Vesico-vaginal Fistula (VVF) is an uncommon problem in the developed countries. Therefore, results might be influenced by the workload the surgeon encounters in the daily practice. 
Learning curves have been demonstrated for many urological procedures but yet have not been identified and/or calculated for vesico-vaginal fistula repair.

The 1st 100 women having surgery for VVF under the care of 1 surgeon between January 2002 and March 2019 were retrospectively identified; data on patient demographics, fistula aetiology, fistula size, surgical approach and outcomes were collected. 

All patients underwent an examination under anaesthesia and a cystoscopy. Most of the patients were further studied with a CT-U and MRI.

The surgery was performed by a single surgeon. Vaginal approach was attempted when feasible. Fistula tract was excised and a Martius fat pad was used as interposition graft.  When vaginal route was discarded, and abdominal repair was used, omentum or peritoneum was used as an interposition graft. 

They were reviewed by quartile and in total for: surgical procedure (diversion or VVF closure), route of VVF closure, % of ‘true’ vaginal closures  (assuming only absolute indications such as need for simultaneous ureteric re-implant or closure of associated bowel fistulae into the urinary tract or skin would result in abdominal repair), % anatomical closure at 1st attempt and overall (after additional attempt(s)) closure. 
Statistical Analysis was by Fishers Exact Test and Students T-Test. Significance was P<0.05.

The 100 women had a median age of 50 years (range 22-88). There were no significant differences in patient or fistula demographics: The most frequent cause of VVF was gynaecological surgery (55,6%) followed by urological surgery (19,2%). Obstetric fistula represented only 8% of the cases. Only 22,2% of the cases were due to a malignant cause. Median fistula size was 1 cm (0,2-7 cm). 

Their outcomes are as detailed in Table 1.

Contrary to developing countries, obstructed labor is not an issue in this setting; most of our cases develop after gynaecological or urological surgery. 
In this cohort, 6 patients were not considered for repair; 4 of them had extensive damage after radiotherapy. 

Vaginal repair is a viable option in most cases, except for those who need ureteral reimplantation or bowel fistula repair. Experience seems to be determinant in the use of vaginal route and the primary closure rate. In this case, after 75 cases the surgeon achieved a 100% closure rate at first attempt.

VVF closure rates are excellent in experienced hands. There is a learning curve in VVF repair, which appears to be about 75 cases. Vaginal repair utilisation increases with experience.