Application of Small Intestinal Submucosa Graft for Repair of Complicated Vesicovaginal Fistula: A Pilot Study Yasser A. Farahat, Mohamed A. Elbendary, Osama M. Elgamal, Ahmad M. Tawfik,* Mohamed G. Bastawisy, Mohamed H. Radwan and Mohamed Rasheed From the Urology Department, Tanta University, Tanta, Egypt Purpose: Vesicovaginal fistula is a socially debilitating problem with important psychological and medicolegal implications. Complicated fistulas include large fistu- las or those with failed prior repair attempts. The key to successful closure of such fistulas is the use of adjuncts such as a Martius, peritoneal or omental flap. Small intestinal submucosa is an acellular collagen matrix graft that is nonimmunogenic, biodegradable and ready to use off the shelf. We evaluated small intestinal submu- cosa as an interposition patch during complicated vesicovaginal fistula repair. Materials and Methods: A total of 23 women with a mean age of 33.5 years who had a complicated vesicovaginal fistula were enrolled in this clinical trial. Com- plicating factors were failed primary repair in 9 cases, excessive perifistulous scarring in 4 patients and a fistula 1.5 cm or greater in the remainder. Trans- vaginal repair was done in 7 low fistula cases and transabdominal repair was done in the remainder with a high fistula. A small intestinal submucosa patch was interposed in all cases at classic abdominal or vaginal repair. All patients were evaluated 1, 3 and 6 months postoperatively. Results: All patients who underwent vaginal repair were dry during followup. Of the 16 women who underwent transabdominal repair 14 were dry. The overall success rate was 91.3%. No reported allergic or inflammatory reactions were documented. Conclusions: Using small intestinal submucosa as an interposition layer at anatomical vaginal and/or transabdominal repair of complicated vesicovaginal fistulas seems to be a simple, feasible solution. Key Words: urinary bladder, vagina, urinary fistula, surgical flaps, reconstructive surgical procedures Abbreviations and Acronyms LUTS = lower urinary tract symptoms SIS = small intestinal submucosa VVF = vesicovaginal fistula Submitted for publication January 5, 2012. Study received institutional review board ap- proval. * Correspondence: Urology Department, Faculty of Medicine, Tanta University, Tanta, Egypt (tele- phone: 00201144201075; FAX: 0020403312645; e-mail: dr_ahmad_tawfik@yahoo.com). VESICOVAGINAL fistula is one of the old- est recognized human diseases. 1 The associated psychological and urologi- cal problems of such fistulas together with their socioeconomic impacts make this condition a major health problem, especially in the developing world. It was estimated that as many as 3.5 mil- lion women might have this condition in Africa alone. 2 In rural areas of developing countries VVFs are common sequelae of obstructed labor. Other causes include surgical trauma during hysterectomy, pelvic ma- lignancy, infectious process, inflamma- tory disease and congenital conditions. 3 Except in a few cases surgical clo- sure of the fistula is the only solution. 4 The abdominal approach has tradition- ally been used for supratrigonal fistulas while the vaginal approach is usually used for infratrigonal, bladder neck and proximal urethral fistulas. 5 Factors that could affect the outcome of surgical cor- 0022-5347/12/1883-0861/0 http://dx.doi.org/10.1016/j.juro.2012.05.019 THE JOURNAL OF UROLOGY ® Vol. 188, 861-864, September 2012 © 2012 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH,INC. Printed in U.S.A. www.jurology.com 861