Vesicovaginal fistula repair closes an abnormal bladder-to-vagina connection and restores normal bladder drainage through the urethra. The repair may be performed vaginally, through the abdomen, laparoscopically or robotically. The best route depends on fistula location, size, proximity to ureteric openings, previous repair attempts, radiation history and surgeon experience. Successful repair is based on healthy tissue, tension-free watertight closure, careful separation of bladder from vagina and reliable catheter drainage while the repair heals.

Who needs surgical repair?

Many established VVFs require surgery, particularly when they are large, mature, recurrent, radiated or have not closed with an appropriate trial of catheter drainage. Active infection and tissue inflammation are addressed before repair whenever possible.

Preoperative mapping

• Speculum examination to assess vaginal access and scarring.
• Cystoscopy to identify the bladder opening and relation to ureteric orifices.
• Dye test if diagnosis is uncertain.
• CT urography to exclude ureteric injury when indicated.
• Renal function and urine culture.
• Review of pelvic-surgery and previous fistula-repair records.

Vaginal versus abdominal or minimally invasive repair

How is the repair performed?

• The fistula is exposed and bladder separated from vagina enough to remove tension.
• Scarred edges are managed according to tissue quality without unnecessary removal of healthy tissue.
• The bladder opening is closed securely.
• The vaginal layer is closed separately.
• Healthy vascularised tissue can be interposed in complex, recurrent or radiated cases.
• The bladder is continuously drained with a catheter during healing.

Is a Martius flap always needed?

No. A Martius labial fat-pad flap can provide vascularised tissue between closures in selected vaginal repairs, especially recurrent or poor-quality tissue, but routine use in every simple fistula is unnecessary.

Recovery

• A bladder catheter remains while the repair heals.
• Mild bladder spasms or catheter discomfort can occur.
• Avoid intercourse and vaginal insertion until healing is confirmed.
• Avoid heavy exertion during early recovery.
• Treat constipation and avoid straining as advised.

Risks

• Recurrent fistula.
• UTI.
• Bleeding or wound infection.
• Bladder storage symptoms.
• Ureteric obstruction in fistulas close to ureteric orifices.
• Persistent stress or urgency incontinence even after fistula closure.

What determines the route and timing of VVF repair

The best timing is when infection, tissue necrosis and significant inflammation have resolved and the surgeon can obtain healthy tissue for closure. This does not mean every woman must wait an arbitrary three or six months. Modern guidance supports individualised timing; selected fresh postoperative fistulae can be repaired earlier when tissue is suitable, while radiation-associated or inflamed fistulae often need more time.

A vaginal route offers direct access to many low and mid-vaginal fistulae with relatively little abdominal morbidity. An abdominal, laparoscopic or robotic route may be preferred for high/supratrigonal fistulae, difficult ureteric involvement, need for concomitant abdominal reconstruction or according to surgeon expertise. Systematic review evidence does not show one route to be universally superior; fistula anatomy and experience are more important.

The closure is performed in well-vascularised layers with no tension. Interposition flaps such as Martius or omentum are useful in selected complex, recurrent or radiated repairs, but high-quality evidence does not support using a flap routinely for every simple primary VVF. Continuous postoperative bladder drainage is essential while the repair heals.

How a tension-free multilayer closure is built

At surgery, the fistula is exposed through the route that offers the safest access. The bladder and vaginal walls are separated enough to allow each organ to close independently without tension. Devitalised scar is removed when necessary, but excessive excision can enlarge the defect and reduce available tissue.

The bladder is closed watertight, usually in one or more layers, and the vaginal wall is closed separately. When tissue is thin, recurrent or radiated, a vascularised interposition flap such as Martius fat pad or omentum can be placed between the two suture lines. Ureteric catheters or stents may be used if the fistula lies close to the ureteric orifices.

Continuous catheter drainage protects the repair while it heals. The exact duration is individual; current EAU guidance supports roughly 10–14 days after uncomplicated postoperative fistula repair and longer drainage for complex or radiation-associated cases. Catheter removal may be preceded by imaging when the surgeon wants confirmation that the closure is watertight.

What happens during the operation and recovery

Under anaesthesia, the fistula is identified and the bladder and vaginal tissues are mobilised enough to achieve closure without tension. The tract may be excised selectively, but aggressive removal of healthy tissue is not required for every fistula. Bladder and vaginal layers are closed separately so the suture lines do not overlap directly when possible.

A Martius fat-pad flap, omentum or other interposition tissue can be added in recurrent, radiated or otherwise complex repairs to bring vascularised tissue between the closures. This is not mandatory for every simple postoperative VVF.

Continuous bladder drainage is maintained with a urethral catheter, sometimes with additional suprapubic drainage. EAU expert guidance commonly uses about 10-14 days for simple postoperative fistulae and longer, often 14-21 days, for complex or post-radiation repairs, although the exact duration is individual. Some surgeons confirm healing with a cystogram before catheter removal.

Sexual intercourse and heavy pelvic activity are delayed until vaginal healing is complete. After successful closure, urgency or stress incontinence can persist because these are separate bladder or outlet problems and may need later treatment.

How success is checked after repair

The clearest sign is cessation of continuous vaginal urine leakage, but catheter removal is usually planned rather than used as an unmonitored trial. Depending on fistula complexity and surgeon preference, a cystogram or dye assessment may be used before or around catheter removal.

Later review asks about continence, urgency, infection, vaginal healing and intercourse. If leakage recurs, its timing and pattern help distinguish recurrent fistula from stress or urge incontinence. Dye testing and cystoscopy can localise uncertainty.

A first failed repair does not make closure impossible. Recurrent fistula requires careful remapping, attention to tissue vascularity and often an interposition flap or different surgical route.

Route of VVF repair should follow anatomy, not technology

A vaginal repair can provide excellent access to many low or mid-vaginal fistulas with less abdominal dissection. An abdominal, laparoscopic or robotic route may be preferred when the fistula is high, close to a ureteric orifice, associated with ureteric injury, difficult to expose vaginally or requires simultaneous abdominal reconstruction.

Current systematic-review evidence has not shown that one route is universally superior for fistula closure. Surgeon experience, fistula location, tissue quality and associated injuries therefore matter more than choosing the most technologically advanced approach.

Interposition tissue is selective, not mandatory

The core principles of fistula repair are clear exposure, healthy tissue, tension-free closure, separation of bladder and vaginal suture lines and dependable postoperative bladder drainage. A Martius flap, omentum or other vascularised tissue can be helpful in recurrent, radiated or poor-quality tissue.

For a straightforward primary fistula with healthy tissue, routine interposition has not been proven to improve closure in high-quality comparative evidence. The decision is therefore individual rather than a marker of whether the repair was ‘complete.’

What to bring for consultation

• Operative and discharge records from the hysterectomy, Caesarean section or pelvic surgery.
• CT urography, ultrasound or MRI images/reports if already performed.
• Cystoscopy, dye-test or ureteric stent records if available.
• Serum creatinine, urine routine and culture.
• A simple description of when leakage started and whether normal urination still occurs.
• Details of fever, pelvic pain, drain output, wound leakage or previous repair attempts.

FAQs

Related reading

• Vesicovaginal Fistula: Symptoms, Diagnosis and Treatment
• Ureterovaginal Fistula After Hysterectomy
• Urinary Fistula After Gynecological Surgery
• Urethrocutaneous Fistula: Causes and Treatment
• Urologist in Latur

References

• European Association of Urology. EAU Guidelines on Non-neurogenic Female LUTS: Urinary Fistula, 2026 https://uroweb.org/guidelines/non-neurogenic-female-luts/chapter/disease-management
• European Association of Urology. EAU Guidelines on Urological Trauma, 2026 https://uroweb.org/guidelines/urological-trauma
• Thompson JC, et al. Repair of Vesicovaginal Fistulae: A Systematic Review. Obstet Gynecol. 2024;143:229-241. PMID: 38033311 https://pubmed.ncbi.nlm.nih.gov/38033311/