Urogynecologic fistulae (UGF) are abnormal communications between the urinary tract and the genital tract that result in continuous urinary leakage through the vagina, causing major physical, psychological, and social morbidity in affected women. They represent one of the oldest known surgical challenges in medicine, with early descriptions found in ancient Egyptian and Greek texts such as the Ebers Papyrus and writings of Soranus of Ephesus, who documented obstetric injuries causing incontinence in the second century A.D. [1]. The modern history of UGF repair began with J. Marion Sims in the 19th century, whose pioneering surgical techniques marked a turning point in urogynecologic surgery, later refined by contributions from Latzko and O’Connor [2]. Despite improvements in anesthesia, asepsis, and suture materials, the burden of these injuries remains high in developing regions, where they primarily result from obstructed or neglected labor [3]. Globally, more than two million women live with untreated obstetric fistula, with 50,000–100,000 new cases annually. This figure likely underestimates the true prevalence due to underreporting and social stigma [4]. In low- and middle-income countries, especially in sub-Saharan Africa and South Asia, the lack of skilled obstetric care during prolonged labor remains the principal cause of UGF formation [5]. In contrast, in developed countries, the epidemiologic shift favors iatrogenic causes — predominantly hysterectomy and cesarean section injuries — reflecting both the availability and risk of surgical obstetric interventions [6,7]. The pathophysiology of obstetric fistula formation centers on ischemic necrosis of the vesicovaginal septum due to prolonged compression between the fetal head and the maternal pelvic bone, causing tissue sloughing and subsequent fistula tract formation. Other etiologies include surgical trauma, pelvic malignancy, radiotherapy, and pelvic infections [8,9]. The sociodemographic factors contributing to UGFs are multifactorial — early marriage, adolescent pregnancy, short stature, poor nutrition, illiteracy, and lack of prenatal care all increase risk. Cultural and geographic barriers often delay access to emergency obstetric services, compounding morbidity [6]. In India, fistula prevalence is highest in northern and central states with low maternal health indices, and despite national initiatives such as the Janani Suraksha Yojana and the National Rural Health Mission, disparities in the quality of institutional deliveries persist [5]. Since 2003, the World Health Organization (WHO) and the United Nations Population Fund (UNFPA) have collaborated under the Campaign to End Fistula, emphasizing prevention through skilled obstetric attendance, improved surgical training, and social reintegration of survivors [20]. Nonetheless, awareness, dedicated fistula centers, and surgeon training remain inadequate in India, leading to persistent incidence despite preventive programs [10]. Surgical management of UGFs requires meticulous preoperative evaluation and individualized planning. Common procedures include O’Connor’s transabdominal repair and vaginal flap repair, supplemented by ureteric reimplantation or stenting when the ureter is involved [11]. The choice of surgical route depends on fistula type, size, location, and prior repair history. The primary aim is anatomical closure, restoration of continence, and improvement in quality of life [12]. Despite extensive literature, institutional data from Indian tertiary centers remain sparse. Therefore, this prospective study was conducted to analyze the clinical profile, etiology, surgical management, and outcomes of UGFs at a tertiary referral hospital in South India, aiming to contribute region-specific insights to the global understanding of this preventable yet persisting problem.

Study design and setting A prospective observational study was undertaken in the Department of Urology, Government General Hospital, Guntur, Andhra Pradesh, affiliated with Guntur Medical College. The study period extended from January 2023 to January 2025. The hospital functions as a tertiary referral centre serving urban and rural districts, providing a representative case mix of both obstetric and iatrogenic urogynecologic fistulae [5]. Ethical clearance was obtained from the Institutional Ethics Committee, and written informed consent was obtained from all participants before enrolment. Study population Thirty consecutive women aged ≥ 18 years who presented with continuous urinary leakage through the vagina and were diagnosed clinically and radiologically with urogynecologic fistula (UGF) were included. All were evaluated and managed in accordance with a standardized departmental protocol. Inclusion criteria 1. Patients with vesicovaginal fistula (VVF), ureterovaginal fistula (UVF), or combined VVF + UVF confirmed by clinical examination and imaging. 2. Patients fit for anesthesia and consenting for definitive surgical repair. 3. Minimum follow-up of six months after repair. Exclusion criteria 1. Fistulae secondary to malignancy with residual disease or recurrence. 2. Patients with poor general condition, active infection, or uncorrected anemia precluding surgery. 3. Traumatic or postoperative urethrovaginal fistulae not involving the bladder or ureter. 4. Patients unwilling or lost to follow-up before six months. Clinical evaluation A detailed history was recorded, including age, parity, obstetric history, antecedent event (obstructed labour, cesarean section, hysterectomy, pelvic irradiation, or prior surgery), duration of symptoms, and previous repair attempts. General and systemic examinations were followed by pelvic examination to identify fistula location, size, and number. Dye tests (methylene blue or indigo carmine) were used to confirm vesical communication. Speculum examination and bimanual palpation assessed vaginal scarring and accessibility for vaginal repair [7,8]. Diagnostic investigations Routine hematologic and biochemical parameters were obtained for pre-operative fitness. Specific investigations included: • Ultrasound KUB and CT urogram to delineate the urinary tract and identify ureteric involvement. • Cystoscopy to assess the bladder mucosa, exact fistula site, number, and proximity to ureteric orifices. • Intravenous pyelography (IVP) in selected patients for confirmation of ureteric obstruction or extravasation. All patients were screened for urinary tract infection and treated appropriately prior to surgery [9,10]. Surgical management The choice of surgical approach was individualized according to fistula size, site, prior surgery, and vaginal accessibility. • Abdominal (O’Connor) repair was performed for supratrigonal, multiple, or high vesicovaginal fistulae and when concomitant ureteric reimplantation was required. The fistula tract was dissected, closed in two layers with absorbable sutures, and omentum interposed when feasible. • Vaginal flap repair was used for low-lying, accessible, or obstetric fistulae. The fistulous tract was excised, bladder and vaginal walls mobilized, and multilayer closure performed using well-vascularized flaps (Martius fat pad when required). • Ureterovaginal fistulae were managed by ureteric reimplantation with stenting (modified Lich-Gregoir technique) or ureteroneocystostomy ± psoas hitch depending on ureteric length. All procedures were performed under regional or general anesthesia by senior urologic surgeons experienced in reconstructive techniques [11–13]. Post-operative care Continuous bladder drainage was maintained using a Foley catheter for 14 days and ureteric DJ stents for 4–6 weeks when applicable. Intravenous antibiotics were administered for 48 hours, followed by oral coverage. Patients were encouraged early ambulation and adequate hydration. Catheter removal was followed by a voiding trial to assess continence [14]. Patients were reviewed at 1 month, 3 months, and 6 months post-surgery. Follow-up assessments included physical examination, symptom review, urinalysis, and ultrasound to exclude residual or recurrent fistula. Success was defined as complete closure without urinary leakage at six months. Failure was persistent or recurrent leakage from the vagina confirmed by dye test or cystoscopy [15]. Data collection and statistical analysis Data were entered into a pre-structured proforma capturing demographic variables, etiology, surgical approach, intra- and post-operative complications, and outcomes. Statistical analysis was performed using SPSS version 26 (IBM Corp., USA). Descriptive statistics were used for frequencies and percentages; continuous variables were summarized as mean ± standard deviation. The Chi-square test was used to assess associations between categorical variables such as etiology and success rate; a p-value < 0.05 was considered statistically significant [16]. Ethical considerations This study adhered to the Declaration of Helsinki (2013 revision) and institutional research ethics standards. Confidentiality of patient data was ensured throughout. No external funding was received, and there were no conflicts of interest [17].

A total of 30 women with confirmed urogynecologic fistulae (UGF) were included in this study. The mean age was 38.6 years, with a majority (63.3%) belonging to the 30–49-year group, reflecting the reproductive and perimenopausal demographic most affected by the condition. The youngest patient was 19 years, and the oldest 62 years. Most patients (76.7%) belonged to low socioeconomic backgrounds and were multiparous, having had at least two deliveries. Antecedent Events The etiologic spectrum in this cohort reflected a transition from obstetric to iatrogenic causes. The main antecedent factors were: • Obstructed labor in 33.3% of cases (n=10), • Lower-segment cesarean section (LSCS) in 23.3% (n=7), • Hysterectomy in 23.3% (n=7), and • Radiotherapy in 10% (n=3). Three cases (10%) were grouped under miscellaneous or unknown causes. These trends indicate that while obstetric trauma remains significant, surgical interventions are emerging as equally important etiologic contributors in modern clinical settings. Comparative evaluation of published literature revealed a parallel pattern: Pandey et al. (2020) identified LSCS as the predominant cause (45%), whereas Kapoor et al. (2022) reported a higher incidence following hysterectomy (31%) and obstetric injuries (25%). Okoye et al. (2019) and Mohammed et al. (2021) described obstructed labor accounting for over 70% and 80% of cases respectively in African cohorts, emphasizing regional variability driven by access to obstetric care. Type and Distribution of Fistulae Among the 30 patients, vesicovaginal fistula (VVF) was overwhelmingly predominant, observed in 26 cases (86.7%). Ureterovaginal fistula (UVF) occurred in 3 patients (10%), and a combined UVF + VVF was seen in 1 patient (3.3%). The pattern suggests that bladder injury remains the chief pathology, often due to difficult obstetric or gynecologic procedures. When compared with external datasets, the findings align with Gupta et al. (2021) (VVF 80%, UVF 12%), Eke et al. (2020) (VVF 89%), and Yadav et al. (2019) (VVF 82%), confirming that bladder-derived fistulae constitute the bulk of urogynecologic fistula pathology across different populations. Surgical Approach and Intraoperative Findings The O’Connor transabdominal repair was the most frequently employed technique, performed in 14 patients (46.7%), followed by vaginal flap repair in 9 (30%), DJ stenting alone in 2 (6.7%), and ureteric reimplantation in 1 (3.3%). One patient (3.3%) underwent laparoscopic VVF repair, another (3.3%) had combined O’Connor + vaginal flap, and two (6.7%) were managed conservatively following spontaneous closure. The O’Connor repair demonstrated an 85.7% success rate (12/14), while vaginal flap repair achieved 100% closure (9/9). Other methods such as DJ stenting, reimplantation, laparoscopic, and conservative management also yielded 100% success, though case numbers were limited. Intraoperatively, most VVFs were supratrigonal (65%), with the remaining 35% infratrigonal. The mean fistula size was 1.2 cm. Dense fibrosis and scarring were seen in 13.3%, often among patients with prior failed repair or radiotherapy exposure. Martius fat pad interposition was used in 4 cases (13.3%), mainly in recurrent or irradiated fistulae. Omental flap interposition was employed in three O’Connor repairs (10%) where adequate omentum was available. Postoperative Complications Postoperative morbidity was generally low. Urinary tract infection (UTI) occurred in 8 patients (26.7%), while 73.3% experienced no complications. Among those with UTI, one patient developed mild fever and dysuria; all responded to culture-guided antibiotics. No cases of wound dehiscence, peritonitis, or deep pelvic abscess were reported. Minor issues such as mild suprapubic discomfort and low-grade fever were transient. Patients with UTI had a slightly reduced success rate (87.5%) compared to those without complications (90.9%), but the difference was not statistically significant (p > 0.05). Functional Outcomes Functional recovery was excellent. At six-month follow-up: • Continence was achieved in 93.3% (n=28) of patients. • Lower urinary tract symptoms (LUTS) such as urgency or frequency were reported in 6 patients (20%), while 24 (80%) had normal voiding function. • Sexual function was normal or good in 23 patients (76.7%), whereas 7 (23.3%) reported dyspareunia or diminished desire. These results correspond with global data — Thakar et al. (2021) reported continence in >90% of cases, Dandolu et al. (2020) observed LUTS in 15%, and Kapoor et al. (2022) documented sexual function recovery in 72%. Final Surgical Outcomes The overall success rate in this series was 93.3% (28/30), defined as complete closure with continence at six months. Only 2 patients (6.7%) had failure — one with a recurrent small supratrigonal leak and another with persistent urinary leakage after radiotherapy-associated VVF. Both were advised delayed re-repair after tissue optimization. When analyzed by fistula type, VVF cases achieved a 92.3% success, UVF and combined UVF + VVF both had 100% closure. By surgical approach, O’Connor repair had 85.7% success, while vaginal flap repair, DJ stenting, ureteric reimplantation, and laparoscopic repair all achieved 100% success. Correlations Between Etiology and Outcome Fistulae following obstructed labor and LSCS showed near-total closure rates (90–100%), whereas those due to hysterectomy had a slightly lower success (85.7%) owing to fibrosis and tissue devascularization. Radiotherapy-induced fistulae exhibited partial healing in 66.7%, reinforcing the challenge of managing ischemic, scarred tissues. Scar and Cosmetic Findings Scar assessment revealed 13.3% of patients had visible perineal or abdominal scars, 6.7% had none, and 80% were unrecorded due to retrospective documentation gaps. Despite this, cosmetic and psychological recovery was satisfactory based on patient interviews during follow-up. Summary of Findings • Mean age: 38.6 years (range 19–62) • Most common etiology: Obstructed labor (33.3%) • Most common fistula type: VVF (86.7%) • Commonest surgery: O’Connor repair (46.7%) • Overall success rate: 93.3% • Commonest complication: UTI (26.7%) • Continence at follow-up: 93.3% • Normal sexual function: 76.7% These findings affirm that with proper case selection and surgical technique, high closure and continence rates are achievable, even in resource-constrained tertiary centers. Table 1: Age Distribution of Patients Age Group n % ≤19 2 6.7 20–29 3 10.0 30–39 10 33.3 40–49 9 30.0 50–59 3 10.0 60–69 2 6.7 ≥70 1 3.3 Table 2: Duration of Symptoms Duration (months) n % ≤3 5 16.7 4–6 8 26.7 7–12 9 30.0 13–24 6 20.0 >24 2 6.7 Table 3: Antecedent Event Antecedent Event n % Obstructed Labor 10 33.3 LSCS 7 23.3 Hysterectomy 7 23.3 Radiotherapy 3 10.0 None/Others 3 10.0 Table 4: BMI Categories BMI Category n % Underweight (<18.5) 3 10.0 Normal (18.5–24.9) 12 40.0 Overweight (25–29.9) 8 26.7 Obese (≥30) 7 23.3 Table 5: Type of Fistula Type n % VVF 26 86.67 UVF 3 10.0 UVF+VVF 1 3.33 Table 6: Surgical Approach Approach n % O’Connor repair 14 46.7 Vaginal flap 9 30.0 DJ stenting 2 6.7 Reimplantation 1 3.3 Laparoscopic VVF repair 1 3.3 Conservative 2 6.7 O’Connor + Vaginal flap 1 3.3 Table 7: Fistula Type and Surgical Approach Fistula Type O’Con nor Vagin al Flap DJ Stenti ng Reimplant ation Laparosc opic VVF Repair Conserva tive O’Con nor + Vagina l Flap Tot al VVF (n=26) 14 (53.84%) 9 (34.61%) 0 (0%) 0 (0%) 1 (3.84%) 2 (7.69%) 0 (0%) 26 UVF (n=3) 0 (0%) 0 (0%) 2 (33.3 %) 1 (33.3%) 0 (0%) 0(33.3%) 0 (0%) 3 UVF+V VF (n=1) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (100%) 1 Table 8: Fistula Type and Final Outcome Fistula Type Success Failure Total VVF (n=26) 24(92.30%) 2 (7.70%) 26 UVF (n=3) 3 (100%) 0 (0%) 3 UVF+VVF (n=1) 2 (100%) 0 (0%) 1 Table 9: Surgical Approach and Final Outcome Surgical Approach Success Failure Total O’Connor (n=14) 12 (85.71%) 2 (14.29%) 14 Vaginal Flap (n=9) 9 (100%) 0 (0%) 9 DJ Stenting (n=2) 2 (100%) 0 (0%) 2 Reimplantation (n=1) 1 (100%) 0 (0%) 1 Laparoscopic VVF Repair (n=1) 1 (100%) 0 (0%) 1 Conservative (n=2) 2 (100%) 0 (0%) 2 O’Connor + Vaginal Flap (n=1) 1 (100%) 0 (0%) 1 Table 10. Surgical Approach and Success Rates Study O’Connor (%) Vaginal (%) Laparoscopic/Robotic (%) Success Rate (%) Present study 46.7 30.0 3.3 93.33 Yadav et al., 2019⁷⁹ 52 28 – 92 Okonkwo et al., 2020⁸⁰ 30 60 – 88 Li et al., 2021⁸¹ – – – 89 (meta-analysis) Zhao et al., 2023⁸² – – 100 >90

The present prospective study of 30 patients with urogynecologic fistulae (UGF) demonstrates that the problem, though preventable, persists as a significant cause of female morbidity in India. The results reaffirm the dual epidemiologic pattern—obstetric trauma continuing in rural settings and iatrogenic injury emerging in urban hospitals. The mean age of 38.6 years corresponds to the reproductive and perimenopausal age group reported in other Indian series, such as Thakar et al. (2021) and Gupta et al. (2021) [18,19]. These women are typically multiparous, socially active, and economically productive; thus, the disability caused by continuous urinary leakage has profound implications for mental health, family relationships, and economic independence. The predominance of multiparous women emphasizes the cumulative obstetric risk over successive deliveries, particularly where prolonged labor and delayed referral remain common. Obstetric trauma accounted for 33.3 % of cases in this cohort, comparable with Pandey et al. (2020) and Okoye et al. (2019) [20, 21]. However, the nearly equal representation of iatrogenic causes (LSCS 23.3 %, hysterectomy 23.3 %) indicates a transitional epidemiology similar to that described by Kapoor et al. (2022) and Eke et al. (2020) [22,23]. The steady rise in postoperative fistulae reflects the expansion of gynecologic and obstetric surgical services without commensurate improvement in intra-operative identification and repair of bladder or ureteric injuries. In many peripheral hospitals, limited surgical experience and lack of cystoscopic facilities delay detection until postoperative leakage appears. Vesicovaginal fistula (VVF) formed the bulk of cases (86.7 %), a proportion consistent with Yadav et al. (2019) and Gupta et al. (2021) [24,25]. Ureterovaginal fistula (UVF) comprised 10 %, again paralleling large tertiary-centre experiences. The single combined VVF + UVF case emphasizes that complex or high supratrigonal fistulae may simultaneously involve the ureteric orifice, requiring individualized repair. The supratrigonal location in 65 % of VVFs also matches the distribution reported by Waaldijk (2004) and Rovner (2021) [26,27]. The success of surgical management in this series—overall closure and continence 93.3 %—is comparable with global data. Most authors report success rates between 90 % and 95 % after first-time repair [28, 29]. Vaginal repair achieved 100 % closure here, slightly higher than O’Connor repair (85.7 %). The difference likely arises from case selection: low, accessible obstetric fistulae were treated vaginally, whereas O’Connor procedures were reserved for high, fibrotic, or recurrent lesions. This supports the long-held principle that the route should be dictated by fistula characteristics rather than surgeon preference. The O’Connor approach, first standardized in 1957, remains the gold standard for supratrigonal or complex lesions. Meticulous dissection, multilayered closure, and omental interposition provide excellent vascularity and long-term durability [30]. Our series’ 85.7 % success for this method is within reported ranges (83–92 %). Laparoscopic and robotic O’Connor repairs now replicate these outcomes with less morbidity [80, 81]; the single laparoscopic case in this cohort had complete closure, reflecting feasibility where expertise exists. Vaginal flap repair, pioneered by Latzko and Martius, continues to yield the highest success in low obstetric fistulae [31]. The 100 % closure rate in our study mirrors the 96–100 % success reported by Hancock and Browning (2009) and Thakar (2021) [32]. Use of Martius fat pad in recurrent or irradiated cases enhanced vascularity and healing. The ability to perform these repairs under regional anesthesia makes the approach especially valuable in resource-limited settings. The observation that radiotherapy-induced fistulae had only 66.7 % healing corroborates prior evidence that ischemic, fibrotic tissue has limited reparative potential [31]. Such cases often require tissue interposition (omentum or muscle flap) and delayed repair after resolution of mucosal necrosis. Likewise, hysterectomy-related fistulae showed marginally lower success (85.7 %), likely due to devascularized bladder base and difficult surgical planes. Post-operative complications were minimal. The 26.7 % incidence of urinary tract infection (UTI) is similar to Yadav et al. (2019) (28 %) and Kapoor et al. (2022) (25 %) [25]. These infections were managed conservatively and did not significantly affect success. The absence of wound dehiscence or peritonitis underscores meticulous technique and antibiotic prophylaxis. Early ambulation and hydration, emphasized in the present protocol, contributed to smooth recovery. Functional outcomes deserve emphasis. Continence at six months reached 93.3 %, closely matching Dandolu et al. (2020) and Thakar et al. (2021) [26]. Lower urinary tract symptoms (LUTS) were transient, seen in 20 %, reflecting detrusor instability after prolonged catheter drainage. Restoration of sexual activity in 76.7 % parallels Kapoor et al. (2022) (72 %), affirming that modern reconstructive techniques not only close the fistula but also preserve or restore vaginal dimensions and function [25]. From a public-health perspective, the persistence of obstetric fistulae—despite institutional deliveries promoted under national schemes—reveals continuing gaps in the quality of intrapartum care. Timely cesarean section, skilled birth attendance, and availability of obstetric blood transfusion remain inconsistent across districts. The coexistence of iatrogenic injuries further highlights the need for perioperative urologic awareness among gynecologic surgeons. Routine intra-operative cystoscopy following difficult hysterectomy or cesarean section could identify and immediately repair most small bladder or ureteric perforations [30]. This study also demonstrates the value of a multidisciplinary team—urologists, gynecologists, anesthetists, and physiotherapists—in optimizing outcomes. Standardization of repair protocols, adherence to timing (generally 3 months after injury), and structured follow-up ensure both anatomical and functional success. Comparing our institutional outcomes with international benchmarks reveals parity in results despite resource constraints. Thakar et al. (2021) reported 94 % closure, Li et al. (2021) 95 %, and Waaldijk (2004) 92 %; our 93.3 % lies squarely within this range [25,27,29]. This supports the principle that excellent outcomes depend more on surgical precision and tissue handling than on high-technology facilities. However, challenges remain. Many patients presented late—often months after initial insult—because of stigma, financial barriers, or lack of awareness. Such delays increase inflammation, fibrosis, and scarring, making surgery technically difficult. Public-health messaging emphasizing that fistula is treatable and curable must therefore accompany obstetric reforms. Long-term follow-up is essential. Although six-month outcomes are reassuring, late recurrence from suture line breakdown or infection can occur up to two years post-repair [30]. Continued surveillance also allows evaluation of bladder capacity, compliance, and sexual rehabilitation. Psychosocial support groups have proven beneficial in reintegration and prevention of marital separation [31]. The limitations of this study include its single-centre design, modest sample size, and relatively short follow-up. Larger multicentric registries could better delineate predictors of success and refine management algorithms for complex or recurrent fistulae. Nevertheless, the homogeneity of protocol and prospective data collection strengthen its validity. In conclusion, the present series underscores that urogynecologic fistula remains a preventable tragedy in the twenty-first century. The coexistence of obstetric and iatrogenic causes in equal measure reflects an evolving healthcare landscape. With proper obstetric vigilance, perioperative urologic training, and adherence to standardized surgical principles, closure and continence rates exceeding 90 % are achievable even in resource-limited environments. The emphasis must now shift from repair to prevention through safe surgery and safe motherhood, translating these institutional successes into population-level elimination of fistula.

Urogynecologic fistula remains a preventable yet persistent cause of morbidity among women in India. Despite growing institutional deliveries, obstructed labor continues to contribute substantially, while iatrogenic injuries following cesarean section and hysterectomy are emerging as important etiologies. This dual burden underscores that both obstetric and surgical safety need strengthening. In the present series, the overall closure and continence rate of 93.3 % demonstrates that meticulous technique and appropriate selection of surgical route yield excellent results. The O’Connor transabdominal repair continues to be the standard for supratrigonal and complex lesions, whereas vaginal flap repair offers equally reliable outcomes for low, accessible fistulae. High success rates with minimal morbidity confirm that established procedures, when performed by trained teams, remain effective even in resource-limited centres. Prevention must now take precedence through skilled intrapartum care, timely recognition of bladder and ureteric injuries, and routine intra-operative cystoscopy during difficult gynecologic and obstetric surgeries. Early referral, dedicated fistula services, and psychosocial rehabilitation are crucial to comprehensive management. With coordinated public-health measures and sustained surgical training, elimination of obstetric and iatrogenic fistula as a public-health problem is an achievable goal.

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