Vesico-vaginal fistula (VVF) is a rare cause of urinary incontinence. Its main etiology in developed countries is iatrogenic (mainly urogynecological surgery or radiotherapy). Pelvic radiation for cervical cancer is the main cause of radiation-induced VVFs. The repair of this type of injuries is extremely complex, requiring frequently multiple procedures.

A 32 year-old female patient who underwent combined pelvic radiotheraphy (external beam plus brachytherapy) due to cervical cancer develops continuous urinary leakage one year after treatment. Physical examination revealed a big yuxtacervical VVF, thus biopsy was performed to rule out recurrence/malignance. 
During the preoperative study, we performed a cystoscopy showing a 4-5 cm supratrigonal vesico-vaginal fistula. In addition, for the evaluation of the upper urinary tract, MRI and CT-Urogramm were performed ruling out upper urinary tract involvement (present between 4-10% of cases).

The fistula was periodically assessed, and repair was performed after 8 months since the fistula appeared. We show the operative steps of the classic transabdominal-transvesical  O'Connor technique, with the addition of omental flap to provide interposition tissue between suture lines as well as additional vascularization. 
Surgical time was 225 minutes, with no intraoperative complications. Bleeding less than 100 cc. Drainage is removed 2 days after surgery. The patient was discharged on postoperative day 5, requiring re-admission 2 weeks after surgery because of  a febrile urinary tract infection so after broad spectrum antibiotic coverage we proceeded to remove ureteral stents and urethral catheter. Four weeks after surgery cystography revealed successfully fistula closure, then suprapubic catheter was removed.
The patient is currently dry, with slightly increased micturition frequency (10-12/day and 1-3/night).

Radiation induced VVF is one of the most challenging problems in female reconstructive urology. Poor tissue vascularity due to radiation obliterative endarteritis and fibrosis make surgical repair extremely difficult, with success rates in the first attempt around 50% even in high volume centers.  
Classic transabdominal-transvesical repair with the addition of omental flap remains a viable option for this complex patients.

Pushkar DY, Dyakov VV, Kasyan GR. Management of radiationinduced vesicovaginal fistula. Eur Urol 2009; 55: 131–7.
Turner-Warwick R, Chapple C eds. Functional Reconstruction of the Urinary Tract and Gynaeco-Urology. Oxford: Blackwell Science, 2002