Transvaginal Latzko Repair (Partial Colpocleisis)
The Latzko repair (Wilhelm Latzko, 1942) is a transvaginal partial colpocleisis for vesicovaginal fistula (VVF). It removes the surrounding vaginal epithelium and imbricates the underlying fibromuscular tissue, without formal fistula-tract excision. Selected series report high closure rates, but closure and continence are different outcomes and should not be combined into a universal success range.[1][2][3][4]
For the broader VVF clinical algorithm, see the vesicovaginal fistula clinical page. For conservative and endoscopy-guided alternatives, see Conservative VVF Management and Endoscopic VVF Management.
Principle
Latzko originally described the technique for post-hysterectomy VVFs at the vaginal cuff. Rather than dissecting the bladder off the vagina and closing each layer separately (multilayer closure), the Latzko denudes vaginal epithelium circumferentially around the fistula and imbricates the surrounding fibromuscular tissue in multiple layers, obliterating the upper vagina over the fistula site. The tract is left in situ and is sealed by apposition of the raw, denuded surfaces.[1][5]
Indications
- Post-hysterectomy (vaginal cuff) VVFs — the classic and most common indication; the apex is where the technique sits most naturally.[5][6][2]
- Small to moderate-sized fistulae that can be visualized and accessed transvaginally.
- Selected fistulae near the ureteral orifices — limited dissection may be useful, but identify and protect the ureters. Preference in a radiation series is not proof of a lower injury rate than other techniques.[7]
- Radiation-induced VVF — used in 35.7% of cases in one large series (n = 210 radiation VVFs), particularly when ureteral proximity is a concern.[7]
- Complex / recurrent fistulae — versatile across concurrent prolapse repair, complex urologic surgery, and the postpartum setting.[5][8]
- Repeat repairs — acceptable to repeat the Latzko after a prior vaginal failure.[3]
Contraindications / poor fit
- Fistula too low (mid-vaginal or distal) for adequate apical denuding and imbrication.
- Ureteral reimplantation required.
- Bladder augmentation required.
- Very large fistula preventing tension-free closure.
- Concurrent abdominal pathology requiring transabdominal access.[1]
- Particular concern about vaginal shortening in a sexually active patient (see below).
Surgical Technique
The classic technique and modifications proceed in this order:[5][6]
1. Positioning and exposure
- Dorsal lithotomy (high or exaggerated for optimal exposure).
- Weighted posterior vaginal retractor and lateral retractors.
- Identify the fistula and pass a small catheter / probe through the tract to confirm location.
- Cystoscopy to assess fistula size, location relative to the ureteral orifices, and to place ureteral stents if needed for protection.
2. Hydrodissection
- Hydrodissect the vaginal epithelium from the underlying fascia. The published technique describes local vasopressin; if used, the concentration and dose require an agreed anesthetic/medication protocol rather than an unspecified dilution.
- Dual purpose: hydrodissection to elevate vaginal epithelium from underlying fascia, plus hemostasis.[5]
3. Circumscribing incision and denuding
- Circumferential incision in vaginal epithelium 2–3 cm from the fistula margin.
- Sharply dissect the vaginal epithelium within this circle off the underlying pubovesical (endopelvic) fascia, leaving a ring of denuded raw fibromuscular tissue around the fistula.
- The fistula tract is not excised — the defining feature of the Latzko vs multilayer closure.[1][5]
4. Purse-string closure of the fistula
- Place a fine absorbable purse-string suture in the fibromuscular tissue just outside the epithelialized tract.
- Remove the catheter used to identify the tract as the purse-string is tied, avoiding entrapment; this is distinct from postoperative bladder drainage.[5]
5. Imbrication (layered closure)
- Place interrupted imbricating sutures over the purse-string and additional layers appropriate to the available tissue; the described technique uses one to two subsequent imbricating layers. Avoid leaving a channel at the base.
- Each successive layer imbricates the previous, creating a multilayered tension-free closure.
- Sutures incorporate anterior and posterior vaginal fibromuscular tissue, bringing the walls together over the fistula site (partial colpocleisis).[5][7]
6. Vaginal epithelial closure
- Close the remaining vaginal epithelium over the repair with interrupted or running absorbable sutures.
- Vaginal pack as needed.[5][6]
7. Catheter
Modified Latzko Techniques
| Modification | Detail | Outcome |
|---|---|---|
| Apical-VVF modification (Luo & Shen) | Addresses the firm transverse scar at the vaginal apex after hysterectomy. | 100% closure in n = 108 at mean 40.7 months, no immediate or delayed complications.[2] |
| Modified Latzko with separate pubovesical-fascia closure (Cardenas-Trowers) | Mobilizes vaginal mucosa around the fistula, then closes pubovesical fascia and vaginal mucosa as separate layers. | Adds a distinct fascial layer to the repair.[6] |
| Latzko + Martius flap interposition | Labial fat-pad flap interposed between bladder and vaginal walls for additional blood supply and bulk. | One radiation-induced recurrent VVF salvaged on third Latzko after two failures, with Martius adjunct.[9] |
Outcomes
| Series | n | Fistula type | Success | Follow-up |
|---|---|---|---|---|
| Luo & Shen 2019[2] | 108 | Apical (post-hysterectomy) | 100% | Mean 40.7 mo |
| Mohr 2014[4] | 60 vaginal Latzko repairs | VVF | 82% continence, not a separately specified anatomical closure endpoint in the abstract | 6 mo |
| Pushkar 2009[7] | 210 vaginal repairs, including 75 Latzko | Radiation-induced VVF | 101/210 primary and 169/210 cumulative closure for the entire vaginal cohort; not Latzko-specific rates | Series accumulated over more than 40 years |
| Angioli 2003 (narrative review)[3] | — | Non-irradiated VVF | Historical vaginal-route mean 91%; includes different vaginal techniques and case mixes | Variable |
| Kieserman-Shmokler 2019[5] | Technique/video report | Diverse selected cases | Describes operative steps; no comparative efficacy estimate | Variable |
Key takeaways:
- Selected non-irradiated series report favorable results, but different endpoints and patient selection prevent establishing equivalence to abdominal repair.[4][3][2]
- In the radiation study, 48.1% primary and 80.4% final closure refer to all 210 vaginal repairs, not the 75 Latzko cases. These cannot be used to estimate Latzko-specific efficacy.[7]
- The Latzko is repeatable — a second or third attempt is acceptable, with or without Martius adjunct.[7][9]
Advantages and Evidence Limits
Latzko avoids formal tract excision and extensive vesicovaginal dissection. In Mohr's nonrandomized comparison, vaginal repair had shorter operations, less blood loss and shorter hospitalization than abdominal repair. Selection by anatomy and case complexity limits causal comparison.[3][4][5]
Limited dissection does not guarantee freedom from ureteral injury or obstruction. Protect nearby ureters and assess the final repair; no direct comparative study establishes a universally lower injury rate than separate-layer vaginal closure.[7]
Disadvantages and Concerns
Vaginal shortening
The principal concern. The Latzko is by definition a partial colpocleisis — obliteration of the upper vagina — which shortens the canal. The functional consequence varies; discuss baseline length, scarring and the patient’s sexual goals. A comparative transvaginal-vs-transabdominal study, however, found sexual function significantly improved after both, with no difference in FSFI at 6 months.[4] Broader prolapse/vaginal-surgery studies did not find consistent anatomical–sexual function correlations; they do not rule out shortening, dyspareunia or loss of penetrative function after an individual Latzko repair.[10][11]
Other
- Not suitable for all fistula locations — the classic Latzko targets apical / cuff fistulae; mid-vaginal or distal fistulae may not be amenable.
- Tract not excised — deliberate tissue preservation; it does not eliminate the possibility of recurrence.
Latzko vs Multilayer Closure
| Feature | Latzko (Partial Colpocleisis) | Multilayer Closure |
|---|---|---|
| Fistula tract excision | No | Debated (some excise; some freshen edges) |
| Vesicovaginal-space dissection | Minimal | Wide mobilization required |
| Closure layers | Imbrication of denuded fibromuscular tissue | Separate bladder (1–2 layers) + vaginal wall |
| Vaginal shortening | Yes (partial colpocleisis) | Minimal |
| Ureteral considerations | Identify/protect ureters despite limited dissection | Identify/protect ureters during mobilization |
| Comparative efficacy | No high-quality evidence establishes superiority | Case mix and endpoint definitions differ |
| Access requirement | Adequate vaginal access and tissue for imbrication | Adequate exposure and tissue for separate-layer closure |
The 2026 Cochrane protocol plans to evaluate surgical interventions including partial colpocleisis and multilayer closure. It provides no completed comparative results.[1] Practically, this means the Latzko should not be viewed as an inferior "unexcised" repair; for the right apical fistula, non-excision is the design of the operation.
Postoperative Care
- Maintain reliable bladder drainage and treat troublesome spasms after checking catheter function. Individualize duration: WHO supports 7–10 days for selected simple obstetric repairs, whereas EAU expert guidance uses 10–14 days for simple/postsurgical and 14–21 days for complex/radiation repairs.[12][13]
- Assess closure before catheter removal using the clinical setting and appropriate dye testing or imaging. Routine follow-up cystoscopy at a fixed interval is not established for every uncomplicated Latzko repair.
- If leakage persists, investigate its source. The 29/52 improvement with an extra catheter week was reported after obstetric repair with a positive dye test after at least 14 days, not after every Latzko repair; see the postoperative drainage evidence.[14]
- Discuss activity and resumption of intercourse according to tissue healing and patient goals, and assess continence and sexual function separately from closure.
Radiation-Induced VVF
Pushkar reported 216 radiation-associated VVF cases, including 210 vaginal repairs and 75 Latzko procedures. The 101/210 initial and 169/210 eventual closures belong to the entire vaginal cohort. The authors describe selected staged/repeat repair and use of Latzko or Martius tissue; the uncontrolled, four-decade experience cannot establish the best technique. Reassess tissue, urinary function and goals before another attempt.[7]
See Also
- Vesicovaginal Fistula (clinical)
- Conservative VVF Management
- Endoscopic VVF Management
- Female Fistula Repair (atlas)
- Fistula Repair Principles
- Martius Flap
References
1. Okada Y, Matsushita T, Hasegawa T, et al. Surgical interventions for treating vesicovaginal fistula in women. Cochrane Database Syst Rev. 2026;1:CD015413. Protocol. doi:10.1002/14651858.CD015413
2. Luo DY, Shen H. Transvaginal repair of apical vesicovaginal fistula: a modified Latzko technique — outcomes at a high-volume referral center. Eur Urol. 2019;76(1):84–88. doi:10.1016/j.eururo.2019.04.010
3. Angioli R, Penalver M, Muzii L, et al. Guidelines of how to manage vesicovaginal fistula. Crit Rev Oncol Hematol. 2003;48(3):295–304. doi:10.1016/s1040-8428(03)00123-9
4. Mohr S, Brandner S, Mueller MD, Dreher EF, Kuhn A. Sexual function after vaginal and abdominal fistula repair. Am J Obstet Gynecol. 2014;211(1):74.e1–6. doi:10.1016/j.ajog.2014.02.011
5. Kieserman-Shmokler C, Sammarco AG, English EM, Swenson CW, DeLancey JO. The Latzko: a high-value, versatile vesicovaginal fistula repair. Am J Obstet Gynecol. 2019;221(2):160.e1–4. doi:10.1016/j.ajog.2019.05.021
6. Cardenas-Trowers O, Heusinkveld J, Hatch K. Simple and effective: transvaginal vesicovaginal fistula repair with a modified Latzko technique. Int Urogynecol J. 2018;29(5):767–769. doi:10.1007/s00192-017-3471-8
7. Pushkar DY, Dyakov VV, Kasyan GR. Management of radiation-induced vesicovaginal fistula. Eur Urol. 2009;55(1):131–137. doi:10.1016/j.eururo.2008.04.044
8. Roberts BL, Chang ES, Hidalgo RJ, Wiegand LR, Wyman AM. Vesicovaginal fistula repair at the time of colpocleisis. Int Urogynecol J. 2021;32(7):1939–1940. doi:10.1007/s00192-021-04787-x
9. Kołodyńska A, Streit-Ciećkiewicz D, Kot A, Kuliniec I, Futyma K. Radiation-induced recurrent vesicovaginal fistula — treatment with adjuvant platelet-rich plasma injection and Martius flap placement: case report and review of literature. Int J Environ Res Public Health. 2021;18(9):4867. doi:10.3390/ijerph18094867
10. Kim-Fine S, Antosh DD, Balk EM, et al. Relationship of postoperative vaginal anatomy and sexual function: a systematic review with meta-analysis. Int Urogynecol J. 2021;32(8):2125–2134. doi:10.1007/s00192-021-04829-4
11. Occhino JA, Trabuco EC, Heisler CA, Klingele CJ, Gebhart JB. Changes in vaginal anatomy and sexual function after vaginal surgery. Int Urogynecol J. 2011;22(7):799–804. doi:10.1007/s00192-011-1386-3
12. European Association of Urology. Non-neurogenic Female LUTS guideline, section 4.8: urinary fistula. 2026 edition. Full guideline section.
13. World Health Organization. Duration of catheterization after simple obstetric fistula repair. 2018. Official recommendation.
14. Chang OH, Ganesh P, Wilkinson JP, Pope RJ. Extended bladder catheterization for women with positive dye tests after obstetric vesicovaginal fistula repair surgery. Int J Gynaecol Obstet. 2020;149:61–65. doi:10.1002/ijgo.13088.