Vesicovaginal fistula (VVF) is an abnormal epithelialized connection between the bladder and the vagina, resulting in persistent urinary incontinence1,8,9. This condition severely affects the physical, mental, and social well-being of

women8,9. It commonly arises as a complication of gynaecological surgeries, obstetric trauma, or advanced malignancies2.

Epidemiology and Impact:

VVF predominantly affects women in low-resource settings due to factors such as early marriage, limited access to obstetric care, malnutrition, and lower social status1. The incidence in developed countries has decreased significantly due to better surgical practices and improved obstetric care, but it remains a significant public health issue in developing regions2,3. According to a study by Ockrim et al., despite being less common in the developed world, VVFs continue to pose a significant health challenge5.

Classification

 VVFs can be categorized into simple and complex types. Simple fistulas are typically small, non-radiated, and easier to repair. Complex fistulas are larger, may have multiple tracts, and often result from chronic diseases or previous failed surgeries, requiring more intricate management1.

Clinical Presentation

Patients with VVF present with continuous urinary leakage from the vagina, leading to significant discomfort, skin irritation, and social stigma. The continuous leakage affects daily activities and quality of life, necessitating prompt and effective treatment8,9.

Management Approaches

Treatment of VVF involves various surgical techniques, including open repair, laparoscopic repair, and endoscopic fulguration. The choice of technique depends on the fistula's size, location, aetiology, and the patient's overall health10. This study aims to evaluate the outcomes of different surgical approaches used at a tertiary care centre in India.

Aim of the Study:

To report the outcomes of VVF management performed at Gandhi Medical College and Hospital between September 2021 and June 2024.

• Study Design: Retrospective analysis
• Duration: September 2021 to June 2024
• Location: Gandhi Medical College and Hospital, Secunderabad

Inclusion Criteria

Patients with exclusive VVF without concomitant ureteric injuries

Exclusion Criteria

 VVF secondary to malignancy or radiotherapy

Data were collected from inpatient records, including demographic data, surgical approaches, operative details, and post-operative outcomes.

Patient Demographics:

• Mean Age: 38.6 years
• Range: 28-46 years
• Symptom Duration: Mean duration of symptoms was 3.5 months

VVF Characteristics:

Sizes:

• <0.5 cm: 5 patients
• 0.5-2.5 cm: 11 patients
• >2.5 cm: 7 patients

• Location: All supratrigonal
• Number: 3 patients had multiple fistulas; Rest 20 had single fistula

Table 1: Patient Demography

Surgical Approaches:

• Laparoscopic Repair: 13 patients
• Open Repair: 7 patients
• Endoscopic Repair: 5 patient

Figure 1: Surgical Approaches for Management of VVF

Complications:

• Bowel Injury: 1 patient (laparoscopic repair)
• Surgical Site Infection: 1 patient (open repair)
• Recurrence: 2 patients (endoscopic repair, managed with laparoscopic repair)

Mean Post-Op Stay by Surgery Type:

                  Table 2: Mean Post-Op Stay by Surgery Type

              Figure 2: Mean Post-Op Stay (Days) by Surgery Type

Mean Post-Op Pain Score by Surgery Type:

         Table 3: Mean Post-Op Pain Score by Surgery Type Pain Score by

            Figure 3: Mean Post-Op Pain Score by Surgery Type

Recurrence Rates by Surgery Type:

                  Table 4: Recurrence Rates by Surgery Type

Table 5: Statistical Analysis

The findings from this study highlight the variability in patient related outcomes based on the type of surgical approach used for VVF management. All cases in this study were due to iatrogenic causes, particularly following gynaecological surgeries such as hysterectomy and lower segment caesarean sections (LSCS)7. This is consistent with findings from Ockrim et al., who noted that most VVF cases are due to gynaecological interventions5.

Comparison of Surgical Approaches:

• Laparoscopic Repair: This approach showed a favourable outcome with shorter hospital stays (mean of 3.5 days) and lower post-operative pain scores (mean of 5). The minimally invasive nature of laparoscopic surgery contributed to these results, making it a preferred choice for suitable cases1,6.
• Open Repair: While effective, this method resulted in longer hospital stays (mean of 7 days) and higher pain scores (mean of 7). The extended recovery time and increased discomfort underscore the need for careful patient selection11.
• Endoscopic Repair: This technique offered the shortest hospital stays (mean of 2 days) and the lowest pain scores (mean of 3.5). However, it had a high recurrence rate (40%), indicating that it may be more suitable for smaller, less complex fistulas4.

Complications: The study recorded minimal complications, with only one case of bowel injury during laparoscopic repair and one surgical site infection in the open repair group. These complications were manageable and did not significantly affect the overall outcomes.

Recurrence: The recurrence rate was notably high in the endoscopic repair group. Two out of five patients experienced recurrence, highlighting the importance of proper patient selection and the limitations of this technique for larger or more complex fistulas4.

Clinical Implications: The results suggest that while laparoscopic and endoscopic approaches offer significant benefits in terms of recovery and pain management, the choice of surgical method should be tailored to the individual patient's condition. Laparoscopic repair stands out as a balanced option, combining effectiveness with minimal invasiveness6,12.

Future Directions: Further research with larger sample sizes and prospective studies are needed to confirm these findings and refine surgical techniques. Additionally, improving access to early diagnosis and timely intervention in low-resource settings could reduce the prevalence and severity of VVF1.

Laparoscopic repair emerges as a viable and effective option for VVF management, ensuring shorter hospital stays and less postoperative pain compared to traditional open repair, provided stringent surgical principles are followed i.e. adequate separation of both the walls, nonoverlapping suture lines and use of interposition flaps5,6,12. The minimally invasive nature of laparoscopic surgery offers significant advantages in terms of recovery and patient comfort6.

Endoscopic approaches, while beneficial in terms of hospital stay and pain, showed a higher recurrence rate, indicating the need for judicious patient selection and possibly reserving this method for smaller, less complex fistulas. Proper selection of patients for endoscopic fulguration has to be done very judiciously (fistula size <0.5 cm and oblique tract) for desired results. Of the three procedures, endoscopic fulguration is the least morbid procedure, worth attempting in selected cases with proper and cautious patient counselling, as this avoids a major procedure4.

Open repair, although effective, resulted in longer hospital stays and higher postoperative pain scores, underscoring the importance of careful patient selection and consideration of alternative approaches when appropriate10,11.

Both early and delayed interventions demonstrated similar efficacy in this study, highlighting that the timing of surgery should be tailored to the patient's overall health and specific clinical circumstances11.

Future research with larger sample sizes and prospective designs is necessary to validate these findings and further refine surgical techniques. Additionally, improving access to early diagnosis and timely intervention in low-resource settings could significantly reduce the prevalence and severity of VVF, ultimately enhancing the quality of life for affected women.

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