Iatrogenic VVF are closed vaginally in approximately 70% cases. Reasons for abdominal closure are often soft vesico- vaginal access difficulty rather than absolute. We postulated that surgical preference often dictates choice of abdominal route. We have compared the routes and outcomes of 3 consultant surgeons working closely together at different stages of their careers and with differing levels of experience in VVF repair.

137 women having surgery for VVF between January 2002 and March 2019 were retrospectively identified and data on patient demographics, fistula aetiology, position and size, surgical approach and outcome 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 one of three consultant surgeons dedicated to reconstructive surgery.  Whenever possible, an interposition graft used, either a Martius fat pad, or omentum or peritoneum when an abdominal surgery was performed. 

The patients were reviewed for surgeon, surgical procedure (diversion or VVF closure), route of VVF closure, % anatomical closure at 1st attempt and overall (after additional attempt(s)) closure. % of vaginal VVF closures was assessed both as a % of overall VVF closures and as a % 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.
Statistical Analysis was by Chi Squared Test and Students T-Test.

The 137 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 was hysterectomy (60,2%). Only 21,2% of the cases were secondary to a malignant cause. 10,6% of the patients had previous radiotherapy, being the main cause of the fistula in 35% of them.  12% had a previous repair attempt before referral.  Median fistula size was 1,25 cm (0,2-7 cm). 

Their outcomes are as detailed in Table 1.

The overall closure rate is excellent, higher than 85%; however it must to be taken into account that all three surgeon are dedicated to reconstructive surgery. 
The route of repair seems to be highly influenced by the surgeon preference; however, we also observed that experience influences this decision, with increasing use of the vaginal approach with increasing case numbers in preference and reservation of the use of an abdominal technique for only when there is an absolute indication for it.

VVF closure rates are excellent in experienced hands. Vaginal closure of VVF does not appear to be a function of experience but rather a combination of experience and choice.