Ureterovaginal Fistula Research Articles

This study retrospectively reviewed genitourinary fistula (GUF) cases repaired at a leading tertiary care center in northern India, analyzing surgical outcomes. The study was conducted in the Department of Urology at King George's Medical University, Lucknow, from 2000 to 2024. This study obtained ethical approval from the institutional committee. Data were collected from hospital records, telephonic communication, and digital media. Obstetric and gynecologic histories, examination findings, cystoscopy, vaginoscopy results (including site, size, number of fistulae, and vaginal status), and imaging findings were documented. Operative details of open transabdominal (TA), transvaginal (TV), and laparoscopic repairs, along with surgical success rate and follow-up, were analyzed. A total of 638 GUF cases were repaired over a 25-year period. Vesicovaginal fistula (VVF) was the most common (572 cases, 89.65%), followed by ureterovaginal fistula (44 cases, 46 units, 6.89%), and urethrovaginal fistula (UVF) (12 cases, 1.88%). Hysterectomy was the leading cause (431 cases), followed by obstetric causes (175 cases), traumatic (12), radiation (5), and other causes (15). Surgical techniques included open TA (309 cases), TV (213), and laparoscopic repairs (116). The surgical success rate (cure of urinary incontinence with complete restoration of bladder and vaginal functions at 3 months) following first repairs was 93.95% (TA), 94.24% (TV), and 96.55% (laparoscopic). The surgical success rate following the second repair at 3 months was 82.05% (TA) and 82.75% (TV). No repeat laparoscopic repairs were performed. The overall success rates (combined first and second repair) were 95.78% (TA) and 95.77% (TV). The overall mean follow-up was 48 months (ranging from 3 to 120 months). Over 25 years, our single-center experience reveals a shift from obstetric to gynecologic causes of genitourinary fistulas, with hysterectomy emerging as the leading etiology. Surgical repairs via TA, TV, and laparoscopic approaches showed high success rates. A clear trend toward minimally invasive techniques was observed, reflecting advancements in surgical practice.

Barbed Suture Causing Ureterovaginal Fistula Postconservative Surgery for Deep Infiltrating Endometriosis

To synthesize the current literature regarding the evaluation and management of genitourinary fistula in women. Genitourinary fistula are aberrant communications between the urinary tract and genital tract that present with urinary leakage per the vagina. Initial management often involves conservative measures, such as urethral catheter or ureteral stent placement, progressing to surgical repair when needed. Key surgical principles include a tension-free, watertight closure with well-vascularized tissue including tissue interposition as appropriate, and postoperative urinary drainage. When surgical management of vesicovaginal fistula is necessary, a transvaginal repair is the most common. Other minimally invasive approaches are increasing and result in similarly high success rates with lower patient morbidity compared to open abdominal surgeries. The initial management of ureterovaginal fistula commonly includes ureteral stent placement. When not feasible or in persistent fistula, laparoscopic and robotic surgical repair with ureteral reconstruction offers high success rates with lower morbidity than an open approach. Successful management of genitourinary fistula ranges from conservative urinary tract drainage to surgical interventions based on etiology, location, and complexity. Approaches to repair are shifting toward less invasive procedures. With optimal technique and surgical planning, high success rates can be achieved, particularly in primary repairs.

Cervical fibroids (CFs) grow in the narrowest part of the uterus, which is adjacent to the ureter, uterine vessels and their branches. The ureter is at risk of being divided, thermally injured, and/or misligated when handling the vessels during total laparoscopic hysterectomy (TLH) to treat CFs We present a series of videos to detail the methods and skills required to perform blunt ureterolysis and handle the uterine vessels during TLH for CFs. This video contains three cases of CFs that underwent TLH. In Case 1, the surgeon did not separate the ureter in advance and mistook the ureter for a vessel during coagulating the vessels with bipolar forceps, which resulted in thermal injury to the ureter. Therefore, a ureteral stent was placed under cystoscopy, which was removed three months after the operation. In both Cases 2, 3, the surgeon used a curved vascular clamp to bluntly separate and fully expose the pelvic part of the ureter and then coagulated and divided the vessels. The separation started when the ureter traced the base of the posterior lobe of the broad ligament until it entered below the uterine artery. The uterine artery dissection site differed in Cases 2 and 3, with Case 2 being at the origin of the internal iliac artery and Case 3 in an area close to the CF, depending on the space between the CF and uterine artery. After six months of follow-up, all three patients were free of pyelonephrosis and ureteral dilatation, and no ureterovaginal fistulae occurred. Blunt ureterolysis procedure can effectively avoid ureter injury in TLH for CFs.

Trends and Outcomes of Ureteral and Bladder Injury Intraoperatively Repaired During Open and Minimally Invasive Hysterectomy From 2013 to 2023: A National Matched Cohort Study.

Allium stents are widely used in patients with ureteral stricture, with ongoing research continuously evaluating their clinical safety and efficacy. This study aimed to describe our technique and report the outcomes of Allium stent in the treatment of refractory ureteral strictures. We retrospectively collected perioperative data on all patients treated with Allium stents in our department between January 2017 and April 2024 and assessed their clinical outcomes. Following ureteroscopy, a guidewire was advanced under fluoroscopic guidance into the renal pelvis. The retrograde ureterography was performed to determine the location and length of the ureteral stricture. Dilation was performed using a ureteral balloon dilator, a flexible ureteroscope sheath, or a rigid ureteroscope. Subsequently, the Allium stent was deployed into the stricture segment and confirmed via fluoroscopic imaging. A total of 23 patients (25 ureters) were included, with a mean age of 57.7years (32-76 years). The mean length of ureteral strictures was 4.5cm (range: 1-18 cm). All stents were successfully positioned. As of December 2024, the stent patency rate was 68%, with a median follow-up of 39.5months (13-67 months). In eight patency failure cases, the mean indwelling time was 14 months, with the shortest recorded duration being 2months. Causes of failure included four (50%) stent migration, one (12.5%) encrustation, two (25%) persistent stenosis and severe infection (12.5%). Management strategies for these cases included two (25%) stent removal, two (25%) robot-assisted pyeloureteroplasty, one (12.5%) ureterolithotripsy, one (12.5%) exchange with a new Allium stent, one (12.5%) add new Allium stent, and one (12.5%) replacement with a different type of metal stent. Notably, one case of a ruptured ureter was successfully bridged with an Allium stent, and another case of a uretero-vaginal fistula was effectively treated with Allium stent, both without complications. Allium stents appear to be a feasible and effective treatment for various ureteral strictures, including cases of ureteral perforation and rupture. However, long-term complications such as stent migration and occlusion remain challenges that should not be overlooked.

Background: Most ureterovaginal fistulas (UVFs) are caused by gynecologic, urologic, or colorectal surgeries. Urine leaks, renal failure, and infections lower patients' quality of life. Minimally invasive endoscopic double-J (DJ) stenting has become popular. There is insufficient research on the effects of DJ stenting on fistula size, diagnostic timeliness, and patient comorbidities.Objective and methods: This study examines the efficacy of endoscopic DJ stent implantation in treating UVFs and addresses aspects such as fistula size, diagnosis timing, and comorbidities. This is a five-year retrospective study (2019 to 2024) conducted in Bhopal, India, comprising 31 patients with UVF who received endoscopic DJ stenting as the main treatment. Analyses included patient demographics, clinical presentation, fistula features, treatment outcomes, and complications. Statistical analysis includes chi-square tests for categorical variables and logistic regression for risk factor assessment, with a p-value < 0.05 considered significant.Results: DJ stenting showed a success rate of 77.4% (24/31 cases), with higher rates for early diagnosis (<4 weeks) and small fistula size (<5 mm) (p=0.038 and 0.032, respectively). Late diagnosis (>4 weeks), large fistula size (>5 mm), diabetes, and elevated creatinine (>1.2 mg/dL) were independent predictors of treatment failure in multivariate analysis. Minor issues included dysuria (16.1%, n=5) and hematuria (9.7%, n=3). One patient (3.2%) needed surgery due to a forgotten DJ stent.Conclusion: If the UVF is minor and detected early, endoscopic DJ stenting can work. Renal failure, diabetes, larger fistulas, and delayed diagnosis reduce treatment success. Early prognostic identification and patient selection are crucial to maximize results and minimize surgery.

Postoperative Urinary Complications in Minimally Invasive Versus Abdominal Radical Hysterectomy: A Meta-Analysis With a Focus on Ureterovaginal Fistula.

Objective: The study aims to determine the characteristics of ureterovaginal fistula patients at Hasan Sadikin Hospital in Bandung for the 2017-2021 period. Material &amp; Methods: This research was conducted using a descriptive method with a cross-sectional approach. The inclusion criteria in this study were all patients who experienced ureterovaginal fistula and underwent surgery at Hasan Sadikin Hospital. Exclusion criteria in this study were incomplete patient data until the variables studied did not exist. Results: From a total of 35 people who experienced ureterovaginal fistula the most in 2020 were 7 people (23.3%). The mean age was 39.93 ± 11.26 years, the longest distance to surgery was 10.17 ± 9.56 months, and duration of hospitalization 7.31 ± 5.45 days. The highest percentage of age who experienced ureterovaginal fistula was 36-45 years as many as 3 people (30%). Based on the etiology, the most common was supravaginal hysterectomy as many as 5 people (45.5%). The most frequently performed procedure in this study was ureteroneocystostomy with a percentage of 65%. Conclusion: The most common cases of ureterovaginal fistula in 2017 to 2021 were in 2020, the most common age for experiencing ureterovaginal fistula was 36-45 years of age and the most common etiology was supravaginal hysterectomy. Keywords: Ureterovaginal fistula, characteristics, Hasan Sadikin Hospital

Analysis of technical improvements and efficacy of modified laparoscopic ureteral bladder reimplantation for the treatment of ureterovaginal fistula. A retrospective analysis was conducted on clinical data from 20 patients who developed a ureterovaginal fistula due to gynecological surgeries and underwent modified laparoscopic ureteral bladder reimplantation at our hospital from September 2018 to May 2024. 20 patients with ureterovaginal fistula were included, with 9 cases on the left side, 9 on the right side, and 2 bilateral. The locations of the ureterovaginal fistulas were all in the distal ureter. The average age was 50.24 ± 5.22years, and the average body mass index was 23.22 ± 3.98. The average duration of urine leakage before surgery was 12.20 ± 7.05days. All surgeries were successful (20/20), with an average operation time of 140.85 ± 55.80min, intraoperative blood loss of 14.50 ± 7.42ml, and postoperative hospital stay of 8.24 ± 4.47days. The ureteral stents were left in place for a mean duration of (51.50 ± 9.65) days postoperatively. No complications occurred after the surgery, and imaging follow-up at 9months indicated that all patients had recovered well. Early diagnosis and treatment are essential for patients with ureterovaginal fistula. During the modified ureteral bladder reimplantation, it is crucial to ensure tension-free anastomosis without excessive dissection of the distal ureter. Laparoscopic ureteral bladder reimplantation is a reliable, safe, minimally invasive, and well-accepted surgical method, deserving of further promotion.

Robotic-assisted ureteric reimplantation in the setting of post-surgical ureterovaginal fistula, remains challenging due to difficulties in ureteric identification in the absence of tactile feedback. Indocyanine green (ICG) is a water-soluble dye that can be identified using near infra-red fluorescence (NIRF). We describe our experience with the intraureteral instillation of ICG for identifying the ureter under NIRF during robotic-assisted ureteric reimplantation in patients with ureterovaginal fistulae. This was a retrospective study of 8 patients who underwent robotic-assisted ureteric reimplantation after a diagnosis of ureterovaginal fistula following pelvic surgery between November 2022 and November 2023. Informed consent was obtained from all patients for the off-label use of ICG. All patients underwent regular follow-up postoperatively for a mean period of 12 ± 1.44 months, with none having developed any clinical or radiological signs of failed repair. Thus, the intraureteral instillation of ICG allows precise localisation of the ureter, facilitating accurate dissection, which in turn helps reduce perioperative morbidity.

ABSTRACT Background: Genitourinary fistula is an embarrassing condition to women. Various routes of surgical intervention exist with regards to the management of vesicovaginal fistula (VVF). Laparoscopic repair has been shown to be an efficient surgical modality. Objectives: To review the success rate of laparoscopic repair of VVF and to highlight the benefits/advantages of the laparoscopic approach. Materials and Methods: Using various databases, previous studies of patients who underwent laparoscopic VVF and ureterovaginal fistulae (UVF) repair between 2017 and 2023 were reviewed. Outcome measures from these studies were success rate, mean blood loss, mean operating time, length of hospital stay, major intraoperative complications and conversion to open surgery. Results and Discussion: A total of 35 patients underwent laparoscopic repair of urogenital fistula (UGF) during this period. 20 out of 35 patients were operated for VVF whereas 13 had UVF and two patients had both VVF and UVF. The commonest cause for the patients with VVF was post-hysterectomy (15/20) and with UVF in our series was hysterectomy (9/15) followed by lower segment caesarean section (LSCS) for birth (6/15). The main symptom in all patients presenting to us with UGF was continuous leakage of urine per vaginum. The average duration of symptoms from the previous surgery was 7 days (range, 5–30) in VVF patients while it was 20 days (range, 15–35) for UVF patients. The mean size of the fistula in VVF patients was 1.4 mm (range, 1.2–2 mm). The average duration of symptoms from the previous surgery was 7 days (range, 5–30) in VVF patients while it was 20 days (range, 15–35) for UVF patients, mean blood loss was 75 mL in VVF and 60 mL in UVF, length of hospital stay was 5.1 in VVF and 4.5 days in UVF 1.1–7.8 days while the mean operating time was 160 min in VVF and 140 min in UVF. There were no serious intra-operative or post-operative complications in the patients operated by us. Conclusion: Laparoscopic repair of UGF is an excellent and a lesser morbid alternative to traditional open repair. Optimal and successful surgical cure of UGF alleviates the patients from severe distress and morbidity.

IntroductionA 57-year-old patient was referred to our tertiary referral urogynecology unit due to persistent and profuse vaginal discharge 1 year after undergoing laparoscopic sacrocolpopexy with subtotal hysterectomy for apical prolapse. During clinical examination, abundant yellowish discharge from the cervix was observed. Creatinine testing and Uro-CT excluded vesicovaginal or ureterovaginal fistulas and large abscesses. However, owing to suspected infection and the patient’s poor quality of life, a decision was made to proceed with laparoscopic revision.Results and MethodsIntraoperatively, transcervical injection of ICG (indocyanine green) successfully illuminated a hidden retroperitoneal sinus and a low-volume abscess extending to the sacral promontory. Therefore, the previously installed mesh and the cervix were removed in a challenging but complication-free procedure. The patient was followed up after 3 months, remaining asymptomatic and satisfied with the outcome.ConclusionsManaging complications following laparoscopic sacrocolpopexy requires thorough clinical and instrumental evaluation. In this case, the strategic use of ICG injection proved to be an innovative approach to visualizing hidden complications, offering valuable insights for handling complex scenarios.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00192-025-06148-4.

Injuries to the urinary tract are a frequent occurrence during gynecological procedures, particularly laparoscopic hysterectomy, with acute and chronic complications being reported. Urinary tract injuries occur in about 0.73% of laparoscopic hysterectomies, similar to abdominal hysterectomy rates. These injuries can lead to significant complications, including the formation of vesicovaginal (3.4%) and ureterovaginal (2.4%) fistulas, often requiring additional surgery. Bladder injuries are more prevalent than ureteral injuries. Bladder injury rates range from 0.5% to 0.66%, with Ureteral injuries ranging from 0.02%-0.4%. Thermal bladder injuries can occur due to the use of electrosurgery near the bladder. The spread of electrothermal injuries is greater than the initial area of blanching, creating a significant area of necrosis. Consequently, intraoperative detection of such injuries is challenging and the depth of injury is difficult to assess even if detected. This case report describes a 34-year-old woman who experienced a thermal bladder laceration during a laparoscopic supracervical hysterectomy with sacrocolpopexy for a symptomatic grade II lateral cystocele, grade I uterine descensus and adenomyosis. Two weeks after the operation, the patient presented with bladder pain of varying intensity. After ruling out a urinary tract infection, a cystoscopy was performed which revealed a 1 cm thermal injury to the posterior wall of the bladder. Conservative treatment with NSAIDs was recommended as well as subsequent cystoscopy. At the 4-week follow-up, complete resolution was observed with no further evidence of injury. To our knowledge, there are no similar cases in the literature which were successfully treated without any surgical intervention. However, there are studies that recommend debridement prior to repairing all thermal bladder injuries, regardless of their size. This case highlights firstly the importance of caution when using electrosurgery and provides successful conservative management of iatrogenic thermal injury.

Background Ureterovaginal fistulae usually follow iatrogenic injury to the ureter during pelvic surgery. This manifests as urine incontinence and results in serious psychosocial effects on women. Ureterovaginal fistulae unlike vesicovaginal fistulae present challenges in diagnosis and management especially in resource-constrained settings. Objective The objective of this study is to describe the magnitude, etiology, diagnosis, management, and outcomes of iatrogenic ureterovaginal fistula in Uganda over a 12-year period. Methods A retrospective review of charts for women who had fistula repair at four fistula repair centers in Uganda from 2010 to 2021 was conducted. The diagnosis of ureterovaginal fistula was made clinically using a history of leakage of urine through the vagina following a pelvic surgery, a negative methylene blue dye test, and a three-swab test. All women were managed using open transvesical ureteral reimplantation with or without a Boari flap. The outcome of surgery was successful fistula repair with urine continence and was determined at two months post-surgery. Results Overall, 477 women were managed for genitourinary fistulae during the study period. Approximately one in every 10 women with genitourinary fistula had an iatrogenic ureterovaginal fistula (n=47, 9.8%). The mean age of women with ureterovaginal fistula was 31.9(SD: ±11.8) years. The majority of ureterovaginal fistulae (n=33, 70.7%) followed cesarean sections done at general hospitals (n=22, 46.8%) by medical officers (n=32, 68.1%). Clinical assessment was accurate in diagnosing ureterovaginal fistula. Successful fistula repair was achieved in 45 (95.7%) cases. Conclusion Iatrogenic ureterovaginal fistulae are common in Uganda, and most follow cesarean section performed at lower-level health facilities by medical officers. In resource-limited settings where advanced diagnostic techniques are not available or not affordable, simple stepwise clinical evaluation is effective in making a diagnosis. Open ureteral reimplantation with or without a Boari flap has a high successful repair rate.

Objective. The purpose of this systematic review is to analyze the results of the use of new Versius robotic surgical system in clinical practice. Material and methods. As part of this study, articles were searched in the Elibrary, MEDLINE, PubMed, Scopus databases. Possible search terms were used: «robotic surgery», «Versius», «robot Versius», «visceral surgery», «gynecology», «colorectal surgery», «urology», «thoracoscopy». Reviewed Peer-reviewed studies from around the world were reviewed. Our study found no published articles in languages other than English. Studies published in English were analyzed using the Versius system in colorectal, visceral, urological, thoracic and gynecological surgery. 46 articles were recorded in the databases, of which 16 established requirements are met. Results from the Versius robot were obtained, which revealed: patient demographics (age and gender), conversion to laparoscopy or open surgery, duration of operation, hospital stay, intraoperative bleeding, postoperative complications, and information on other adverse events, including postoperative mortality. Results. The study examined the parameters of 1064 patients who were involved in surgery using the Versius robot. The mean age of patients included in this review was 50.6 years. The gender ratio (male/female) was 576/433. The average duration of operation was 142.7 minutes. Conversion to laparosacopy or open surgery was mentioned in 5 studies and was recorded in 25 patients (2.3 [1.4; 3.3]%). The average length of stay in the hospital was 4.0 days. Data on postoperative complications occurred in all articles. The total number of complications was 33 (3.1 [2.1; 4.1]%). The most frequently recorded was wound infection in the area of standing robotic ports, which did not require repeated operations. The formation of ureterovaginal fistulas was noted in 2 patients. Postoperative ileus was registered in 2 cases. Other rarer complications have been described, such as, for example, rupture of a tumor capsule (1), leakage of the intestinal anastomosis (1), intestinal rupture (1) and leakage of the cystic duct stump (1). An adverse outcome in terms of mortality was recorded in one trial. Conclusion. Thus, surgical interventions performed using the robot Versius are feasible, effective and safe. These procedures are well tolerated by patients, with follow-up and late follow-up consequences. Obviously, to further evaluate the effectiveness of the Versius robot, it is required to study the long-term results of treatment and the quality of life of patients, performed in the framework of randomized trials.

Background Laparoscopic hysterectomy is a substitute for the abdominal hysterectomy technique for endometrial carcinoma. Goel's technique is a unique laparoscopic hysterectomy. The main feature of Goel's technique is that vaginal manipulators or myoma screws are not used in the procedure as vaginal manipulators or myoma screws contribute to an increased risk of spread of malignancy in the systemic circulation. Methods In this retrospective, observational, pilot, single-centre study, the patient's baseline demographics, clinical characteristics, and assessment and outcome measures of Goel's technique of laparoscopic hysterectomy were recorded. The following metrics were used to assess the postoperative recovery: average time to discharge the patients after the surgery; postoperative complications/pain assessment; correlation between pain and day of hospital discharge; association between the day of discharge and postoperative pain assessment; association between operation time and complications. Results A total of 35 female patients with early-stage endometrial cancer were included, their mean age being 56.29 years. The mean time to hospital discharge of the patients was 2.94 days. Of the cases,2.9% had a ureteral injuryand ureterovaginal fistula as complications, which were resolved during the follow-up period. On day one, the mean pain score decreased significantly to 50% from day zero (D0), and on day two, the mean pain score showed a significant fall of 91.5% from D0. Ten patients with a mean pain assessment score of 3.60 at D0 were released on the second day, 20 patients with a mean score of 3.80 at D0 were released on the second day, and five patients with a mean score of 5.60 at D0 were released at ≥ four days. Not a single patient developed any wound infection, dehiscence, or herniation for six months. Conclusion Goel's technique helped patients with endometrial carcinoma to recover faster and it reduced hospital stays with fewer postoperative complications.

Middle-aged women suffering from vesicovaginal fistula following hysterectomy represent a significant health issue within the community. Accurate diagnosisand appropriate treatment selection are crucial for achieving effective outcomes. Ureterovaginal fistula is a severe condition that poses considerable clinicalchallenges, exacerbated by social and psychological factors. On September 19, 2024, a one-day workshop was conducted in partnership with the Pakistan National Forum on Women’s Health and Muhammad Medical and Dental College, featuring Professor Pushpa Sirichand and her team. The event took place at Muhammad Medical and Dental College in Mirpurkhas and included participants from the Obstetrics and Gynecology department, postgraduate trainees, house officers, and paramedic staff from Muhammad Medical College and Isra University.

Background: Vesicovaginal fistula (VVF) is an abnormal connection between the bladder and vagina, causing urinary incontinence. It often results from surgical injury or malignancy. Interposition flaps, including the omentum flap in trans-abdominal repairs, help close the defect and improve outcomes. Objective: To compare the outcome among patients undergoing vesicovaginal fistula repair through transabdominal approach with and without interposition omental flap. Patients and Methods: A randomized controlled trial was conducted from July 2021 to January 2022 at the Urology Department, Sir Ganga Ram Hospital, involving 44 patients with supratrigonal vesicovaginal fistulas (VVF) ≤2 cm and ≤2 openings. Patients with malignancy, radiotherapy, recurrent or infratrigonal VVF, ureterovaginal fistula, or localized infection were excluded. The experimental group underwent VVF repair with an interposition omental flap, while the control group underwent repair without the flap. SPSS version 24 was used for data analysis. The comparison between groups for proportions of fistulous openings, peri-operative complications and treatment success by chi-square test. P-value of ≤0.05 was considered as significant Results: The experimental group (mean age 36.5 ± 7.4 years) and control group (mean age 39.1 ± 10.1 years) showed similar peri-operative wound infection rates (9.1%). Complications in the experimental group included bleeding (9.1%), bowel perforation (4.5%), and higher fistula recurrence (22.7% vs. 18.2%). Treatment success at 2 weeks was 81.8% with the graft and 90.9% without it. Conclusion: In conclusion, using an interposition graft in VVF repair did not significantly improve success rates or reduce morbidity compared to repairs without a graft.

BackgroundComplex vesico-vaginal fistulae (VVF) pose unique surgical challenges and necessitate the use of interposition tissue to ensure surgical success. Herein, we describe a case of complex VVF with right uretero-vaginal fistula post radical surgery for locally advanced ovarian cancer and chemotherapy in which the rectus abdominis muscle flap was used as the interposition tissue, as the more routine used options such as omentum and peritoneum were removed in the prior radical surgery.Case presentationWe describe a case report of a vesico-vaginal and right uretero-vaginal fistula in a 34-year-old female post ovarian cancer radical surgery managed surgically with the traditional transvesical technique of repair and ureteric reimplantation with a unique interposition with rectus abdominis muscle considering the absence of the more routine options.ConclusionComplex VVFs pose unique surgical challenges and necessitate the use of interposition tissue to ensure surgical success. The inferior pedicle based rectus abdominis muscle flap is an excellent interposition tissue for repairs via the transabdominal approach especially in scenarios where the more routine options are unavailable.