Vesico-Vaginal Fistula in Females in 2010–2020: a Systemic Review and Meta-analysis

Abstract

IntroductionIn the Western world today, urogenital fistula, including vesicovaginal fistula (VVF), is rare. However, while it remains significant in developing parts of the world due to prolonged and obstructed labor, in this study, we systematically reviewed the existing literature, discussing VVF occurrence, its etiology, and outcomes.Material and Methods
We used electronic databases to search relevant articles from 2010–2020. The screening was performed with the help of Covidence. Relevant data from included studies were extracted in excel sheets, and final analysis was done using CMA-3 using proportion with 95% confidence interval (CI).ResultsFifteen studies reported the VVF among the fistula series. The pooled result showed 76.57% cases of VVF (CI, 65.42–84.96), out of which 27.54% were trigonal, 55.70% supra-trigonal, and the rest with a varied description like circumferential, juxta-cervical, juxta-urethral. Obstetric etiology was commonly reported with 19.29% (CI, 13.26–27.21) with cesarean section and 31.14% (CI, 18.23–47.86) with obstructed labor. Hysterectomy was the commonly reported etiology among gynecological etiology (46.52%, CI; 36.17–57.19). Among different surgical treatments employed for fistula closure, 49.50% were by abdominal approach (CI, 37.23–61.82), and 42.31% by vaginal approach (CI, 31.82–53.54). Successful closure of fistula was reported in 87.09% of the surgeries (CI, 84.39–89.38).Conclusion
The vesicovaginal fistula is the most common type of genitourinary fistula. Major causes of fistula are gynecological surgery, obstructed labor, and cesarean section. The vaginal approach and abdominal are common modalities of repair of fistula with favorable outcomes in the majority of the patients.

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Reproductive Sciences
https://doi.org/10.1007/s43032-021-00832-8
REVIEW
Vesico-Vaginal Fistula inFemales in2010–2020: aSystemic Review
andMeta-analysis
DhanBahadurShrestha1 · PravashBudhathoki2 · PearlbigaKarki3· PinkyJha3· GaurabMainali3·
GaneshDangal4· GehanathBaral5· MarishaShrestha5· PratikGyawali6,7
Received: 20 May 2021 / Accepted: 14 December 2021
© Society for Reproductive Investigation 2021
Abstract
Introduction In the Western world today, urogenital fistula, including vesicovaginal fistula (VVF), is rare. However, while
it remains significant in developing parts of the world due to prolonged and obstructed labor, in this study, we systematically
reviewed the existing literature, discussing VVF occurrence, its etiology, and outcomes.
Material and Methods We used electronic databases to search relevant articles from 2010–2020. The screening was per-
formed with the help of Covidence. Relevant data from included studies were extracted in excel sheets, and final analysis
was done using CMA-3 using proportion with 95% confidence interval (CI).
Results Fifteen studies reported the VVF among the fistula series. The pooled result showed 76.57% cases of VVF (CI,
65.42–84.96), out of which 27.54% were trigonal, 55.70% supra-trigonal, and the rest with a varied description like cir-
cumferential, juxta-cervical, juxta-urethral. Obstetric etiology was commonly reported with 19.29% (CI, 13.26–27.21) with
cesarean section and 31.14% (CI, 18.23–47.86) with obstructed labor. Hysterectomy was the commonly reported etiology
among gynecological etiology (46.52%, CI; 36.17–57.19). Among different surgical treatments employed for fistula closure,
49.50% were by abdominal approach (CI, 37.23–61.82), and 42.31% by vaginal approach (CI, 31.82–53.54). Successful
closure of fistula was reported in 87.09% of the surgeries (CI, 84.39–89.38).
Conclusion The vesicovaginal fistula is the most common type of genitourinary fistula. Major causes of fistula are gyneco-
logical surgery, obstructed labor, and cesarean section. The vaginal approach and abdominal are common modalities of repair
of fistula with favorable outcomes in the majority of the patients.
Keywords Cesarean section· Hysterectomy· Vesicovaginal fistula
* Dhan Bahadur Shrestha
medhan75@gmail.com
Pravash Budhathoki
pravash.budhathoki123@gmail.com
Pearlbiga Karki
pearlbiga@gmail.com
Pinky Jha
jhapinky.ktm@gmail.com
Gaurab Mainali
gaurab.mainali06@naihs.edu.np
Ganesh Dangal
ganesh.dangal@gmail.com
Gehanath Baral
gehanath@gmail.com
Marisha Shrestha
drmarishashrestha@gmail.com
Pratik Gyawali
pratikgyawali2073@gmail.com
1 Department ofInternal Medicine, Mount Sinai Hospital,
Chicago, IL, USA
2 Department ofInternal Medicine, BronxCare Health System,
Bronx, NY, USA
3 Nepalese Army Institute ofHealth Sciences, Kathmandu,
Nepal
4 Department ofObstetrics andGynecology, National
Academy ofMedical Sciences (NAMS), Kathmandu44600,
Nepal
5 Department ofObstetrics andGynecology, Nobel Medical
College, Biratnagar, Kathmandu University, Dhulikhel, Nepal
6 Manila Central University Hospital, Manila, Philippines
7 SAARC Tuberculosis andHIV/AIDS Center,
Bhaktapur44800, Nepal

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Introduction
Vesicovaginal fistula (VVF) is an abnormal connection
between the urinary bladder and the vagina, which causes
leakage of urine in the vagina. Although a rare entity, uro-
genital fistula is caused mainly by surgery, radiation therapy,
or malignancy in the Western world [1]. It occurs due to
obstetric complications such as prolonged and obstructed
labor in developing parts of the world. It remains an impor-
tant but neglected topic that the World Health Organization
has referred to as a forgotten disease [2–4]. The incidence
of VVF ranges from 0.3 to 2% [5]. At least 3 million women
worldwide are believed to have an untreated vesicovaginal
fistula, with the majority of them from Africa and Southern
Asia. In Africa, 30,000 to 130,000 women develop vesicov-
aginal fistula annually [1]. Women having VVF are continu-
ously damp from urine leakage and sometimes suffer genital
ulceration, infections, and an unpleasant smell. Approxi-
mately 20% of women with fistula often develop unilateral
or bilateral foot drop that restricts their daily activities [6].
In women with this disorder, it causes physical, social,
and psychological effects. VVF prevention and management
can be supported by knowledge of the disease, professional
birth attendance, surgical care, along with therapeutic sup-
port. Addressing the rising public health concerns of VVF,
various charitable and non-governmental organizations are
developing management programs and establishing particu-
lar centers for the care of patients with VVF [3, 7].
The majority of reports for VVF consisted of case series
and experiences of health professionals. Whereas the exist-
ing studies were not specific, with studies mostly focused on
obstetric fistulas as mainstream. In this study, we system-
atically reviewed the existing literature of the last decade,
discussing the occurrence of vesicovaginal fistula, its etiol-
ogy, surgical approach, and outcomes after developing VVF.
Material andMethods
Protocol
Our systematic review and meta-analysis were conducted
according to the MOOSE guidelines after registration in
PROSPERO (CRD42020215772) [8].
Eligibility Criteria
We included cross-sectional studies, case-control stud-
ies, cohort studies, and case series (more than 20 patients)
with women diagnosed with vesicovaginal fistula during
2010–2020 and excluded studies with women diagnosed as
other causes of urinary incontinence and pregnant women.
We also excluded the study with inadequate data and results.
In addition, letters to the editor, viewpoints, and experiences
were also excluded in the study.
Search Strategy
We used electronic databases like PubMed, PubMed Central,
Scopus, and Embase to search relevant articles from 2010
to 2020 using terms like “vesicovaginal fistula”, “VVF” and
“gynecological fistula” with appropriate Boolean operators.
The detailed search strategy is included in the supplemen-
tary file.
Study Selection
Two reviewers (PJ and PK) independently screened the title
and abstract of imported studies, and any arising conflict
was solved by the third reviewer (GM). A full-text review
was done independently by GM and PK. Data were extracted
for both quantitative and qualitative synthesis. The conflicts
were resolved by taking the opinion of the third reviewer
(PJ). The screening was performed with the help of Covi-
dence [9].
Data Extraction
Relevant data, including study characteristics, quality, and
endpoints, were extracted onto a standardized form designed
in Excel. Our outcomes were the prevalence of overall geni-
tourinary fistulas, vesicovaginal fistulas among different
genitourinary fistula, anatomical types of vesicovaginal fis-
tula, and gynecological etiology of vesicovaginal fistula, the
surgical approach for closure, and success of closure of the
vesicovaginal fistula. We extracted the data from included
studies based on our outcomes of interest.
Methodologic Quality
The quality of individual articles was evaluated using the
Joanna Briggs Institute (JBI) critical appraisal. In addition,
the risk of bias was assessed. Two of the authors had inde-
pendently assessed the design of each study, the number of
patient included outcomes of VVF, included risk factors, and
if the outcome as mentioned earlier were measured. Disa-
greements were resolved by discussion with a third person.
Data Analysis
Data were analyzed using CMA-3 [41]. The proportion was
used as a measure of effects, and the I2 test measured het-
erogeneity. The random/fixed-effect model was used based
on heterogeneity.

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Sensitivity Analysis
Sensitivity analysis was done by excluding individual studies
to observe the impact of individual studies.
Subgroup Analysis
Subgroup analysis was performed while evaluating the out-
come of interest as appropriate. In addition, less commonly
reported results were tabulated in supplementary files.
Publication Bias
Publication bias across the study was assessed using Egger’s
funnel plot using the MD and 1/SE values for appropriate
outcomes.
Results
We identified a total of 8288 studies after thorough
database searching and a total of 1875 duplicates were
removed. We screened 6413 studies and excluded 6014
studies. After assessing 399 studies for full-text eligibil-
ity, 368 were excluded for definite reasons (Fig.1). The
remaining 31 studies were included in the qualitative sum-
mary and quantitative analysis (Table2 and Supplemen-
tary file 2).
Quantitative Analysis
Total of 31 studies were included in the analysis. There
was no study from an apparently normal population inves-
tigating genitourinary fistula, but two studies evaluated
the prevalence of genitourinary fistula (GUF) among risk
groups and showed 12.3% (CI: 1.5–56%) (Supplement file
3, Fig.1).
Rate ofVVF Among GUF
Fifteen studies reported the VVF among the GUF series
they have studied. Pooling the data using the random effect
model showed 76.57% of cases were VVF among GUF
(proportion, 0.7657; CI, 0.6542–0.8496) (Fig.2). Sensi-
tivity analysis to gauge the impact of individual studies in
the overall result was conducted by excluding individual
studies and showed no significant change after excluding
particular studies (Supplement file 3, Fig.2).
Fig. 1 PRISMA flow diagram
Records identified through database
searching
(n =8288)
gnineercSIncluded EligibilitynoitacifitnedI
Additional records identified
through other sources
(n =0)
Records after duplicates removed
(n =6413)
Records screened
(n = 6413)
Records excluded
(n =6014)
Full-text articles assessed for
eligibility
(n = 399)
Full-text articlesexcluded, with reasons
(n = 368)
Reasons for exclusion:
117 Studiesbefore 2010
96 Does not meet the criteria
46 Insufficient data/results
31 Case report/case series <20
25 Poster presentation
19 Opinion/editorial/viewpoint
9Secondary data: SR and MA
8Experience
8Different languages: could not
extract data
4Videos
2Different language data
2Duplicate files
1audit
Studies included in qualitative
synthesis
(n =31)
Studies included in quantitative
synthesis (meta-analysis)
(
n = 31
)

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Common Anatomical Types ofFistula Reported
In most studies, there were no clear specifications of differ-
ent anatomical types of VVF rather classified overall GUF,
so while pooling anatomical types of all GUF pooled.
Pooling of data from six studies reporting a common
anatomical type of fistula using a random-effect model
showed supra-trigonal in 55.70% (Proportion, 0.5570; CI,
0.3439–0.7510; I2, 93.87), trigonal in 27.54% (Proportion,
0.2754; CI, 0.1811–0.3952; I2, 83.86) (Fig.3). Rest, less
commonly reported fistula were circumferential, juxta-
cervical, juxta-urethral, etc. (Supplement file 3, Table1).
Obstetric Fistula
Obstetric etiology was commonly reported etiology in
most of the studied fistula population.
Cesarean Section
Pooling of data from 19 studies reporting a cesarean sec-
tion using a random-effect model showed 19.29% (pro-
portion, 0.1929; CI, 0.1326–0.2721; I2, 97.78) (Fig.4).
Sensitivity analysis to gauge the impact of the individual
study on the cesarean section as etiology was carried out
by excluding individual studies and showed no significant
change after excluding particular studies (Supplement file
3, Fig.3).
Obstructed Labor
Pooling of data from 13 studies reporting an obstructed labor
using a random-effect model showed 31.14% (proportion,
0.3114; CI, 0.1823–0.4786; I2, 96.80) (Fig.5). Sensitiv-
ity analysis to gauge the impact of the individual study on
obstructed labor as etiology was carried out by excluding
individual studies and showed no significant change after
excluding a particular study (Supplement file 3, Fig.4).
Other less commonly reported obstetric etiology of fistula
were vaginal delivery, cesarean hysterectomy, instrumental
delivery, etc. (Supplement file 3, Table2). Most obstetric fis-
tulae were iatrogenic in origin, and the commonly reported
were cesarean section, cesarean hysterectomy, instrumental
deliveries, etc. (Supplement file 3, Table3).
Gynecological Etiology ofFistula
Among gynecological etiology, hysterectomy (vaginal,
abdominal) was the commonly reported etiology. Less
widely reported gynecological etiologies include radiation
therapy for cancer, different gynecological procedures, and
cancer (Supplement file 3, Table4).
Among 16 studies reporting hysterectomy, pooling of
data using a random-effect model showed 46.52% of fis-
tula associated with hysterectomy (proportion, 0.4652; CI,
0.3617–0.5719, I2, 95.72) (Fig.6). Sensitivity analysis to
gauge the impact of the individual study on hysterectomy as
etiology was carried out by excluding individual studies and
Fig. 2 Rate of vesico-vaginal
fistula (VVF) among genitou-
rinary fistula (GUF) studied in
different studies

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showed no significant change after excluding a particular
study (Supplement file 3, Fig.5).
Surgery forFistula Closure
Different types of surgical treatment were employed as a
definitive treatment of fistula closure. Due to the unavailabil-
ity of data on surgical treatment of VVF, the management
of GUF was only reported in most studies, so pooling was
done for the management of GUF. Surgical approach for
closure includes the vaginal approach, abdominal approach,
combined abdominal and vaginal, laparoscopic approach,
and less commonly employed procedures were diversion
techniques, etc. (Supplement file 3, Table5).
The abdominal approach was reported in 17 studies. Pool-
ing of data showed that 49.50% of the surgical closure was
done by the abdominal approach (proportion, 0.4950; CI,
0.3723–0.6182; I2, 93.55) (Fig.7). Sensitivity analysis to
gauge the impact of the individual study on the abdominal
approach for fistula closure was carried out by excluding
individual studies and showed no significant change after
excluding particular studies (Supplement file 3, Fig.6).
A vaginal approach for fistula closure was reported in
14 studies. Pooling of data showed 42.31% of procedures
carried out by a vaginal approach (proportion, 0.4231; CI,
0.3182–0.5354) (Fig.8). Sensitivity analysis to gauge the
impact of the individual study on the vaginal approach for
fistula closure was carried out by excluding individual stud-
ies (Supplement file 3, Fig.7).
Successful Closure oftheFistula
Twenty-three studies reported successful closure of fis-
tula in their outcome. In 87.09% of the surgeries (propor-
tion, 0.8709; CI, 0.8439–0.8938), a successful closure
of fistula was reported (Fig.9). Sensitivity analysis on
successful fistula closure by excluding individual studies
showed no differences (Supplement file 3, Fig.8). Among
operated cases, 82.69% were successful and continent sur-
geries (Proportion, 0.8269; CI, 0.7393–0.8895; I2, 83.39)
Fig. 3 Commonly reported anatomical types of fistula

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Table 1 JBI assessment of included studies
Study name Was the sample
frame appropri-
ate to address
the target
population?
Were study
participants
sampled in an
appropriate
way?
Was the sample
size adequate?
Were the study
subjects and
the setting
described in
detail?
Was the
data analysis
conducted
with sufficient
coverage of
the identified
sample?
Were valid
methods used
for the identi-
fication of the
condition?
Was the condi-
tion measured
in a standard,
reliable way for
all partici-
pants?
Was there
appropriate
statistical
analysis?
Was the
response rate
adequate, and
if not, was the
low response
rate managed
appropriately?
RESULT (Over-
all appraisal:
Include □
Exclude □ Seek
further info □)
Akpak etal.
[10] (2020)
Yes Ye s Yes Yes Yes Yes Ye s Yes Yes Include
Barageine etal.
[11] (2014)
Yes Ye s Yes Yes Yes Yes Ye s Yes Yes Include
Chandna etal.
[12] (2020)
Yes Unclear Yes Yes No Yes No No Yes Include
Chang etal.
[13] (2019)
Yes Ye s Yes Yes Yes Yes Ye s Yes Yes Include
Cromwell etal.
[14] (2012)
Yes Ye s Yes Yes Yes Yes Ye s Yes Yes Include
Delamou etal.
[15] (2015)
Yes Ye s Yes Yes Yes Yes Ye s Yes Yes Include
Farahat etal.
[16] (2012)
Yes Unclear No No No Ye s Yes Unclear Yes Include
Gupta etal.
[17] (2010)
Yes Unclear No No No Ye s Yes Unclear Unclear Include
Hilton [18]
(2011)
Yes Unclear Yes Ye s Yes Yes Yes Ye s Ye s Include
Kayondo etal.
[19] (2011)
Yes Ye s No Ye s Yes Yes Yes Yes Ye s Include
Kumar etal.
[20] (2018)
Yes Ye s Yes Yes Yes Yes Ye s Yes Yes Include
Kurniawati
etal. [21]
(2020)
Yes Not Clear Yes Ye s No No No No Yes Include
Lee etal. [22]
(2014)
Yes Ye s Yes Yes Yes Yes Ye s Yes Yes Include
Mancini etal.
[23] (2020)
Yes Ye s Yes Yes Yes Yes Ye s Yes Yes Include
Mathur etal.
[24] (2010)
Yes Ye s Yes Yes Yes Yes Ye s No No Include
McCurdie etal.
[25] (2018)
Yes Ye s Yes No No Yes Ye s No No Include
Nawaz etal.
[26] (2010)
Yes Ye s Yes Yes Yes Yes Ye s No No Include

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Table 1 (continued)
Study name Was the sample
frame appropri-
ate to address
the target
population?
Were study
participants
sampled in an
appropriate
way?
Was the sample
size adequate?
Were the study
subjects and
the setting
described in
detail?
Was the
data analysis
conducted
with sufficient
coverage of
the identified
sample?
Were valid
methods used
for the identi-
fication of the
condition?
Was the condi-
tion measured
in a standard,
reliable way for
all partici-
pants?
Was there
appropriate
statistical
analysis?
Was the
response rate
adequate, and
if not, was the
low response
rate managed
appropriately?
RESULT (Over-
all appraisal:
Include □
Exclude □ Seek
further info □)
Ojewola etal.
[27] (2018)
Yes Ye s Yes Yes Yes Yes Ye s Yes No Include
Osman etal.
[28] (2018)
No Unclear No Yes Ye s Yes Yes Ye s Yes Include
Pradhan etal.
[29] (2020)
Yes Unclear Yes Unclear Yes Ye s Ye s Yes Ye s Include
Raassen etal.
[30] (2014)
Yes Unclear Yes Ye s Ye s Yes Yes Ye s Yes Include
Reddy etal.
[31] (2019)
No Yes No No Ye s Ye s Ye s Ye s Yes Include
Richter etal.
[32] (2020)
Yes Ye s Yes Unclear Yes Ye s Unclear Yes Ye s Include
Rupley etal.
[33] (2020)
Yes Unclear Yes Yes Yes Unclear Ye s Unclear Unclear Include
Shaker etal.
[34] (2011)
Yes Ye s Yes Yes Yes Yes Ye s No No Include
Singh etal.
[35] (2010)
No Unclear No Yes Ye s Yes Yes Ye s Yes Include
Singh etal.
[36] (2011)
Yes Ye s Yes Yes No Yes Ye s No Ye s Include
Sunday-Adeoye
etal. [37]
(2011)
Yes Ye s Yes Yes Yes Yes Ye s Yes Yes Include
Tatar etal. [38]
(2017)
No Unclear No Yes Ye s Yes Yes Ye s Yes Include
Wahab etal.
[39] (2016)
No Unclear No No No Yes Ye s Unclear Unclear Include
Zhou etal. [40]
(2016)
Yes Unclear Yes Ye s Ye s Yes Yes Ye s Yes Include

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(Supplement file 2, Fig.9.). Sensitivity analysis on suc-
cessful and continent surgeries by excluding individual
studies showed no significant differences (Supplement
file 3, Fig.10).
Publication Bias
Included studies showed some publication bias for the
respective outcome. Supplementary file 3, Fig.11 showed
publication bias of reporting VVF among fistula using Egg-
er’s funnel plot.
Fig. 4 Cesarean section as cul-
prit etiology for fistula among
GUF cases reported in various
studies
Fig. 5 Obstructed labor as cul-
prit etiology for fistula among
GUF cases reported in various
studies

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Table 2 Qualitative summary
Study ID Study design Population Types of surgery Other outcomes Etiology/risk Parity
Akpak etal. [10] (2020) Retrospective case series Total population: 56
VVF patient: 51
Age: >18
Abdominal: 17/51
Vaginal: 31/51
Laproscopic: 2/51
Successful surgery:
43/51
Unsuccessful surgery:
8/51
FGM/C: 47/51
H/o prior repair: 12/51
Barageine etal. [11]
(2014)
Case control study Population: 140
VVF: 110/140, VVF and
RVF: 5/140
Not specific Not specific Mode of delivery:
Vaginal delivery: 71/140
CS: 69/140
Primipara: 46/140
Para 2–4: 47/140
Grand multipara: 47/140
Chandna etal. [12]
(2020)
Prospective observational
study Robot assisted surgery:
73
VVF population: 33
Age: 35.5 years -49.9
years
Location of VVF:
Supratrigonal: 30/33
Trigonal: 3/33
Successful: 31/33
Unsuccessful: 2/33
Hysterectomy: 27
CS: 4
Obstructed Labor: 1
Radiation: 1
Recurrent: 20/33
Chang etal. [13] (2019) Retrospective case-
control Total population: 1298
VVF population: 1187 Patients with post-
repair urinary reten-
tion: 40
Cromwell etal. [14]
(2012)
Retrospective cohort
study Urogenital cases: 1194
VVF and urethro-vagi-
nal fistula: 905/1194
Age: 52.4(15.6)
Successful surgery:
797/905
1st repair failed:
108/905
Hysterectomy: 426/905
CS: 33/905
Delamou etal. [15]
(2015)
Retrospective cohort
study Total surgery: 2116
VVF population:
2045/2116
VVF and RVF: 48/2116
Age:
< 17 = 63/2116, 17–24
= 402/2116,25–49 =
1293/2116, ≥ 50 =
326/2116, unknown:
32/2116
For VVF
Fistula Closed: 1744/2045
Dry: 1630/2045
Residual Incontinence: 114/1744
Fistula not closed: 297/2045
For VVF and RVF
Fistula closed: 28/48
Dry: 27/28
Residual Incontinence: 1/28
Fistula not closed: 20/48
Mode of delivery:
Vaginal: 1377/2116
CS: 698/2116
Unknown: 41/2116
1 birth: 625/2116
2–5 births: 950/2116
≥ 6 birth: 510/2116
Unknown: 31/2116
Farahat etal. [16] (2012) Pilot study VVF population: 23
Location:
Trigonal: 7/23
Trigonal +ureteral orifice
encroachment: 2/23
Posterior bladder wall:
14/23
Types of surgery done
Abdominal: 16/23
Vaginal: 7/23
Successful Surgery:
Dry: 21/23
Unsuccessful surgery:
Wet on 1st follow-up:
2/23
Obstructed labor: 8/23
Cystocele repair: 3/23
AH: 9/23
VH: 3/23

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Table 2 (continued)
Study ID Study design Population Types of surgery Other outcomes Etiology/risk Parity
Gupta etal. [17] (2010) Retrospective study VVF population: 32
Previous delivery (in
obst VVF): N = 22
Hospital: 5/22
Home with TBA: 6/22
Home with untrained BA:
11/22
Successful Surgery: 30
Unsuccessful surgery: 2 Obstructed labor: 18/32
Post hysterectomy: 10/32
CS: 4/32
Primi-para:21/32
Multi-para:11/32
Hilton P [18] (2011) Retrospective study Total ample: 348
VVF: 256/348
Combined VVF + UVF:
13/348
Age: 44 (7–89)
Fistula site
Vault:180/256
Midvaginal: 32/256
Bladder neck: 17/256
Large: 13/256
Juxtacervical: 11/256
Subsymphyseal: 3/256
Types of surgery done
Abdominal: 90/291
Vaginal: 201/291
Outcome:
Healed spontanously: 24/348
No surgery: 33/348
Primary diversion: 8/348
Primary repair Procedure: 283/348
Closed at First operation: 267/283
AH: 132/348
Radical hysterectomy:
19/348
VH: 8/348
Obstetric cause:
CS: 15/348
Ruptured uterus: 8/348
Obstructed labor: 2/348
Kayondo etal. [19]
(2011)
Prospective observational
study VVF population: 69/77
Age: < 18 years: 2/77
18–34: 50/77
> 35 year: 25/77
Types of VVF:
Juxta urethral: 16/77
Circumferential: 12/77
Recurrent VVF: 32/77
Vaginal scarring: 17/77
Hospital stay days: 14–21
Successful surgery: 55/69
Continent: 42/69
Incontinent: 13/69
Instrumental delivery:
8/77
Obstructed labor: 18/77
CS: 46/77
Kumar etal. [20] (2018) Retrospective study Sample size: 311
VVF population:
248/311
Mean age in years ± SD
(34.4 ± 7.6 (20–61)
Mean interval since
presentation in
months ± SD: 26.2 ±
49.9 (1–360)
Mean size of fistula
(mm): 36 (5–60)
Mean Hospital stay
days: 14.9 ± 5.3 (5–36)
Types of surgery done
Abdominal: 111/248
Abdominal repair +
ureteroneocystostomy:
14/248
Vaginal: 103/248
Laparoscopic repair:
19/248
Continent cutaneous
diversion: 2/248
Augmentation with
ileum: 2/248
Successful surgery:
Abdominal: 106//111
Vaginal: 95//103
Laparoscopic repair:
17/19
Obstructed Labor: (vaginally): 85/248, (LSCS):
40/248
LSCS for other indications: 12/248
Cesarean hysterectomy: 9/248
AH: 88/248
VH: 2/248
Uterus rupture: 3/248
Carcinoma cervix: 2/248
Dilatation and curettage: 6/248
Myomectomy: 1/248

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Table 2 (continued)
Study ID Study design Population Types of surgery Other outcomes Etiology/risk Parity
Kurniawati etal. [21]
(2020)
Observational study VVF population: 35 Treatment
Conservative manage-
ment: 19/35
Surgical Management:
16/35
Types of surgery done
Abdominal: 1/16
Vaginal: 15/16
Successful surgery:
11/16
Unsuccessful surgery:
5/16
Lee etal. [22] (2014) Retrospective study Sample size: 66
VVF population: 66
Age mean ± SD: 45 ±
10.4
Previous surgery-defini-
tive VVF repair: 66/66
Location of VVF
Trigonal 18/66
Supratrigonal: 47/66
Ureteral: 1/66
Types of surgery done
Abdominal: 16/66
Vaginal: 50/66
Successful surgery:
64/66 Hysterectomy (total): 58/66
Hysterectomy (unknown route): 48/58
AH: 7/58
VH: 2/58
LH: 1/58
Obstetric: 3/66
Other: 5/66
Mancini etal. [23]
(2020)
Retrospective study Sample size: 138
VVF population:
113/138
VVF + RVF: 6/138
VVF + ureterovaginal:
3/138
Neobladder + VVF:
2/138
Mean age (SD): 48
(10.9)
Location in the bladder:
Trigonal: 21/124
Subtrigonal: 3/124
Supratrigonal: 78/124
Bladder neck: 5/124
Lateral wall: 2/124
Posterior wall: 11/124
Not reported: 4/124
Types of surgery done
Vaginal: 14/138
Abdominal: 124/138
Noncontinent urinary
diversions: 6/124
Considered for outcome
measures: 118/124
Successful surgery:
111/118
Failed repair: 7/118
Follow up possible in
95/138 patients only
Symptom free on fol-
low-up (30 months):
91/95
Persistence of urinary
leakage per vaginum:
2/95
Urge urinary inconti-
nence: 2/95
Hysterectomy: 91/124
Radiotherapy: 10/124
Vaginal delivery: 9/124
CS:4/124
Bladder biopsy: 1/124
Bladder diverticulectomy: 1/124
Resection of urethral lesion: 3/124
Vaginoplasty: 2/124
Sacral colpopexy: 1/124
Radical cystectomy and neobladder: 2/124
Trauma: 1/124
Not reported: 1/124
Previous closure attempts: 36/138
Mathur etal. [24] (2010) Prospective study. Sample size: 50
VVF population: 32/50
Age:
< 20 years: 2/50
20–39 year: 28/50
> 40 year: 20/50
Surgery done: 44/50
Abdominal: 22/50
Vaginal: 14/50
Both: 8/50
Conservative treatment:
6/50
Successful surgery:
30/32
Obstructed Labor: 16/32
Post LSCS: 6/32
Post TAH: 10/32

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Table 2 (continued)
Study ID Study design Population Types of surgery Other outcomes Etiology/risk Parity
McCurdie etal. [25]
(2018)
Retrospective case review Sample size: 93
VVF population: 93
Age:
< 20 years: 11/93
20–39 year: 68/93
> 40 year: 14/93
Successful surgery: 87/93
Symptom free on follow-up: 24//26 Recurrent VVF: 15/93
Nawaz etal. [26] (2010) Retrospective study. Sample size: 213
VVF population:
133/213
Location of vesicovagi-
nal fistula
Trigonal: 61/133
Supratrigonal: 42/133
Mixed: 30/133
Mean hospital stay
(days): 15 ± 3.5
Types of surgery done
Vaginal: 51/133
Transvesicle: 29/133
Abdom. + vaginal: 28/133
Abdominal: 13/133
Endoscopic fulguration: 02/133
Ileal conduit: 02/133
Uretero- singmoidostomy: 04/133
Mitraffinof: 04/133
Successful surgery: 117/133
Failed repair: 16/133
AH: 19/133
VH: 6/133
CS: 17/133
Forceps delivery: 15/133
Pressure Necrosis:50/133
CS hysterectomy: 19/133
Colporrhaphy: 1/133
Others: 6/133
Ojewola etal. [27]
(2018)
Retrospective study Sample size: 53
VVF population: 53
Age Mean ± SD: 29.8 ±
15.4 years
Location in the bladder
Trigonal: 18/53
Supratrigonal: 35/53
Types of surgery done
Abdominal: 53/53
Trans peritoneal trans-
vesical: 44/53
Extra peritoneal trans-
vesical: 9/53
Successful surgery:
47/53
Failed repair: 6/53
Obstetric: 41/51
AH: 3/51
VH: 6/51
History of previous
repairs: 43/51
Osman etal [28] (2018) Retrospective cohort
study VVF population: 17/32
Age (years) (range)
mean: (17–62) 43.0
Mean post-treatment
follow-up duration:
13 months (range: 2
months to 3 years)
Procedure (Total
number of procedures
= 40)
Types of surgery done
(for VVF):
Abdominal: 9/24
Vaginal: 10/24
Robotic: 3/24
Fulguration: 2/24
Need for repeat proce-
dure: 6/17
Cured based on symp-
toms and the findings
of physical and radio-
logic investigations:
30/32
Iatrogenic obstetric: 22/32
Cesarean delivery: 20/22
Cervical cerclage: 2/22
Gynecologic: 9/32
Motor vehicle accident: 1/32
Pradhan etal. [29] (2020) Retrospective study Total cases of fistula:
261
Total obstetric fistula =
155/261
VVF: 85/155
RVF: 42/155
Circumferential fistula:
10/155
Juxtacervical fistula:
7/155
Successful surgery:130/155
Successful surgery with continence: 121/155
Successful surgery with urinary incontinence:
9/155
Unsuccessful surgery: 23/155
Obstetrical cause (n = 155)
After prolonged VD: 65
Instrumental delivery: 43
CS: 34
After cesarean hysterectomy: 7
Ruptured uterus: 6

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Table 2 (continued)
Study ID Study design Population Types of surgery Other outcomes Etiology/risk Parity
Raassen etal. [30] (2014) Retrospective record
review
Waaldijk classification
VVF population (I +
II + III): (351/805 +
181/805 + 273/805)
Previous laparotomy
among women with
iatrogenic fistula:
201/805
Not mentioned Obstetric procedures
C-section(I + II + III): (324/462 + 0/462 + 138/462)
Repair of ruptured uterus(I + II + III): (9/25 + 0/25
+ 16/25)
Hysterectomy for ruptured uterus(I + II + III) :
(16/159 + 86/159 + 57/159)
Gynecological procedures
Gynecological hysterectomy(I + II + III): (1/158 +
95/158 + 62/158)
Other(I +I I + III): (1/1 + 0/1 + 0/1)
Reddy etal. [31] (2019) Retrospective case series
study Sample size: 34
VVF population: 34
Age Mean ± SD: 36.62
± 9.02
Types of vesicovaginal
Fistula
Juxta urethral: 3/34
Circumferential: 8/34
Mid-vaginal: 20/34
Juxta cervical: 3/34
Recurrent VVF: 6/34
Types of surgery done
Abdominal: 21/34
Vaginal: 8/34
Laparoscopic: 5/34
Hospital stay days: 10–21
Successful surgery: 28/34
Failed to repair: 6/34
Symptom free on follow-up (33 months): 33/33
1 patient lost to follow-up
Instrumental delivery: 8/34
Delay in seeking medical help during labor: 8/34
Hysterectomy: 11/34
History of CS: 4/34
Richter etal. [32] (2020) Cross-sectional study Sample: 2091 women
screened
Total Genitourinary
fistulas: 630/2091
VVF: 392/630
VUF: 185/630
Ureterovaginal F:
56/630
Surgical Fistula Repairs (N) = 259
Vaginal Repair: 127/259
Required Hysterectomy: 1/127
Abdominal Repair: 132/259
Required Hysterectomy: 103/132
History of Surgery: 268/392
CS: 179/392
No History of Surgery: 114/392
Unknown Surgical Hx: 10/392
Rupley etal. [33] (2020) Case-control study Women with VVF
at time of delivery
(cases): 1046
Length of labor
< = 12 hours: 309/1046
> 12 hours: 734/1046
Missing: 3/1046
Not mentioned Type of delivery
Vaginal: 589/1046
Cesarean section:
454/1046
Missing: 105/1046

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Table 2 (continued)
Study ID Study design Population Types of surgery Other outcomes Etiology/risk Parity
Shaker etal. [34] (2011) Randomized prospective
study VVF population: 63
Non-trimming (NT):
32/63
Trimming (T): 31/63
Age mean 29 ± 7
Location of fistula:
Urethra: (T = 4/31, NT
= 6/32)
Urethro-vesical: 24 (T =
13/31, NT = 11/32)
Trigone:21 (T = 10/31,
NT = 11/32)
Supratrigonal: 8 (T =
4/31, NT = 4/32)
Successful: T = 21/31, NT = 24/32
Failed repair: T = 10/31, NT = 8/32
Singh etal. [35] (2010) Case series/Experience Urogenital fistulas
(UGFs)-42
VVF cases- 37/42
Vesicovaginal and uret-
erovaginal fistulas
Transabdominal hysterec-
tomy: 1/42
Radical hysterectomy for
malignancy: 1/42
Conservative management with
catheterization(successful): 3/37
Surgical Management of all Urogenital fistulas: 39
Total transabdominal approach- 28/39
Transvaginal approach (VVF)- 11/39
Vesicovaginal fistula
Obstructed labor: 22/42
TAH: 7/42
VH: 4/42
LH: 1/42
Radical hysterectomy for
malignancy: 1/42
Singh etal. [36] (2011) Retrospective case review Sample size: 48
VVF population: 48
Age (range): 24 (18–48)
Mean size of fistula in
cm (range): 4.8 (2.5–7)
Type of surgery:
Abdominal: 48 Successful surgery at
1st attempt: 42 /48
Successful surgery at
2nd attempt: 2/6
Failed repair including
both attempts: 4/48
Obstetric: 30/48
Gynecological: 18/48
Sunday-Adeoye etal.
[37] (2011)
Prospective descriptive
study VVF population: 462
among 10,641 deliver-
ies during the study
period
Age:
< 20 years: 39/462
20–39 year: 232/462
≥ 40 year: 191/462
Not specified Mode of delivery:
Instrumental delivery:
88/462
Spontaneous Vaginal
delivery: 169/462
Cesarean section:
197/462
Obstructed labor:
396/462
Iatrogenic: 60/462
Circumcision: 3/462
Trauma: 3/462
Multiparity:172/462
Grand multipara: 146/462
Primigravida: 138/462
Nullipara: 6/462
Tatar etal. [38]
(2017)
Retrospective study Total cases of VVF (T)
= 20 Abdominal repair:
13/20
Vaginal repair: 5/20
Laparoscopic
repair:2/20
Recurrence
Yes: 1/20
No: 19/20
Follow-up months,
(range) mean: (2–18),
9.1
All Iatrogenic cases
Surgical: 16/20
C-section: 2/20
Cancer related: 2/20

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Discussion
Vesicovaginal fistulas have a significant impact on the
patient’s physical, social, and mental well-being. They
have remained a concealed condition as it affects most
of the overlooked population of women in the rural parts
of the world. It can stigmatize a woman in society and
lower her self-confidence and outlook towards life. A
paper labels obstetric fistula to be the neglected condition
of poverty [42]. There is a need for effective measures to
prevent this condition by properly identifying the etiology,
its occurrence, and risk factors in the community. Fur-
thermore, there is a need for proper universal education,
empowerment of women with accessible and improved
medical services.
We found that the vesicovaginal fistula is the most com-
mon type of genitourinary fistula, and it accounted for
76.57% of various types of genitourinary fistula. This is
concordant with Hillary’s systematic review, which men-
tions vesicovaginal fistula as the most common type of fis-
tula [3]. We found that the prevalence of genitourinary fis-
tula (GUF) among the risk group is 12.3% (CI: 1.5–56%).
However, this estimate was based on just two studies, and
the lack of inclusion of normal women of reproductive
age group makes our finding hard to generalize. Among
the different types of vesicovaginal fistula, the common
types were supra-trigonal in 55.70%, followed by trigo-
nal in 27.54%, and other types including circumferential,
juxta-cervical, and juxtaurethral. VVF can be classified
on various bases like the fistula site, etiology, involve-
ment of continent mechanism, size of fistula, and clinical
examination. Classification of fistula into types aids in the
decision-making about the management of the patients,
adjunct treatments, and follow-up guidance.
The pooling of data from our study showed that the
primary etiology of the fistula was obstructed labor and
C-section among obstetric etiology, and history of gyneco-
logical surgery among gynecological etiology. This aligns
with a review that points out the common cause of VVF in
developed countries to be pelvic surgery [3]. In cases of
underdeveloped countries, prolonged obstructive labor is
noted to be the most common etiology (95.2%), followed
by cesarean section (9%) and instrumental delivery (2%)
[3]. There is a significant discrepancy in VVF’s reported
incidence and causes between the developed (0.3%) and
developing nations (2%) [43]. These figures suggest the
need for more intensive studies in this area, especially in
developing countries, due to its relatively high incidence
and preventable etiology. There is a lack of adequate stud-
ies done in these nations reporting on vesicovaginal fistula.
The timing of repair of the vesicovaginal fistula is
widely debated, dependent on the status of surrounding
Table 2 (continued)
Study ID Study design Population Types of surgery Other outcomes Etiology/risk Parity
Wahab etal. [39] (2016) Descriptive study Sample: 30
Total VVF: 28/30 Successful surgery-
28/28
Zhou etal. [40] (2016) Hospital-based retrospec-
tive study Total patients (T) = 139
Age, years T = 46.6
Fistula number
Single = 123/139
Multiple = 16/139
Approach
Vaginal = 114
Abdominal = 25
Success = 119
Failure = 20
Hysterectomy for malignant
condition = 28/139
Hysterectomy for benign
condition = 68/139
Obstructed labor = 32/139
Cesarean = 7/139
Others = 4/139202
AH, abdominal hysterectomy; CS, cesarean section; LH, laparoscopic hysterectomy; LSCS, a lower segment cesarean section; RVF, recto vaginal fistula; T, total patients; TAH, total abdominal
hysterectomy; UGF, urogenital fistula; VH, vaginal hysterectomy; VVF, vesico-vaginal fistula

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tissues. Early repair is preferred in the case of instrumental
delivery or cesarean section when the tissue is healthy.
However, in cases of gynecological surgery, a 6–12-
week delay allows dissipation of most granulation tis-
sue, increasing the possibility of a successful repair. This
review shows that most of the research displayed that the
surgery successfully treated the fistula, with 87.09% hav-
ing urinary continence post-surgery. Rajamaheswari etal.
[44] demonstrated the successful vaginal and abdominal
repair outcome as 86.7% and 100%, respectively. The
study also concluded that most supratrigonal VVF showed
comparable results when approached vaginally or abdomi-
nally [44]. Another study by El-Azab [45] noted that the
success rate for a vaginal approach was 91%, whereas an
abdominal repair was 84%. The preferred approach for
surgical repair relies on the surgeon’s familiarity, loca-
tion of the fistula, space in the vaginal cavity, need for
procedures like ureteric reimplantation, and feasibility
Fig. 6 Hysterectomy as culprit
etiology for fistula among GUF
cases reported in various studies
Fig. 7 Abdominal approach for
surgery among GUF

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of getting necessary interposition flaps. Both routes have
their advantages and drawbacks. Our study found a higher
rate of abdominal approach for the correction of the fistula
than the vaginal approach. Usually, the abdominal route
is chosen when the vaginal repair is contraindicated. The
vaginal approach was used in 42.31% of patients with vesi-
covaginal fistula based on our study, which is far lower
than Hillary’s review in which 71% and 81% of repair
of lower urinary tract fistula were done transvaginally
[3]. There are multiple advantages with a vaginal repair,
such as shorter operative time, decreased hospital stay,
reduced blood loss, and avoidance of abdominal and blad-
der incisions. However, both studies pointed out a lack of
randomized trials to effectively compare the benefits of
transabdominal and transvaginal approaches, which could
provide an important area of study for future research [44,
45].
Fig. 8 Vaginal approach for
surgery among GUF
Fig. 9 Successful surgery
among GUF

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It is important to implement guidelines on safe obstet-
ric practice and good surgical practice in gynecological
surgeries that would help reduce the genitourinary fistula.
However, one of the limitations of our review could be the
inability to correctly portray the incidence and prevalence
rates because many cases occur in developing nations where
there is a lack of proper diagnosis, documentation, and treat-
ment modalities available. Additionally, most studies did
not clearly report the outcome of VVF separately, instead,
they reported the outcome of overall GUF so we could not
fully dissect the details of VVF alone. Also, our review was
limited to English-language articles alone. Thus, we rec-
ommend formulating national policies that disseminate the
information about the condition among middle-aged women,
proper identification and documentation of the cases seen,
proper maternal prenatal, natal, and postnatal care, and
the provision of proper technologies and resources for its
treatment.
Selecting the abdominal or vaginal approach of vesico-
vaginal fistula repair may be biased by the surgeon’s basic
specialization, whether gynecologist or urologist. Thus,
another variable of study would be a basic specialization or
specialty unit carrying out the repair.
Conclusion
Vesicovaginal fistula is the most common type of geni-
tourinary fistula. Still, there is a significant discrepancy in
the incidence and causes of VVF between developed and
developing nations, and obstructed labor leads to the most
common cause in developing countries. Though we have
noticed that both vaginal and abdominal approaches are
almost equally used to repair a fistula, both show favora-
ble outcomes. This could be the result of bias of operating
surgeons’ preference based on their initial training. More
robust studies and improved reporting of cases should be
encouraged to improve the data in the future.
Abbreviations AH:Abdominal hysterectomy; CS:Cesarean section;
LH:Laparoscopic hysterectomy; LSCS:Lower segment cesarean sec-
tion; RVF:Recto vaginal fistula; TAH:Total abdominal hysterectomy;
UGF:Urogenital fistula; VH:Vaginal hysterectomy; VVF:Vesico-
vaginal fistula
Supplementary Information The online version contains supplemen-
tary material available at https:// doi. org/ 10. 1007/ s43032- 021- 00832-8.
Acknowledgements None.
Availability of Data and Materials The datasets analyzed during the
current study are available within manuscripts or supplementary files.
Author Contribution DBS, PB, and GD contributed to the concept and
design, analysis, and interpretation of data. DBS, PB, PK, PJ, GM, MS,
and PG contributed to the literature search, data extraction, review, and
initial manuscript drafting. GD and GB interpretation of data, revising
the manuscript for important intellectual content, and approval of the
final manuscript.
All authors were involved in drafting and revising the manuscript
and approved the final version.
Declarations
Ethics Approval and Consent to Participate Not applicable.
Consent for Publication Not applicable.
Competing Interests The authors declare no competing interests.
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