Vesicouretherovaginal fistula with distal ventral urethral loss following obstructed labour is a rare and severe complication causing continuous urinary incontinence with profound impact on quality of life. The partial loss of the ventral urethra, in combination with a bladder neck fistulous tract, presents a technically demanding reconstructive challenge distinct from complete urethral loss. Surgical management is particularly complex in the salvage setting owing to fibrosis and poor tissue vascularity from prior interventions. We describe the technique and outcome of transvaginal reconstruction performed in the prone position, comprising bladder neck reconstruction, urethral tubularisation, and Martius labial fat pad interposition in this complex salvage case.

A 23-year-old woman presented with continuous urinary leakage persisting for two years following obstructed vaginal delivery. She had undergone primary bladder repair and a subsequent transvaginal fistula repair at another institution, both without resolution of symptoms. Clinical examination demonstrated a 2×1 cm anterior vaginal wall defect situated 2 cm from the introitus with pooling of urine and partial urethral loss on ventral aspect . Pelvic floor muscle contractility was preserved on assessment. CT urography identified contrast extravasation into the vagina at the level of the bladder neck. Cystovaginoscopy confirmed partial ventral urethral loss with a vesicouretherovaginal fistulous tract at the bladder neck; bilateral ureteric orifices were intact and normally positioned. Ethical approval was obtained, and written informed consent was provided by the patient prior to surgery.
Surgery was performed in the prone position. The operative technique comprised five steps, all video-recorded and presented with narration: (1) prone positioning and draping with urethral and ureteric catheter placement; (2) excision of the residual scarred ventral urethral tissue to healthy tissue margins; (3) development of a plane in the anterior vaginal wall with mobilisation and debridement of the fistula margins; (4) precise bladder neck reconstruction with layered closure to restore the continence mechanism; and (5) urethral tubularisation over a urethral catheter using healthy local tissue, followed by Martius labial fat pad flap interposition and layered vaginal wall closure.

Surgery was completed successfully. Layered closure was performed meticulously with Martius fat pad interposition providing vascularised tissue reinforcement at the repair site. The postoperative course was uneventful with no immediate complications. On follow-up assessment, the patient demonstrated urinary continence with satisfactory voluntary voiding and no clinical or radiological evidence of residual or recurrent fistula. Patient-reported quality of life showed marked improvement compared with the preoperative state.

Transvaginal reconstruction of vesicouretherovaginal fistula with distal ventral urethral loss is a viable and effective salvage procedure, achievable in the prone position even following multiple failed prior repairs. The key technical principles include complete excision of the residual scarred ventral urethra before repair, careful development of the anterior vaginal wall plane, precise bladder neck reconstruction, urethral tubularisation over a catheter to ensure lumen patency, and Martius labial fat pad interposition to provide well-vascularised tissue reinforcement and reduce ischaemic breakdown. Careful patient selection and thorough preoperative imaging are essential for optimal functional outcomes. The video demonstrates this step-by-step operative approach as a reproducible technique for this rare and technically demanding condition.

Continence 19S (2026) 102603
DOI: 10.1016/j.cont.2026.102603