Vesicovaginal fistula (VVF) is a devastating condition posing a negative impact on the quality of life in both the patient and partner. Although various approaches have been described in the literature, transabdominal (TA) and transvaginal (TV) approaches were commonly done surgical procedures. While the anatomical success rate following both the procedures is comparable, there is a dearth in the literature on long-term continence and sexual outcomes following successful repair. With this background, we tried to analyse the continence of the patient and sexual functions of the couple long after successful VVF repair between the two approaches.

We retrospectively analysed women who underwent VVF repair at our institute from 2011 to 2019. Isolated ureterovaginal fistula, vesicouterine fistula, urethrovaginal fistula and fistula after radiation were excluded. Medical records of preoperative, intraoperative and postoperative details were reviewed from the electronic data software. We assessed urinary and sexual function outcomes using International Consultation of Incontinence Questionnaire–Short Form (ICIQ-SF) and Female Sexual Function Index (FSFI) questionnaires, respectively at the time of the last follow-up. Successful repair (continence) was defined as the cessation of urine leakage following catheter removal. Stress urinary incontinence (SUI) was defined as an involuntary loss of urine on effort or physical exertion or on sneezing or coughing. Urge urinary incontinence (UUI) was defined as an involuntary loss of urine associated with urgency. The individual couple were called in person to the follow-up clinic for evaluation of functional outcomes. Patients not able to turn to the follow-up clinic were reached by a structured telephone interview with the same questionnaires. All statistical analyses were performed using STATA version 14.0.

A total of 94 patients underwent VVF repair, including 34 with transabdominal (TA) and 60 with transvaginal (TV) repairs. The mean age was 36.7 years (range 19 to 58 years), mean fistula diameter was 12.9 mm (range 3 to 30 mm) and mean follow-up was 31.7 months (range 6 to 80 months). The most common cause of VVF was hysterectomy 64.9% (61 patients) followed by obstetric cause in 28.7% (27 patients). Thirty-nine patients (41.5%) had previous failed repairs. Ten patients (10.6%) had three or more fistulae. The fistulae were found at supra-trigonal and trigonal regions in 80.9% (76 patients) and 19.1% (18 patients), respectively. Women with TA repair had significantly higher fistula size (14.5 vs 11.9 mm, p value=0.008), operative time (141.6 vs 102.8 minutes, p value=0.001) and estimated blood loss (147.6 vs 102.8 ml, p value=0.001) than women with TV repair. Overall, 81 patients (86.2%) had successful VVF repair (82.4% vs 88.3% in TA and TV, respectively; p value=0.42). Length of stay, catheterisation time and postoperative complications were comparable between the two groups. In the postoperative period, de novo SUI were reported by 3 patients with TA and 5 patients with TV repair (p value=1.00). Five women reported de novo UUI following TA as compared to 2 women following TV repair (p value=0.09). All the patients had conservative treatment as symptoms were tolerable. Eighty-three patients (88.3%) reported being sexually active before developing VVF, and 20 patients (21.3%) had intercourse even with VVF. Of the 81 women with successful repair, 74 patients (91.4%) reported being sexually active, however, 11 patients denied completing the questionnaires. Seven women (8.6%) reported sexual inactivity despite successful repair. 63 patients (77.8%) completed the FSFI and ICIQ-SF questionnaires at the time of the last follow-up. Both the groups were comparable in all the domains (desire, arousal, lubrication, orgasm, satisfaction and pain) of FSFI questionnaire. The mean overall FSFI score (17.1±14.7 vs 21.5±14.8, p value=0.16) was comparable. Similarly, the mean ICIQ-SF score (the sum of 3 domains- frequency, amount and bother) between the two groups were comparable (0.5±1.4 vs 0.3±1.0, p value=0.35). When asked specifically, women reported urine leak during coitus (2 patients), fear of urine leak (3 patients) and fear of VVF recurrence (1 patient) as the reasons for sexual inactivity despite successful VVF repair (1 patient did not reveal).

Our data suggested comparable long-term sexual and continence outcomes following successful TA and TV repairs for VVF. Although 15 women (18.5%) had de novo incontinence (including SUI and UUI) after the successful repair, none of them had bothersome symptoms requiring invasive treatment. Also, the mean ICIQ-SF score at the time of the last follow-up was comparable. Because VVF repairs inherently involve mobilisation of vaginal and/or paravaginal tissues, it is appreciable that it may anatomically or physiologically affect the detrusor, sphincter and perineal tissues resulting in issues of continence and sexual health of the individual. Though 7 patients (8.6%) reported sexual inactivity because of psychological or situational issues, in the present study, both the groups had comparable sexual function outcomes.

Although a subset of patients developed de novo urinary incontinence and sexual dysfunction, our data on vesicovaginal fistula repair suggests comparable long-term continence and sexual function outcomes between TA and TV repairs.