To report a 16-year, multicountry experience in the surgical management of female urogenital fistulas and evaluate the role of combining traditional reconstructive techniques with adjunctive regenerative approaches in improving fistula closure rates, continence outcomes, and functional recovery across varied resource settings.

We conducted a retrospective analysis of 1,185 female urogenital fistula repairs performed between 2009 and 2025 across 12 countries in Africa and the Middle East. Data were extracted from surgical records, including patient demographics, fistula aetiology, anatomical classification, surgical approach, use of adjunctive materials, complications, and follow-up outcomes.
Fistula types included vesicovaginal fistula (VVF), rectovaginal fistula (RVF), ureterovaginal fistula (UVF), vesicouterine fistula (VUF), and neobladder-vaginal fistula. Procedures utilized both standard reconstructive techniques (e.g., Martius flap, omental or peritoneal interposition) and biological adjuncts such as platelet-rich plasma (PRP), small intestinal submucosa (SIS), fibrin sealant, cyanoacrylate, and buccal mucosa grafts. Outcomes were assessed in terms of anatomical closure, restoration of continence, and patient-reported functional recovery.

The most prevalent fistula type was VVF (n = 818; 69%), followed by RVF (n = 190; 16%), UVF (n = 95; 8%), VUF (n = 77; 6.5%), and neobladder-vaginal fistula (n = 5; 0.5%). Obstetric trauma was the leading cause (n = 699; 59%), with iatrogenic injuries accounting for 34% (n = 403). Fistulas were classified as simple (n = 427; 36%), recurrent (n = 664; 56%), or complex/post-radiation (n = 94; 8%).
The overall anatomical and functional closure rate was 82% (n = 972). Adjunctive techniques were employed in 76% (n = 537) of complex or recurrent cases, with the use of PRP and SIS associated with improved closure rates and enhanced tissue regeneration. Complication rates were low: infection (5%; n = 59), recurrence (18%; n = 213), and residual urinary incontinence (12%; n = 142). Of those treated with post-repair urethral bulking agents (n = 48), 72% (n = 35) achieved symptomatic improvement in continence. At follow-up, 86% (n = 1,019) of patients reported functional recovery and reintegration into family or community life.

Our findings align with prior data supporting the efficacy of established fistula repair methods [1,2]. Moreover, the incorporation of biologically active materials such as SIS and PRP demonstrated enhanced healing in complex cases, reinforcing their potential role even in low-resource settings [3]. The high success rates across multiple centers and surgical teams highlight the adaptability and reproducibility of a combined traditional-innovative surgical model.

This 16-year, multicountry review underscores that integrating foundational surgical principles with regenerative adjuncts such as PRP and SIS can optimize outcomes in female urogenital fistula management. The approach demonstrates feasibility, safety, and efficacy across low- and middle-income settings and supports broader implementation of resource-sensitive, multidisciplinary models in pelvic floor reconstructive surgery

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