A 32-year-old woman develops a vesicovaginal fistula (VVF) 14 days after total abdominal hysterectomy. The fistula is 0.8 cm, located 1.5 cm above the trigone, with edges that are non-inflamed and viable on cystoscopy. What is the MOST appropriate timing and route for surgical repair?

• A Immediate repair via vaginal route within the first week — success rates are highest with early repair before fibrosis
• B Delay repair 3–6 months to allow inflammation to subside, then repair via vaginal or abdominal route
• C Early repair at 4–6 weeks via vaginal Latzko partial colpocleisis given the fistula location and size
• D Prolonged Foley catheter drainage for 4–6 weeks may result in spontaneous closure for fistulas <1 cm ✓

Explanation

For small post-hysterectomy VVFs (<1 cm) detected early (within 2–4 weeks) with non-inflamed viable edges, prolonged bladder drainage with an indwelling Foley catheter for 4–6 weeks achieves spontaneous closure in approximately 10–15% of cases — an important first conservative step before committing to surgery. The traditional teaching of waiting 3–6 months (B) has been challenged by evidence showing that early repair (4–12 weeks) in selected cases (non-irradiated, non-infected, small fistulas) achieves equivalent success to delayed repair. Immediate repair within the first week (A) is generally avoided as tissue is edematous. The Latzko procedure (C) is specifically for apical VVF from vaginal hysterectomy. Since this fistula is small and edges are viable, catheter drainage is the appropriate first step.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

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Written and medically reviewed by the StethoPrep medical team.