI.

It is important to assess the type and extent of the urethrovaginal  fistula, recurrence factor and assess if continence procedure is required.
 Gracilis muscle flap is to be considered as a good alternative for large defects with recurrent urethrovaginal fistula .The successful outcome with expertise is an ideal choice in  restoring continence and  Quality of Life.

2020 Oct 27;15(5):E276–E280. doi: 10.5489/cuaj.6786
Cureus. 2024 Nov 27;16(11):e74614. doi: 10.7759/cureus.74614 An Outside-the-Box Approach for Treating a Rare Case of Urethrovaginal Fistula Rahul Agrawal 1, Sankalp Goel 2,?, Vilas P Sabale 1, Vikram Satav 1
Pushkar DY et al. Management of urethrovaginal fistulas. Eur Urol. 2006;50:1000–5. doi: 10.1016/j.eururo.2006.08.002