Step-by-step combined surgical approach to successfully repair complex and challenging vesico-vaginal fistulas: Insights from a case series

Introduction: Several surgical approaches are available for the repair of complex vesico-vaginal fistulas; however, robust clinical evidence and standardization of techniques are lacking. Complex vesico-vaginal fistula is defined as either a recurrent fistula following primary surgical repair or a fistula related to prior pelvic surgery and/or radiotherapy. The aim of this study was to describe a step-by-step combined vaginal and laparoscopic technique and to assess its feasibility, safety, and efficacy. Material and Methods: A retrospective study was performed between 2016 and 2023, involving patients diagnosed with complex vesico-vaginal fistulas. Clinical, perioperative, and postoperative data were collected. The surgical technique was standardized, described, and executed by an experienced surgeon in each case. Postoperative urogynecological follow-up was scheduled at one month, 3 months, 6 months, and one year. Results: A total of 20 patients were included in the study. Fifteen patients developed vesico-vaginal fistulas after total hysterectomy, four after radical hysterectomy combined with radiotherapy, and one following a cesarean section. Four patients had a prior diagnosis of gynecological cancer, four had received pelvic radiotherapy, and two had undergone previous chemotherapy. Twenty-five percent of the patients exhibited VVF in the trigone area. The median operative time was 317 min (ranging from 250 to 508 min). One minor postoperative complication occurred, and there was no conversion to laparotomy. All repairs were watertight. The median length of hospital stay was 4 days (ranging from 2 to 6 days). No recurrences were observed during the follow-up period, lasting 42 months on average. Conclusions: This study demonstrated the feasibility and safety of a new surgical approach for repairing complex urogenital fistulas.