Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: A systematic review and meta-analysis
Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: A systematic review and meta- analysis
Barbara Bodner-Adler 0 1
Engelbert Hanzal 0 1
Eleonore Pablik 0
Heinz Koelbl 0 1
Klaus Bodner 0 1
0 Editor: Alberto G. Passi, University of Insubria , ITALY
1 Department of General Gynaecology and Gynaecologic Oncology, Medical University of Vienna , Vienna , Austria , 2 Section for Medical Statistics, Medical University of Vienna , Vienna , Austria
PubMed, Old Medline, Embase and Cochrane Central Register of Controlled Trials were used as data sources. This systematic review was modelled on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, including a registration number (CRD42012002097).
Data Availability Statement: All relevant data are
available in the manuscript.
Funding: This study was supported by the
Department of General Gynaecology and
Gynaecologic Oncology, Medical University Vienna.
Competing interests: The authors have declared
that no competing interests exist.
We reviewed 282 full text articles to identify 124 studies for inclusion. In all, 1379/1430
(96.4%) patients were treated surgically. Overall, the transvaginal approach was performed
in the majority of patients (39%), followed by a transabdominal/transvesical route (36%), a
laparoscopic/robotic approach (15%) and a combined transabdominal-transvaginal approach
in 3% of cases. Success rate of conservative treatment was 92.86% (95%CI: 79.54±99.89),
97.98% in surgical cases (95% CI: 96.13±99.29) and 91.63% (95% CI: 87.68±97.03) in
patients with prolonged catheter drainage followed by surgery. 79/124 studies (63.7%)
provided information for the length of follow-up, but showed a poor reporting standard regarding
prognosis. Complications were studied only selectively. Due to the inconsistency of these
data it was impossible to analyse them collectively.
Although the literature is imprecise and inconsistent, existing studies indicate that operation,
mainly through a transvaginal approach, is the most commonly preferred treatment strategy
in females with postsurgical VVF. Our data showed no clear odds-on favorite regarding
disease management as well as surgical approach and current evidence on the surgical
management of VVF does not allow any accurate estimation of success and complication rates.
Standardisation of the terminology is required so that VVF can be managed with a proper surgical treatment algorithm based on characteristics of the fistula.
Vesicovaginal fistula (VVF) is an abnormal fistulous tract extending between the bladder and
the vagina that allows the continuous involuntary discharge of urine into the vaginal vault. In
addition to the medical sequelae from these fistulas, they affect physical, mental, social and
sexual life of the patients [
]. In developing countries, the predominant cause of VVF is prolonged
obstructed labour (97%) [
]. Conversely, in industrial countries iatrogenic injury to the urinary
tract is the most common cause of VVF and the majority are consequences of benign
gynaecological surgery [
]. It is estimated that 0.8 per 1000 of all hysterectomies are complicated by the
development of a VVF [
]. Other causes in the developed world include malignant disease and
pelvic irradiation [
]. In contrast to obstetric and irradiation fistulas, the typical postsurgical
(post hysterectomy) fistula is the result of more direct and localised trauma to healthy tissue [
Although vesicovaginal fistulas (VVF) are the most commonly acquired fistulas of the
urinary tract, we lack a standardized algorithm for their management [
management including prolonged bladder drainage, glue/fibrin injections, fulguration and so on is a
reasonable option in cases with small, clean and non-malignant VVF [
]. Beside that, an
operation is by far the most commonly preferred approach for affected women and the success
rate varies between 75±95% with various different techniques in literature [3,8±13]. Multiple
different surgical routes like Latzko repair, open transabdominal, transvaginal, laparoscopic,
robotic, transurethral endoscopic with or without tissue interposition have been described
], but no studies have compared surgical with conservative procedures and their
outcomes in patients with VVFs following benign gynaecologic surgery. Furthermore, there is no
general consensus regarding surgical time for a successful repair . However, the evidence
concerning treatment outcome with well-documented success and complication rates as well
as the optimal surgical timing is lacking. To our knowledge, this is the first systematic review
and meta-analysis investigating this topic. Primary outcome of interest was to review and
summarize the current body of literature regarding effectiveness of disease management in patients
with VVF following benign gynaecologic surgery. Our secondary objective was to define the
most commonly reported time point for treatment and determine the types of study designs.
Materials and methods
This study was reported following the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) statement [
]. Before data extraction, the protocol of this review
was registered with the PROSPERO International Prospective Register of Systematic Reviews
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Fig 1. PICO question.
(CRD42012002097) following the PRISMA guidelines for protocols (PRISM-P) [
following PICO question was defined and is shown in Fig 1.
Literature search included 4 data sources using the retrieval systems DIMDI Classic search or
OvidSp. In detail, we performed a computerised English-language Medline, Pub med,
Cochrane Central Register of Controlled trials (CENTRAL) and Embase literature search
using the MeSH terms vesicovag AND fistul AND ( management OR iatrogenic OR
surgery OR repair ), respectively. Our search ranged from 1947 to March 2016.
The limits for literature search were adult human females. Studies were included if they
reported on a) vesicovaginal fistula b) which occurred after a benign gynaecologic surgery c)
with clearly described conservative or surgical management. In screening process we excluded
studies focusing on other types of urogenital fistulas (UGF), congenital fistulas or fistulas due
to malignancy/irradiation or foreign bodies. Studies dealing with obstetrical VVF or trials,
which did not clearly separate outcome parameters regarding fistula cause, were also excluded.
Congress proceedings of international society meetings, textbooks, and review articles did not
meet the inclusion criteria. Reports including men, neonates or adolescents despite the search
limits were not included. Non-English articles with English abstracts were included if they
provided information not found in English-language literature.
Data extraction and study characteristics
Two investigators (BBA and KB) independently reviewed random titles and abstracts to
establish reliable, reproducible inclusion criteria. All pertinent references from the manuscripts
were obtained and reviewed. General characteristics were recorded from each study. Two
authors (BBA and KB) independently abstracted study design, number of included patients,
type or size of the VVF, different types of treatment (surgical/conservative), route and type of
surgical treatment, cause of fistula and time point of surgical repair. The following outcome
parameters were measured: time between fistula occurrence and repair (= surgical time),
complete resolution of symptoms, success rate and treatment complications: postoperative leakage,
de-novo stress incontinence, de novo urgency, urinary tract infection, number of attempts/
repair, new-onset of pain/dyspareunia, recurrent VVF immediately (failure) or at any time
postoperatively and long-term consequences on pelvic health including sexual function immediately
or at any time after treatment. Terminology for success was inconsistent among included
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studies. We used terminology for success when success was either defined as ªanatomical cure±
fistula closed, healed or curedº or ªabsence of urinary loss, resolution of symptomsº. A total of
12 publications showed disagreement between the two reviewers. This was resolved by
discussion with a third person (EH or HK). The findings of all relevant studies were abstracted,
categorized and summarized by study design and outcomes measured. Furthermore, two of the
authors (BBA and KB) independently rated the quality of the studies, using criteria from US
Preventive Services Task Force and the NHS Centre for Reviews and Dissemination [
Studies received a poor rating if they were case reports, case series without adequate control group
or comparative studies where the groups were not comparable.
Risk of bias (RoB) assessment. Risk of bias between included studies was independently
assessed and evaluated by two of the authors (BBA and KB). Due to the types of study design
of included studies the Newcastle Ottowa Scale for risk of bias assessment for comparative
studies was used (Table 1) . This considers 3 criteria (selection of study groups,
comparability of groups and ascertainment of outcome of interest) for quality assessment. Discrepancy
between the review authors over the risk of bias was resolved by discussion, with involvement
of a third author where necessary.
Synthesis of results
The meta-analysis was conducted on individual patient level using random-effect logistic
regression models to calculate the probability of success for every type of therapy (conservative,
surgical, combined) and every route and type of surgical treatment. 95% confidence intervals for the
estimated proportion of successful treatments were calculated based on profile likelihood. To
show the amount of heterogeneity the between trial variance τ is presented for every model.
Random- effects logistic regression models were used to manage study heterogeneity. Furthermore,
calculation of the meta-analysis was also extended to random-effect logistic regression models.
No odds ratios for the comparison between the different types of therapy were calculated as only
4 out of the 124 trials had a comparative study design while 120 studies reported uniform
treatment for all documented patients. Therefore the differences in the outcome might be mainly
influenced by the heterogeneity of the study populations. All statistical calculations were
performed using the R-project for statistical computing (Version R-3.2.5) [
We identified 2165 citations, reviewed 282 full text articles, and identified 124 studies for
inclusion [1,4,8,10,13,19±137]. We excluded 1018 studies because they did not meet the
A study can be awarded a maximum of one star for each numbered item within the selection and outcome categories. A maximum of two stars can be given
*: poor quality
**: moderate quality
***: high quality
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Fig 2. PRISMA Flow Chart.
inclusion criteria. The results of the search and screening procedure are presented as a
PRISMA Flow Chart in Fig 2. The final analysis included 23 case reports, 95 retrospective case
series, 5 comparative studies and 1 uncontrolled prospective study involving 1430 patients in
all. There were no randomized controlled trials and no case-control studies. Case series
contained between 2 and 110 patients. Detailed information of each included study (author, year,
type of procedure and success rate) is summarized in Table 2.
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Fistula type was documented only in 58/124 (47%) studies. Of these, the majority of trials 35/
58 (60%) dealed with simple fistulas, 21/58 (36%) with complex VVF and in a small percentage
of studies (4%) complicated VVF were investigated. The majority of studies (66/124; 53%) did
not comment on fistula type. Mean fistula size could not be calculated due to heterogeneity
and insufficiency of data documentation. The majority of VVF occurred after a
transabdominal hysterectomy (n = 943/1430; 66%), followed by vaginal hysterectomy (n = 126/1430; 9%),
laparoscopic hysterectomy (n = 38/1430; 3%) and other benign gynaecologic operations
(n = 72/1430; 5%). The remaining studies (17%) did not mention the type of hysterectomy
causing the fistula. 46/124 (37%) studies included only patients who underwent a primary
fistula repair (n = 221), 16/124 (13%) studies investigated patients who had previous attempts of
fistula repair (n = 54) and 41/124 (33%) trials described a mixed collective of cases (n = 979).
Remaining 21 studies (17%) did not give any information. Number of attempts varied between
1 and 3 repairs in average.
Conservative treatment: Results of individual studies
10 studies described non-surgical treatment strategies as sole treatment option. These included
transvaginal injection of fibrin sealant in 1 case, Yag Laser welding in 8 patients, cystoscopic
electrocoagulation/fulguration/catheter method in 11 patients, endovaginal application of
cyanoacrylic glue in 3 cases, platelet rich plasma/rich fibrin glue application in 6 women, curettage
of fistula tract in 3 cases and ball technique with rubber/metal ball in 18 females. Success ranged
between 67%-100% and the majority consisted of small VVF (<1 cm) [
239/1430 VVF (16%) were initially managed conservatively with prolonged catheter drainage
(range: 2±12 weeks). Only 19/239 (8%) VVFs resolved with catheter drainage and the remaining
220/239 (92%) VVFs underwent surgical repair.
The majority of patients were treated surgically. In all, 1379 patients were managed surgically
and 97.98% (95%-CI: 96.13±99.29) were cured. The most commonly reported surgical approach
was the transvaginal route (n = 534/1379; 39%), followed by a transabdominal/transvesical
approach (n = 493/1379; 36%), a laparoscopic/robotic route (n = 207/1379; 15%) and a
combined transabdominal-transvaginal approach in 45/1379 (3%) cases. Additionally, further
various surgical techniques like transvaginal transurethral pointed electrocoagulation, transurethral
suture cystorraphy, suprapubic cystotomy with gold leaf and so on were reported in 41/1379
(3%) cases. In 59/1379 (4%) VVFs the surgical route was not documented. Interposition grafts
like Martius flap, Gracilis muscle, omental, peritoneal, labial fat flap or bladder mucosa
autograft were used in the majority of studies (66 studies including 708 cases).
Success after treatment
107/124 (86%) studies documented a success rate after treatment, describing 87 patients being
completely symptom-free, 754 being completely dry and in 406 cases fistula healed completely
or was cured.
Results of each meta-analysis with logistic regression model. Only studies which
consistently evaluated treatment success were used for the meta-analysis. Success rate of conservative
treatment was 92.86% (95%CI: 79.54±99.89), 97.98% in surgical cases (95% CI: 96.13±99.29)
and 91.63% (95% CI: 87.68±97.03) in patients with prolonged catheter drainage followed by
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Type of procedure
transvag. versus transabd.
surgery. Success rates regarding surgical approaches were as follows:
transabdominal/transvescial route 97.05% (95% CI: 94.55±99.18), transvaginal route 93.82% (95% CI: 89.96±97.49),
laparoscopic/robotic approach 98.87% (95% CI: 96.85±99.99) and combined transabdominal/
transvaginal route 90.70% (95% CI: 64.63±99.87). Use of interposition flap showed a success
rate of 97.63% (95% CI: 95.31±99.22), without interposition flap reported success rate was
97.62% (95% CI: 93.63±99.91).
Reported frequency of success rates are summarised in Tables 3±8.
Estimated proportion of successes %
95%-CI of proportion of successes
Between trial variance τ
Intra- and postoperative surgical outcome
Successful intraoperative or postoperative outcome was mentioned in detail in 78/124 (63%)
studies. The majority of these studies defined a successful outcome as an uneventful intra- or
postoperative course and no immediate complications detected. 14 studies mentioned a
complicated postoperative outcome and in 24 patients this was described in detail: ileus (n = 5),
postoperative fever (n = 6), intraoperative bleeding (n = 2), grad II hydroureter (n = 1),
clostridium difficile atelectasis (n = 1), wound infection (n = 2), bowel injuries (n = 2),
compartment syndrome (n = 1), pelvic abscess (n = 1), and occurrence of ureterovaginal (n = 1) and
vesicocolonic fistula (n = 2).
Length of follow-up and complication rates
79/124 (64%) studies provided information for the length of follow-up. The remaining 45
studies did not mention any length of follow-up. The mean available follow-up time was 19.7
months. Complications were studied only selectively. Total number of studies mentioning
complication outcome is shown in Table 9. Due to the inconsistency of these data it was
impossible to analyse them collectively.
Long-term consequences and sexual function after treatment
None of the included studies documented any long-term consequences of pelvic health. Only
3 studies assessed sexual function after treatment [
]. Dorairajan et al. reported that 8/
10 patients were sexual active without any signs of dyspareunia or pain [
], Nerli et al.
reported that 2/4 cases were sexual active and all 3 women were sexual active in the study
published by Xu et al. [
Surgical time: Time between fistula occurrence and repair
In 22/124 (18%) studies, including 241 patients, surgery was initiated < 12 weeks after fistula
occurrence. 15/124 (12%) studies with 223 patients defined the time point of surgical repair
after 12 weeks. No statistically significant difference regarding success rate could be detected
between early and late repair (p>0.05). 11 (9%) studies (n = 147 cases) started surgical
timing < 12 weeks as well as > 12 weeks. The majority of studies (64/124; 52%), including 531
cases did not give any comment on their surgical time and 12 studies (9%) did not document
an adequate time range.
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Vesicovaginal fistulas are among the most distressing complications of obstetric and
gynaecologic procedures, which can cause devasting medical, social, and psychogenic consequences
]. The aetiology has changed, becoming more associated with hysterectomy. Despite
numerous publications on this subject, the management of VVF remains a source of debate.
The options of fundamental issues such as the preferred surgical approach and the optimal
timing of surgery still vary widely [
This systematic review and meta-analysis assessed the effectiveness of disease management in
patients with postsurgical fistulas and investigated treatment outcome with success and
complication rates as well as surgical timing and type of study designs. The scientific literature
consists mainly of case reports and retrospective case series. Furthermore, this analysis contains
only a minority of studies, which used conservative treatment options as sole fistula treatment,
as the majority of patients were treated surgically (96.4%). The preferred surgical approach
was a transvaginal route, followed by transabdominal/transvesical approach, laparoscopic/
robotic approach and combined operation techniques with reported success rates of 93.82%,
97.05%, 98.87% and 90.70%, respectively.
Comparison with literature
Treatment of patients with VVF is currently controversial [
]. Although a trial of
conservative management with prolonged bladder drainage might be tried, the spontaneous closure
rate of VVF is low [
]. We found only 10 studies, which used conservative treatment as sole
treatment strategy. Besides, our data confirmed that VVF resolves with prolonged catheter
drainage only in a low percentage (8%). Some authors indicate that conservative treatment is
only successful in smallest fistulas, and the majority of patients will require definitive surgical
]. However, no studies exist comparing non surgical with surgical treatment
Although an operation is by far the most common recommendation for affected women,
evidence concerning surgical treatment is lacking. Multiple different surgical techniques and
21 72,41% of 29
217 64,98% of 334
62 93,94% of 66
695 98,16% of 708
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Estimated proportion of successes %
95%-CI of proportion of successes
Between trial variance τ
approaches have been described in literature [
], but the choice mainly depends on
location, severity and size of fistula [
]. Additionally, only few studies have compared the
surgical procedures/approaches for VVF [
]. One study compared open and robotic
surgical repair in patients with recurrent VVFs with no significant difference in outcome and
complication rate . Ou et al. evaluated three different surgical techniques (laparoscopic±
open abdominal±transvaginal) in patients with primary fistula repair. Their data suggested
that laparoscopic repair is feasible and results in lower morbidity than transabdominal and
vaginal repair [
]. Phsak et al. compared the outcome between recurrent VVFs and primary
VVFs without tissue interposition. The authors concluded that transvaginal repair of recurrent
VVFs without tissue interposition is equally successful as in primary repairs [
Rajamaheswari et al. investigated the outcome between vaginal and transabdominal repair and reported
comparable success rates between the two groups [
Surgical approach. The most important principle in repair is to provide tension-free,
watertight closure, and the surgical route should be the one that provides the best possible
chance of closure on the first attempt [
]. These principles can be achieved through a
vaginal, abdominal or endoscopic approach. Although the choice of technique partly depends on
the characteristics of the fistula, the surgical experience is also an important factor of successful
]. Although different surgical techniques have been described, a consensus for
the ideal approach for surgical correction of VVF is still required [
Vaginal approach. In general, most gynaecologic surgeons prefer the vaginal approach,
which has been associated with lower morbidity rates and with an equally good outcome
]. The two most commonly reported vaginal repair techniques include Latzko technique
and the layered closure . This systematic review confirmed that vaginal fistula repair was
used in the majority of cases with a reported success rate of 93.82%. Latzko operation was
performed in 170 women and Tancer et al. published the largest investigation with 110 VVFs post
hysterectomy. 107 patients were treated by partial colpocleises (Latzko repair) and 89% were
cured at first attempt [
]. Although the included studies are inconsistent regarding
characteristics of the fistula, we summarize that the vaginal approach for fistula repair is performed
in the majority of female patients and therefore it is the surgical procedure with the highest
level of experience in literature.
Abdominal approach. The abdominal route can be performed using a transvesical or an
extravesical (bivalve technique) approach and is mainly indicated for loculated or complex
]. We included 439 cases managed with an abdominal/transvesical approach with a
Patients in these studies
Observed absolute frequency
Observed relative frequency
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reported success rate of 97.05%. Majority of these cases were treated with interposition graft.
Due to the inconsistency of included trials and lack of fistula characteristics no
recommendation can be made.
Laparoscopic and robotic-assisted approach. Minimally invasive laparoscopic surgery is
increasingly being performed, including laparoscopic VVF repair [
]. In 2005,
Chibber et al. described a laparoscopic approach to the O`Conor technique with reported
advantages of decreased morbidity and a more rapid recovery . One systematic review with 44
eligible studies compared the success rates between laparoscopic/robotic transvesical repair
and extravesical laparoscopic repair techniques in patients with VVF. Due to their results, the
authors summarized that extravesical VVF repair has similar cure rates compared to the
traditional transvesical approach [
]. Most recent technology used in the treatment of VVF repair
is the robotic-assisted approach and some authors reported excellent results with this
operation technique [
]. Disadvantages include increased learning curve, time, costs and
surgeons experience. We included 8 studies, which used a robotic-assisted approach. Success
rates were excellent with 100% success, but number of included patients was small.
Summarizing our data, due to the small number (n = 26 cases in all) and heterogeneity of studies, no
clear statement and recommendation can be made regarding this operation technique and
their success and complication rate in fistula repair.
Specified long-term outcome and complication rates. Postoperative complications are
common and the most frequent postoperative complications reported in literature are de novo
SUI, de novo urgency, leakage, de novo pain/dyspareunia, infection and failure [
Analysing our data, we could demonstrate that the majority of the included studies did not
mention an adequate follow-up time and complications were described only selectively. We
summarised 106/124 papers mentioning any complication, but from the remaining studies,
which did not mention it we cannot assume that none occurred. Due to the inconsistency of
these data it was impossible to analyse them collectively and no accurate prediction of
complication rates can be made.
Surgical time. One of the main controversies in literature is the ideal timing for surgical
intervention for postoperative VVF. Angioli et al. recommended waiting 2±4 months using
continuous drainage of the bladder [
]. However, several other studies showed that,
especially for small uninfected fistulae, early repair has better or at least similar success rates
compared to delayed repair with additional advantage of reduced suffering and early
commencement of normal life [
]. On the other hand, some reports indicate that
timing of repair does not affect the outcome [
]. Our data demonstrated that 22 publications
used an early repair, 15 studies started late surgical repair and 11 trials performed early as well
as late repair. Due to this inconsistency, no serious recommendation can be done regarding
ideal timing for surgical intervention.
Definition success rate and fistula classification. The reported cure rate of VVF varies
between 75±95% with various different techniques in literature [3,8±13]. In accordance to
literature, our findings revealed a success rate of 92.9% with conservative treatment, 97.98% in
cases treated surgically and 91.63% in patients with prolonged catheter drainage followed by
surgery. Summarising our data, no clear odds-on favorite regarding disease management as
well as surgical approach could be identified and no technique was superior to any other. One
major problem we faced was that success was defined in different ways, as many studies
defined success as surgical closure of the fistula in place of function following surgery. In our
opinion, successful surgical closure of the defect should be called `anatomical closure' rather
than `cure', because many women suffer from on going pelvic organ, sexual and psychological
dysfunction. Although this is of significant importance, only 3 studies [
] reported on
sexual function after fistula treatment and the majority did not even mention this topic.
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Another problem that we faced when analysing the included studies was the lack of
standardisation of terminology. The methodology of measuring the fistula as well as the used
classification system was not clear in the majority of articles and none of the included studies stratified
data by fistula type, primary repair versus previous attempts, fistula size or fistula location.
Standardisation of the terminology is therefore required so that VVF can be properly managed
]. Given the limitations of this analysis, future clinical research with a clearly defined VVF
classification system, success definition better than anatomic result is needed to confirm our
Quality and design of studies included. The scientific literature regarding surgical or
conservative management of VVF following a benign gynaecologic surgery in female patients
includes mainly case reports and retrospective case series and a variety of different surgical
techniques. For this reason the majority of the included studies received a poor quality rating
due to the study type. Furthermore, the reporting standard regarding surgical outcome,
follow-up time and complication rate was poor. In addition to differences in reporting, an
adequate documented follow-up time was not mentioned in the majority of cases, making it
difficult to draw meaningful conclusions from these findings.
Strengths and limitations
One of the strengths of our study is the inclusion of study data on the effectiveness of disease
management in females with VVF in a specific population, namely after a benign gynaecologic
surgery. The typical postsurgical fistula is the result of a direct and localised trauma to healthy
tissue and therefore not comparable with obstetric or irradiation/cancer fistula. No similar
analysis was found in literature. Besides, most of the included studies had the same primary
outcome parameter, to be specific success after treatment. Limitations of our study are
inherent to the limitations of the included studies. None of the included studies stratified data by
fistula type, size or location. The methodology of measuring the fistula as well as the used
classification system was not clear in the majority of articles. As no study reported data by
using a unique classification system, a subgroup analysis according to fistula characteristics
was not feasible. Another limitation arises from the study design as the majority of studies
consisted of case reports or case series reporting uniform treatment for all documented patients.
For this reason risk of bias assessment could be performed in a minority of studies with
comparative study design. Furthermore, differences in outcome might be influenced by
heterogeneity of study populations.
Although the literature on disease management of females with postsurgical VVF is imprecise
and inconsistent, our data show that the majority of patients are treated surgically through a
transvaginal route. The quality and design of studies reviewed were weak with a poor reporting
standard, weakening the conclusions that can be drawn. In summary, these data do not allow
accurate prediction of success and complication rates in female patients with VVF following
benign gynaecologic surgery. Standardisation of the terminology is required so that VVF can
be managed with a proper surgical treatment algorithm based on characteristics of the fistula
and well designed RCT are needed in future.
S1 Checklist. PRISMA 2009 checklist.
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We express our sincere thanks to Mag. Wildner, for her support in literature search.
Conceptualization: BBA EH KB.
Formal analysis: BBA EP.
Funding acquisition: HK.
Investigation: BBA EH KB.
Methodology: BBA EH EP KB.
Project administration: BBA.
Software: BBA EP.
Validation: BBA KB.
Writing ± original draft: BBA.
Writing ± review & editing: BBA HK KB.
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Wells GA, Shea B, O`Connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle Ottowa
Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available: http://
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