Vesicovaginal Fistula Repair

A vesicovaginal fistula (VVF) is an abnormal communication between the bladder and vagina that causes continuous urinary incontinence. It is the most common acquired urinary-tract fistula, and repair can be approached transvaginally or abdominally (transvesical/extravesical, open or robotic) — the two have similar success rates, with the choice driven by fistula characteristics and surgeon experience. The condition, its diagnosis, and flap selection are covered in the Reconstruction topic; this page is the operative reference.

Etiology and Presentation

VVF accounts for about 75% of acquired urinary-tract fistulae.

• Industrialised world — most are iatrogenic bladder injury at hysterectomy (iatrogenic cystotomy ~0.5–1.0%; fistula ~0.1–0.2%), typically an unrecognised cystotomy near the vaginal cuff. Patients usually present 7–14 days postoperatively with continuous leakage; the fistula lies on the anterior vaginal wall at the cuff.
• Developing world — most follow prolonged obstructed labour (pressure necrosis); obstetric fistulae are larger, more distal, and often involve the bladder neck/proximal urethra.
• Radiation fistulae can appear decades later — any fistula after radiation for malignancy may represent recurrence.

Diagnosis and Evaluation

• History/exam — constant vaginal urinary drainage is the hallmark (pain is uncommon); a thorough pelvic exam defines location and tissue quality/laxity.
• Cystoscopy and vaginoscopy — identify the tract and its proximity to the ureteric orifices.
• Lower-tract imaging — cystogram/VCUG (non-diagnostic without voiding/post-void images).
• Upper-tract imaging (CT urography, IVU, or retrograde pyelography) is mandatory — up to ~12% of post-surgical VVFs have an associated ureteral injury/ureterovaginal fistula, which may require ureteroneocystostomy and favours an abdominal approach.
• Dye tests — methylene blue per urethra against a vaginal pack (proximal staining = VVF). The double-dye (tampon) test (oral phenazopyridine + intravesical blue) localises the level: yellow-orange at the top = ureterovaginal, green in the middle = VVF, blue at the bottom = urethrovaginal.

Timing

Traditionally repair was delayed ≥ 3 months to let inflammation and necrosis settle, but practice has shifted toward operating when the tissue looks healthy — often 6–8 weeks — and toward early repair (within ~2 weeks) in appropriate, uncomplicated patients, to limit the distress of ongoing leakage. Delay repair of friable, irradiated, or recently failed cases until the tract stabilises. A conservative trial first — indwelling catheter plus an antimuscarinic for 2–3 weeks — closes ~13% (favourable for non-devascularised tracts < 2–3 mm); tracts still open at ≥ 3 weeks rarely resolve. Fulguration of small (< 3–5 mm) epithelialised tracts often fails.

Choosing the Approach

Success is similar between routes and depends most on surgeon experience.

Approach	Best for	Notes
Transvaginal	Most VVF, especially distal/apical post-hysterectomy fistulae	Shorter operative time and stay, less blood loss; limited cuff exposure; Latzko risks vaginal shortening
Abdominal (transvesical/extravesical; open, laparoscopic, or robotic)	Large/complex supratrigonal (> 5 cm), ureteral involvement needing reimplant, small-capacity bladder needing augmentation, irradiated tissue, immobile cuff or poor vaginal tissue, or prior failed vaginal repair	Permits concurrent intra-abdominal surgery; a robotic approach can preserve vaginal length in young, sexually active women

Principles of Repair

Shared across approaches: treat any UTI first, obtain adequate exposure, mobilise the tract, and achieve a watertight yet tension-free, multilayer closure of healthy tissue with non-overlapping suture lines, adding a tissue-interposition flap when the repair is tenuous (recurrence, radiation, ischaemic/obstetric, or large fistulae) and ensuring good postoperative drainage. Wide tract excision is not always necessary.

Transvaginal Repair

Positioning and Exposure

Dorsal lithotomy with moderate Trendelenburg and a Lone Star (or similar) retractor; relaxing incisions at the 5 and/or 7 o'clock positions of the introitus aid exposure. Place traction sutures beside the tract (or a tenaculum on a cervix, if present), and pass a Foley through the fistula from the vaginal side for retraction (dilate to admit an 8-Fr balloon catheter if needed). Place ureteral stents if the fistula is near an orifice.

Technique

1. Traditional — infiltrate with lidocaine-with-epinephrine; incise the vaginal skin and perivesical fascia well outside the scar; develop the plane between vaginal skin and detrusor; trim the edges and close the vesical defect in one interrupted absorbable layer, then close the perivesical fascia and vaginal skin minimising overlap of the suture lines. A U / inverted-U vaginal incision (apex just distal to the fistula) gives better exposure and a flap that covers the defect.
2. Vaginal-cuff-scar excision — a circumferential incision just outside the cuff scar encompassing the fistula; remove the cuff scar and the epithelialised tract (a funnel-shaped specimen), exposing detrusor with the fistula central; close the bladder mucosa, then close multiple detrusor layers over it (a flap is rarely needed) and reapproximate the vaginal skin. This is the one technique that accepts overlapping suture lines — the healthy, tension-free multilayer closure tolerates them without affecting results.

Latzko (Partial Colpocleisis)

For an apical fistula in a non-sexually-active woman: excise the peri-fistula scar widely, invert the fistula into the bladder and close it in two layers, then obliterate the vaginal wall with transverse rows of interrupted suture. Highly successful but decreases vaginal calibre and capacity — avoid in anyone wanting future sexual activity.

Tissue Interposition (vaginal)

• Peritoneal flap — easily accessible for an apical/high post-hysterectomy fistula.
• Martius (labial fat pad) flap — preferred for low/distal fistulae (trigone, bladder neck, urethra); the fat pad is mobilised on its posterior pedicle and tunnelled over the repair. Martius's 1928 description included the underlying bulbospongiosus, though many use the fat pad alone.
• Island flap (Lehoczky) — a 3–4 cm labial skin island with its adipose/vascular pedicle when vaginal skin is insufficient for tension-free closure.
• Gracilis myocutaneous flap — for large defects needing substantial coverage.

Abdominal (Transvesical/Extravesical) Repair

Performed open through a midline infraumbilical incision or minimally invasively (laparoscopic ± robotic, five ports in a W configuration). Cystoscopy with bilateral 5-Fr ureteral catheters protects the ureters; fill the bladder with dilute methylene blue to define the tract.

O'Conor Technique (transvesical)

The classic supratrigonal repair: after lysis of adhesions, bivalve the bladder with a vertical cystotomy carried down to the tract, excise devitalised tissue, and mobilise bladder and vaginal flaps widely (1–2 cm) for a tension-free closure (avoiding excess loss of vaginal length/capacity). Close the vaginal flaps transversely (3-0 absorbable), interpose a peritoneal flap (the peritoneum is not entered), then close the cystotomy in two layers, keeping the suture lines non-overlapping.

Gil-Vernet Technique

A smaller cystotomy is used; rather than extending it to the tract, the fistula is visualised, circumscribed, and excised, then bladder and vaginal flaps are closed tension-free in three layers (one vaginal, two bladder).

Extravesical Approach

Incise the peritoneum over the vagina (or cervix), develop the vesicovaginal plane down to the fistula-tract catheter, then mobilise a few centimetres beyond it; close the vagina transversely in one layer and the cystotomy in two horizontal layers (running 3-0 barbed suture).

Interposition (abdominal)

An omental pedicle flap is preferred for large/complex fistulae or infection/inflammation; a peritoneal flap is an alternative.

Postoperative Care

• Leave an indwelling Foley for 2–3 weeks with an antimuscarinic to prevent spasms (which stress the suture lines); abdominal repairs often add a 22-Fr suprapubic tube and a closed-suction drain, with early ambulation and low-dose antibiotic prophylaxis.
• Confirm healing with a cystogram/VCUG (or office methylene blue dye test) before catheter removal; if leakage persists, extend gravity drainage. Vaginal estrogen helps atrophic tissue heal.

Complications

Major complications are uncommon but include fistula recurrence (the main concern), stress urinary incontinence, urgency incontinence, and dyspareunia. Overall success for primary transvaginal repair is as high as 96%.