Transvaginal vesicovaginal fistula repair – high success with low morbidity despite radiation or prior repair

Introduction: Vesicovaginal fistula (VVF) surgical repair can be done transvaginal or transabdominal, laparoscopic, or robotic. Controversy exists regarding optimal approach, especially in those who have had prior radiation treatment, and those who with prior VVF repair. We aimed to review our large fistula cohort to determine the success of transvaginal VVF repair. Methods: Between 1995-2022, 83 women with VVF underwent transvaginal VVF repair. All data were captured in a prospective database. Transvaginal approach involved multi-layer closure with monofilament absorbable sutures and local flap interposition. Success was cystogram evidence of fistula closure and freedom from re-operation. Results: Mean patient age was 47 (median 49, range 24-81). 96% had previous pelvic surgery, 24% prior pelvic malignancies, and 11% had pelvic radiation. Etiology was hysterectomy (76%), other surgery (12%), childbirth (8%), and radiation (4%). Mean time from fistula to repair was 14.6 months (median 7, range 2-276). 31% had previous failed repair. 99% were successfully closed after one transvaginal repair with a follow-up mean of 17 months (median 9, range 1-142). One patient had fistula recurrence , and had previously been irradiated. No difference in outcome was seen with either post-operative suprapubic or urethral catheter. No significant perioperative morbidity was encountered. 55% had a one day hospital stay. Conclusions: Transvaginal VVF repair is an efficacious treatment for VVF. Due to its relative lack of morbidity and low costs, vaginal repair can be considered first as a surgical option and can be considered in patients who have undergone pelvic irradiation or in those with prior unsuccessful VVF repair.