Urethrovaginal Fistula Repair
Urethrovaginal fistula (UVF) connects the urethra to the vagina. Repair must address closure, continence and unobstructed emptying separately. A vaginal approach is usually feasible; EAU recommends it preferentially, with a weak recommendation. Urethral loss, stricture, radiation injury and associated bladder-neck disease may require more extensive reconstruction.[1][2]
See the Female Fistula treatment atlas and Female Slings & Suspensions.
Define the defect and the functional problem
Prior continence surgery, diverticulectomy, vaginal surgery, obstetric trauma and urethral instrumentation are relevant causes. In Neu's 41-patient referral series, 17 fistulas followed SUI surgery and seven followed diverticulum repair. These are proportions within a selected UVF cohort, not the risk of fistula after those operations.[3]
Record the urethral level and length involved, fistula number and size, residual urethral tissue, stricture, vaginal access, radiation, previous repairs and any retained mesh. Leakage may be continuous or intermittent; symptom pattern alone does not reliably distinguish a urethral from a bladder fistula.[1][2]
| Assessment | Purpose |
|---|---|
| Vaginal examination and observed dye leakage | Identify the vaginal opening and assess tissue quality and access |
| Cystoscopy with careful urethroscopy | Localize the urethral defect, mesh or diverticulum and any additional bladder fistula |
| Urethrogram / VCUG | Clarify a difficult-to-see tract or associated urethral narrowing |
| MRI or CT | Selective imaging for uncertain anatomy, diverticulum, complex disease or suspected upper-tract injury; routine CT urography is unnecessary for every isolated UVF |
| Continence and emptying assessment | Distinguish leakage through the tract from coexisting SUI, urgency incontinence and obstruction; use urodynamics selectively when it will change reconstruction or sling planning |
The clinical/endoscopic evaluation and selective imaging approach were used in Neu's series.[3] In a double-dye test, upper-tract orange leakage can suggest a ureterovaginal source. Both bladder and urethral fistulas can transmit blue urine from the bladder: color alone does not localize the urethral defect. Direct assessment remains necessary.[1][4] Examination under anesthesia may help when access is limited; instruments should not be forced through scarred or poorly defined anatomy.
Timing and initial management
Control infection, protect the skin and assess tissue viability before elective closure. EAU advises individual timing once edema, inflammation, necrosis and infection have resolved; it does not establish a mandatory interval for every etiology.[1]
Selected small, recent defects may close with effective urinary drainage, but a reliable UVF-specific spontaneous-closure rate is unavailable. A mixed urogenital-fistula estimate or a bladder-fistula case report should not be presented as a 15% UVF cure rate. An established epithelialized tract, mesh erosion, urethral loss or stricture requires a plan addressing the underlying defect; prolonged drainage alone may not do so.[4][5]
Operative framework
The plan should preserve urethral lumen and length, achieve viable tension-free closure, and provide a separate vaginal cover. Route and tissue choice depend on actual anatomy, not a fixed sequence of increasingly large flaps.[1][2]
Transvaginal layered repair
- Identify the defect with urethroscopy and vaginal exposure. A small catheter through a suitable tract can aid localization and traction; this is a described technique rather than a requirement for every fistula.
- Separate the vaginal wall from the urethral closure plane, preserving viable tissue. Avoid imposing a fixed excision margin that unnecessarily enlarges a tissue-deficient defect.
- Close the urethral defect with absorbable suture, preserving caliber and avoiding tension. Choose orientation according to the defect; longitudinal closure does not inherently prevent narrowing.
- Provide additional viable coverage with available periurethral tissue and/or selected vascularized interposition, then close the vagina with separated suture lines where possible.
- Maintain dependable urinary drainage, with a urethral catheter and selective suprapubic drainage.
Clifton describes tract localization and layered closure; Neu reports multilayer transvaginal repairs, selective Martius interposition in 9/41 patients and either urethral drainage alone or combined suprapubic/urethral drainage. Neither establishes one mandatory suture size, catheter caliber or closure orientation.[3][6]
Interposition and reconstruction options
| Situation | Option and evidence boundary |
|---|---|
| Adequate viable urethral and vaginal tissue | Layered closure may suffice; interposition is not automatically required for every UVF |
| Tenuous closure, tissue deficit or recurrence | A modified Martius labial fat-pad flap can separate closure planes; it is an adjunct to urethral repair, not a standalone closure. Preserve the bulb and bulbospongiosus in the modified fat-only harvest.[7][8] |
| Severe periurethral deficit with SUI | A fascial patch plus autologous pubovaginal sling has been described; Golomb's report was a single patient, not validation of a universal salvage algorithm.[9] |
| Selected refractory defects after prior Martius failure | Bruce's pedicled rectus-muscle series achieved closure in six women, with five continent and emptying fully at mean 23 months. Consider abdominal donor morbidity and flap bulk; these results do not make rectus obligatory after one failed Martius.[10] |
| UVF with stricture or urethral loss | Individualized anastomosis, flap/graft urethroplasty or neourethral reconstruction; the remaining urethra, vagina and continence mechanism determine feasibility.[11][12] |
| Pelvic-fracture-associated obliteration | A transpubic reconstruction is an option in selected severe injuries. Xu's eight-patient series included one postoperative dilation and one transient SUI; it does not define the best route for all traumatic UVFs.[13] |
See Martius flap for VVF for flap selection, donor morbidity and the distinction between simple-VVF trial evidence and UVF case series. Rangnekar reported UVF closure in 7/8 with Martius versus 1/4 with anatomical repair; the small nonrandomized groups do not establish comparative efficacy.[7]
Latzko partial colpocleisis and Sims-Simon dissection/layered repair are distinct techniques. A Latzko–Martius UVF repair has been reported, but that case does not justify partial colpocleisis as the default for urethral defects.[14]
Continence surgery: concurrent or staged
AUA/SUFU 2023 statement 17 advises against a synthetic midurethral sling during concomitant UVF repair, urethral diverticulectomy or urethral mesh excision. If concurrent SUI surgery is needed, consider an option without synthetic suburethral mesh, preferably autologous fascia. Statement 18 separately advises considering avoidance of mesh where healing is compromised by radiation, substantial scarring or poor tissue quality.[15]
This does not require every continence procedure to wait three to six months. In Neu's retrospective series, 19/41 received a concurrent autologous fascial sling for bothersome SUI established through history, examination and urodynamics. No fistula recurred in that subgroup; two patients had transient retention. The small, selected, single-surgeon cohort cannot prove that concurrent and staged surgery are equivalent.[3]
A staged approach is reasonable when SUI is uncertain, tissue is unsuitable, emptying is problematic or the patient prefers reassessment after closure. Discuss retention, persistent incontinence and later procedures. Prior surgery alone does not make every future synthetic sling categorically prohibited; a healed reconstruction still requires individualized tissue-risk assessment.[3][15]
For mesh-associated UVF, define the intraluminal/eroded mesh and associated urethral damage before planning excision and reconstruction. The extent of mesh removal and interposition must match the lesion. One successful case involving diverticulum, mesh excision and Martius repair does not establish mandatory removal of every remote sling arm or mandatory interposition in all cases.[16]
Outcomes and counseling
| Study | Population and result | Interpretation |
|---|---|---|
| Pushkar 2006 | 71 UVFs: 64 closed after the first repair, 70 after a second; SUI reported in 37/71 | Closure and continence differ. The very long follow-up subgroup contained only 21 patients, not all 71.[2] |
| Neu 2021 | 41 UVF repairs, two recurrences; median follow-up 21 months | Retrospective referral cohort, including 12 previous repair failures; 19 concurrent autologous slings.[3] |
| Xu 2013 | 44 selected UVFs with stricture: 41/44 anatomical and 40/44 functional successes, mean follow-up 42.3 months | Five reconstruction types selected by anatomy; no randomized comparison establishing a superior flap.[11] |
| Lee & Zimmern 2016 | 18 nonirradiated UVFs, 95% closure; six underwent subsequent procedures during mean 52-month follow-up | Closure did not eliminate the need for treatment of incontinence, residual mesh or stricture.[17] |
Results from mixed VVF/UVF cohorts should not be relabeled as UVF-specific primary success rates. Persistent leakage after closure also needs reassessment for SUI, urgency incontinence or another tract before assuming recurrent UVF.
Drainage and follow-up
Maintain drainage until healing is adequately assessed; tailor duration to the urethral repair, tissue and complications. A randomized trial of 524 women with simple genital fistulas already closed at postoperative day seven supported seven rather than fourteen days in that selected population. It does not establish seven-day drainage for complex UVF, urethroplasty or radiation injury.[18]
Plan catheter removal with clinical assessment and selective imaging, including a voiding phase when needed to demonstrate a urethral/bladder-neck leak. Reassess vaginal leakage, wound healing, emptying/PVR, continence and pain after removal. Treat infection when present and address catheter obstruction or troublesome bladder spasms promptly. Later cystourethroscopy is driven by suspected residual mesh, stricture, persistent leakage or other findings rather than an obligatory schedule for every uncomplicated repair.[1][3]
Videos
References
1. European Association of Urology. "Non-neurogenic Female LUTS: urinary fistula." 2026. Official guideline, sections 4.8.3–4.8.4.
2. Pushkar DY, Dyakov VV, Kosko JW, Kasyan GR. "Management of urethrovaginal fistulas." Eur Urol. 2006;50(5):1000–1005. doi:10.1016/j.eururo.2006.08.002
3. Neu S, Locke J, Goldenberg M, Herschorn S. "Urethrovaginal fistula repair with or without concurrent fascial sling placement: a retrospective review." Can Urol Assoc J. 2021;15(5):E276–E280. doi:10.5489/cuaj.6786
4. Rogers RG, Jeppson PC. "Current diagnosis and management of pelvic fistulae in women." Obstet Gynecol. 2016;128(3):635–650. doi:10.1097/AOG.0000000000001519
5. Hillary CJ, Osman NI, Hilton P, Chapple CR. "The aetiology, treatment, and outcome of urogenital fistulae managed in well- and low-resourced countries: a systematic review." Eur Urol. 2016;70(3):478–492. doi:10.1016/j.eururo.2016.02.015
6. Clifton MM, Goldman HB. "Urethrovaginal fistula closure." Int Urogynecol J. 2017;28(1):157–158. doi:10.1007/s00192-016-3111-8
7. Rangnekar NP, Imdad Ali N, Kaul SA, Pathak HR. "Role of the Martius procedure in the management of urinary-vaginal fistulas." J Am Coll Surg. 2000;191(3):259–263. doi:10.1016/s1072-7515(00)00351-3
8. Wilson A, Pillay S, Greenwell T. "How and why to take a Martius labial interposition flap in female urology." Transl Androl Urol. 2017;6(Suppl 2):S81–S87. doi:10.21037/tau.2017.04.38
9. Golomb J, Leibovitch I, Mor Y, Nadu A, Ramon J. "Fascial patch technique for repair of complicated urethrovaginal fistula." Urology. 2006;68(5):1115–1118. doi:10.1016/j.urology.2006.06.001
10. Bruce RG, El-Galley RE, Galloway NT. "Use of rectus abdominis muscle flap for the treatment of complex and refractory urethrovaginal fistulas." J Urol. 2000;163(4):1212–1215. PubMed.
11. Xu YM, Sa YL, Fu Q, et al. "A rationale for procedure selection to repair female urethral stricture associated with urethrovaginal fistulas." J Urol. 2013;189(1):176–181. doi:10.1016/j.juro.2012.09.005
12. Blaivas JG. "Vaginal flap urethral reconstruction: an alternative to the bladder flap neourethra." J Urol. 1989;141(3):542–545. doi:10.1016/s0022-5347(17)40887-1
13. Xu YM, Sa YL, Fu Q, et al. "Transpubic access using pedicle tubularized labial urethroplasty for the treatment of female urethral strictures associated with urethrovaginal fistulas secondary to pelvic fracture." Eur Urol. 2009;56(1):193–200. doi:10.1016/j.eururo.2008.04.046
14. Zilberlicht A, Lavy Y, Auslender R, Abramov Y. "Transvaginal repair of a urethrovaginal fistula using the Latzko technique with a bulbocavernosus (Martius) flap." Int Urogynecol J. 2016;27(12):1925–1927. doi:10.1007/s00192-016-3085-6
15. Kobashi KC, Vasavada S, Bloschichak A, et al. "Updates to surgical treatment of female stress urinary incontinence (SUI): AUA/SUFU guideline (2023)." J Urol. 2023;209(6):1091–1098. doi:10.1097/JU.0000000000003435 Full guideline, statements 17–18.
16. Smith A, Burton L, Mama S. "Surgical approach to urethral diverticulum and urethrovaginal fistula with mesh erosion." Int Urogynecol J. 2024;35(6):1327–1329. doi:10.1007/s00192-024-05787-3
17. Lee D, Zimmern PE. "Long-term functional outcomes following non-radiated urethrovaginal fistula repair." World J Urol. 2016;34(2):291–296. doi:10.1007/s00345-015-1601-9
18. Barone MA, Widmer M, Arrowsmith S, et al. "Breakdown of simple female genital fistula repair after 7 day versus 14 day postoperative bladder catheterisation: a randomised, controlled, open-label, non-inferiority trial." Lancet. 2015;386(9988):56–62. doi:10.1016/S0140-6736(14)62337-0