Experiential Narratives of Factors Limiting and Boosting Access to Support Services for Women with Obstetric Fistula in Southeast Nigeria.

PURPOSE: Obstetric fistula is a chronic health condition that leaves affected women battered and traumatized, thereby exposing them to social recluse life as a result of associated discomfort and odor. Support services to those with challenging health conditions are reputed to help cushion the adverse effects on them; thus women with fistula and other chronic diseases receiving adequate support will help them to cope and recuperate from such illnesses. This study explores the factors limiting and boosting access to support services for those with obstetric fistulainNigeria. MATERIALS AND METHOD: Focus Group Discussions and In-depth Interviews were employed to obtain data from 44 participants. The thematic data analysis method was deployed in analyzing the data collected. RESULTS: Factors like the limited number of fistula specialist doctors, poor funding, withdrawal from seeking help, long distance, and discrimination limit patients' access to support services and adequate fistula care. The study highlighted that community involvement in fistula care, adequate funding, training, and retraining of professionals will boost support services for fistula patients. CONCLUSION: The study recommends the adoption of a multidisciplinary approach in the management of obstetric fistula patients including the involvement of not only medical personnel but also social workers, families, groups, and community leaders.

Genitourinary Fistula: epidemiology, changing trends in etiology and management: A tertiary care institute's perspective.

INTRODUCTION: Urogenital fistula is a physically, socially and psychologically devastating condition for the patient. In developed countries, these fistulae are typically related to gynecological surgery, pelvic pathology like malignancy or post radiation therapy. In contrast, classical teaching is that urogenital fistulae in the developing countries like India are usually associated with prolonged labor and obstetric complications. This retrospective study conducted at a tertiary care health Institute shows a paradigm shift in epidemiology, etiology and management of genitourinary fistulae in India in recent times. METHODS: This retrospective study included patients undergoing surgical repair for various genitourinary fistulae at our institute from 2016 to 2022. Epidemiology, etiology, site, size and number of fistulae, clinical presentation, and management records of these patients were recorded and reviewed retrospectively. RESULTS: In our study, the mean age of the patients was 38.4 ± 10.2 years. Vesicovaginal Fistula (VVF) was found to be most common fistula in the study population (87.5%) followed by vesicouterine (7.1%) and urethrovaginal fistula (5.4%). The causes of genitourinary fistula were iatrogenic (73.2%), carcinoma of cervix (16.1%), obstructed prolonged labor (7.1%), and genitourinary tuberculosis (3.57%). Among the 48 vesicovaginal fistulas that underwent surgery, 45.8% were treated using a transvaginal approach, 29.2% were managed through a laparoscopic transabdominal repair, and 25% were addressed using a robotic approach. Recurrence occurred in 7.1% of the operated patients. CONCLUSION: Enhanced healthcare services in the country have contributed to a decrease in the incidence of obstructed labor, subsequently reducing related injuries. Iatrogenic injuries resulting from gynecological surgeries and carcinoma cervix have given rise to more complex fistulas, necessitating the implementation of advanced treatment strategies.

Fístulas rectoneovaginales en pacientes tras cirugía de reasignación de sexo. Descripción de nuestra experiencia y revisión de la literatura / Rectoneovaginal fistula after sex reassignment surgery. Description of our experience and literature review

La cirugía de reasignación de sexo masculino a femenino o vaginoplastia incluye aquellos procedimientos quirúrgicos cuyo objetivo es recrear un perineo femenino funcional y estéticamente aceptable con una formación mínima de cicatrices. La técnica de elección en nuestro centro es la vaginoplastia con inversión peneana con o sin injertos escrotales. Presentamos 4 casos diagnosticados con fístulas rectoneovaginales tratados en nuestro centro con evolución favorable. La primera paciente fue diagnosticada en el postoperatorio tardío durante las dilataciones. Se sometió a 2 intentos de reparación vaginal sin éxito. Finalmente, se realizó una colostomía temporal y un colgajo rectal. La segunda paciente fue diagnosticada 2 semanas después de la cirugía inicial debido a una dilatación agresiva, siendo tratada con una colostomía temporal y cierre por segunda intención. La tercera paciente se diagnostica en el quinto día postoperatorio, después de la extracción del taponamiento vaginal. Se indicó restricción dietética y se realizó un colgajo rectal. Una cuarta paciente fue diagnosticada durante el postoperatorio tardío, realizando una exploración quirúrgica y un colgajo de pared rectal. Las fístulas rectoneovaginales después de la cirugía de reasignación de sexo tienen una incidencia de alrededor del 2-17%, siendo el tipo más común de fístulas después de este procedimiento. La causa más común es secundaria a lesiones rectales durante la cirugía inicial. Para el manejo de estas fístulas se plantean opciones que van desde el cierre primario a las colostomías de descarga, pasando por un manejo conservador o la confección de colgajos. Se recomienda el abordaje por un equipo multidisciplinario para el diagnóstico y tratamiento de esta complicación. (AU)

Male-to-female reassignment surgery or vaginoplasty includes those surgical procedures that aim to recreate a functional and cosmetically acceptable female perineum with minimal scarring. The technique of choice at our center is penile inversion vaginoplasty with or without scrotal skin grafts. We present 4 cases diagnosed with rectoneovaginal fistulas treated at our center with favorable evolution. The first patient was diagnosed in the late postoperative period during dilation. She underwent 2 failed vaginal repair attempts. Finally, a temporary colostomy and a rectal flap were performed. The second patient was diagnosed 2 weeks after the initial surgery due to aggressive dilation and was treated with a temporary colostomy and secondary wound closure. The third patient was diagnosed on the fifth post-operative day after removal of the vaginal packing. Dietary restriction was indicated, and a rectal flap was performed. A fourth patient was diagnosed within the late postoperative period; she was submitted to surgical exploration and a rectal wall flap was created. Rectoneovaginal fistulas after sex reassignment surgery has an incidence of about 2-17% and they are the most common type of fistula after this procedure. In most cases, it is secondary to rectal injury during the initial surgery. The management of these fistulas ranges from primary closure, diverting colostomies, conservative management, or the performance of flaps. A multidisciplinary team approach is recommended for the diagnosis and treatment of this complication. (AU)

Rectoneovaginal fistula after sex reassignment surgery. Description of our experience and literature review. / Fístulas rectoneovaginales en pacientes tras cirugía de reasignación de sexo. Descripción de nuestra experiencia y revisión de la literatura.

Male-to-female reassignment surgery or vaginoplasty includes those surgical procedures that aim to recreate a functional and cosmetically acceptable female perineum with minimal scarring. The technique of choice at our center is penile inversion vaginoplasty with or without scrotal skin grafts. We present 4 cases diagnosed with rectoneovaginal fistulas treated at our center with favorable evolution. The first patient was diagnosed in the late postoperative period during dilation. She underwent 2 failed vaginal repair attempts. Finally, a temporary colostomy and a rectal flap were performed. The second patient was diagnosed 2 weeks after the initial surgery due to aggressive dilation and was treated with a temporary colostomy and secondary wound closure. The third patient was diagnosed on the fifth post-operative day after removal of the vaginal packing. Dietary restriction was indicated, and a rectal flap was performed. A fourth patient was diagnosed within the late postoperative period; she was submitted to surgical exploration and a rectal wall flap was created. Rectoneovaginal fistulas after sex reassignment surgery has an incidence of about 2-17% and they are the most common type of fistula after this procedure. In most cases, it is secondary to rectal injury during the initial surgery. The management of these fistulas ranges from primary closure, diverting colostomies, conservative management, or the performance of flaps. A multidisciplinary team approach is recommended for the diagnosis and treatment of this complication.

Treatment-seeking for vaginal fistula in sub-Saharan Africa.

BACKGROUND: There is dearth of data regarding the treatment-seeking practice of women living with vaginal fistula. The paper describes the health-seeking behaviour of fistula cases in the sub-Saharan Africa (SSA) where the burden of the problem is high. METHODS: The data of 1,317 women who ever experienced fistula-related symptom were extracted from 16 national Demographic and Health Surveys carried out in SSA between 2010 and 2017. The association between treatment-seeking and basic socio-demographic characteristics was analysed via mixed-effects logistic regression and the outputs are provided using adjusted odds ratio (AOR) with 95% confidence intervals (CI). RESULTS: Among all women who had fistula-related symptom, 67.6% encountered the problem soon after delivery, possibly implying obstetric fistula. Fewer identified sexual assault (3.8%) and pelvic surgery (2.7%) as the underlying cause. In 25.8% of the cases clear-cut causes couldn't be ascertained and, excluding these ambiguous causes, 91.2% of the women possibly had obstetric fistula. Among those who ever had any kind of fistula, 60.3% (95% CI: 56.9-63.6%) sought treatment and 28.5% (95% CI: 25.3-31.6%) underwent fistula-repair surgery. The leading reasons for not seeking treatment were: unaware that it can be repaired (21.4%), don't know where to get the treatment (17.4%), economic constraints (11.9%), the fistula healed by itself (11.9%) and feeling of embarrassment (7.9%). The regression analysis indicated, teenagers as compared to adults 35 years or older [AOR = 0.31 (95% CI: 0.20-47)]; and women without formal education compared to women with formal education [AOR = 0.69 (95% CI: 0.51-0.93)], had reduced odds of treatment-seeking. In 25.9% of the women who underwent fistula-repair surgery, complete continence after surgery was not achieved. CONCLUSION: Treatment-seeking for fistula remains low and it should be improved through addressing health-system, psycho-social, economic and awareness barriers.

Approach to Ureterovaginal Fistula: Examining 13 Years of Experience.

OBJECTIVE: We describe the management and outcomes of ureterovaginal fistulas over a 13-year period and present a treatment algorithm. METHODS: We performed a review of ureterovaginal fistula cases between January 2005 and December 2017 at our tertiary academic center. Demographics, diagnostic approaches, and treatment outcomes were assessed. RESULTS: Nineteen cases of ureterovaginal fistula were identified. Fistulas developed after hysterectomy in 18 cases and cesarean delivery in 1 case. Our primary treatment was conservative management with ureteral stenting in 12 and reimplantation in 6 cases. There was 1 case of spontaneous resolution. Ureteral stenting was successful in 11 (92%) of 12 patients. Stents were left in place for an average of 66 days (27-92 days). Complications of stents included pyelonephritis in 2 cases (18%) and stricture in 1 case (9%). Ultimately, conservative management was successful in treating ureterovaginal fistulas in 10 (83%) of 12 cases. The indications for primary ureteral reimplantation were concurrent vesicovaginal fistula in 3 cases, history of ureteral injury with surgical repair during the index surgery in 2 cases, and a 1-year delay in diagnosis in 1 case. A variety of follow-up surveillance methods were used, including tampon tests, computed tomographic urograms, retrograde pyelograms, and MAG-3 Lasix renal scans. CONCLUSIONS: In carefully selected patients, ureteral stenting results in high cure rates for posthysterectomy ureterovaginal fistulas and should be considered first-line therapy. Complicated ureterovaginal fistulas may be best managed by primary ureteral reimplantation.

Delivery through cervicovaginal fistula - literature review and case report.

Less than 10 deliveries via cervicovaginal fistula (CVF) with closed cervical os were reported so far. In the majority of cases, the patients had a history of induced abortions. The CVF was usually recognized due to postpartum hemorrhage. The facilitating role of prostaglandins used for labor induction was supposed. In all cases, the babies remained unaffected by the delivery route. We report a new case of a 37-year-old gravida 2, para 0, with a history of a paracervical tear following a first trimester abortion 11 years ago. The abortion and the laceration were not reported in the current obstetrical documentation. After labor induction using oral misoprostol in the 41 + 5 weeks of pregnancy, the patient delivered a healthy baby through a left-sided CVF, which imposed as bleeding paracervical laceration, 6 cm in diameter, extending to the vaginal fornix in the 3 o'clock position. The cervical os was only 1-1.5 cm dilated and imposed as an inelastic band ("squid ring") in the 9 o'clock position. The laceration was sutured under spinal anesthesia. The patient recovered quickly, and the postpartum hemoglobin drop was 2.8 g/dl. In conclusion, the possibility of CVF should be considered in women with a history of induced abortion.

An intramural uterine fibroid became submucosal in the puerperium - proposed probable mechanism: a case report.

BACKGROUND: Vaginal prolapse of a large uterine fibroid is a rare phenomenon in a woman who delivered vaginally recently, given that this fibroid might have obstructed labor. The author presents a case report of a vaginally prolapsed large pedunculated submucosal uterine myoma in a woman with a recent uncomplicated vaginal delivery. CASE PRESENTATION: A 25-year-old black African woman had four intramural uterine fibroids of diameters 62 to 94 mm diagnosed in April 2013 with standard ultrasound scan. She got pregnant in July 2014. An ultrasound scan done on 31 August 2014 at 10 weeks' gestation identified four intramural uterine fibroids, with sizes varying from 70 to 150 mm. Her pregnancy was well followed up, without any complications. She had an uneventful vaginal delivery on 10 April 2015. During uterine exploration, indicated for retention of parts of fetal membranes, no pedunculated submucosal fibroid was found. On 15 May 2015, she consulted for difficult micturition and partial urinary retention that occurred 2 days ago. A vaginally prolapsed 10 cm uterine fibroid was diagnosed. Forty-eight hours after administration of intravenously administered broad spectrum antibiotics, the myoma was successfully twisted off by means of vaginal route under general anesthesia, which relieved her symptoms. CONCLUSIONS: To the best of our knowledge, this is the first case of vaginally prolapsed large submucosal uterine fibroid in a woman who delivered vaginally recently. The author recommends that women with known large low situated uterine fibroid should be well observed during the postpartum period to diagnose a vaginally prolapsed uterine fibroid early, so as to prevent fibroid superinfection and obstructive complications.

Demand and capacity to integrate pelvic organ prolapse and genital fistula services in low-resource settings.

INTRODUCTION AND HYPOTHESIS: There is a need for expanded access to safe surgical care in low- and middle-income countries (LMICs) as illustrated by the report of the 2015 Lancet Commission on Global Surgery. Packages of closely-related surgical procedures may create platforms of capacity that maximize impact in LMIC. Pelvic organ prolapse (POP) and genital fistula care provide an example. Although POP affects many more women in LMICs than fistula, donor support for fistula treatment in LMICs has been underway for decades, whereas treatment for POP is usually limited to hysterectomy-based surgical treatment, occurring with little to no donor support. This capacity-building discrepancy has resulted in POP care that is often non-adherent to international standards and in non-integration of POP and fistula services, despite clear areas of similarity and overlap. The objective of this study was to assess the feasibility and potential value of integrating POP services at fistula centers. METHODS: Fistula repair sites supported by the Fistula Care Plus project were surveyed on current demand for and capacity to provide POP, in addition to perceptions about integrating POP and fistula repair services. RESULTS: Respondents from 26 hospitals in sub-Saharan Africa and South Asia completed the survey. Most fistula centers (92%) reported demand for POP services, but many cannot meet this demand. Responses indicated a wide variation in assessment and grading practices for POP; approaches to lower urinary tract symptom evaluation; and surgical skills with regard to compartment-based POP, and urinary and rectal incontinence. Fistula surgeons identified integration synergies but also potential conflicts. CONCLUSIONS: Integration of genital fistula and POP services may enhance the quality of POP care while increasing the sustainability of fistula care.

'I stayed with my illness': a grounded theory study of health seeking behaviour and treatment pathways of patients with obstetric fistula in Kenya.

BACKGROUND: Obstetric fistula classic symptoms of faecal and urinary incontinence cause women to live with social stigma, isolation, psychological trauma and lose their source of livelihoods. There is a paucity of studies on the health seeking behaviour trajectories of women with fistula illness although women live with the illness for decades before surgery. We set out to establish the complete picture of women's health seeking behaviour using qualitative research. We sought to answer the question: what patterns of health seeking do women with obstetric fistula display in their quest for healing? METHODS: We used grounded theory methodology to analyse data from narratives of women during inpatient stay after fistula surgery in 3 hospitals in Kenya. Emergent themes contributed to generation of substantive theory and a conceptual framework on the health seeking behaviour of fistula patients. RESULTS: We recruited 121 participants aged 17 to 62 years whose treatment pathways are presented. Participants delayed health seeking, living with fistula illness after their first encounter with unresponsive hospitals. The health seeking trajectory is characterized by long episodes of staying home with illness for decades and consulting multiple actors. Staying with fistula illness entailed health seeking through seven key actions of staying home, trying home remedies, consulting with private health care providers, Non-Governmental organisations, prayer, traditional medicine and formal hospitals and clinics. Long treatment trajectories at hospital resulted from multiple hospital visits and surgeries. Seeking treatment at hospital is the most popular step for most women after recognizing fistula symptoms. CONCLUSIONS: We conclude that the formal health system is not responsive to women's needs during fistula illness. Women suffer an illness with a chronic trajectory and seek alternative forms of care that are not ideally placed to treat fistula illness. The results suggest that a robust health system be provided with expertise and facilities to treat obstetric fistula to shorten women's treatment pathways.

Fístulas recto-vaginales: un reto terapéutico permanente / Rectovaginal fistulas: a permanent therapeutic challenge

Las fístulas recto-vaginales consisten en una comunicación anormal entre recto y vagina; si la comunicación es más baja se denominan ano-vaginales. La etiología más frecuente es el trauma obstétrico, infecciones locales y cirugía ano-rectal. Se realiza una revisión de la literatura hasta Junio de 2016, analizando el concepto y clasificación de las fístulas recto-vaginales en función de localización, tamaño y etiología. Se estudian los procedimientos diagnósticos y opciones terapéuticas, prestando especial atención a las múltiples técnicas quirúrgicas, vías de abordaje y recomendaciones en función de la etiología de la fístula. Un enfoque individualizado de cada caso proporcionará elevados porcentajes de curación (AU)

Rectovaginal fistulae are defined by the presence of an abnormal epithelialized communication between the rectum and the vagina; when they are lower enough and affect the anorectal region are best referred as anovaginal fistulae. The most common causes are obstetric trauma, local infection and ano-rectal surgery. A systematic review of the literature was undertaken until june 2016 analyzing the concept itself and several classifications considering location, size and etiology. Different diagnostic procedures and therapeutic options, specially focused on the great amount of surgical techniques, ways to approach and advices depending on any kind of fistula. A strict, catious, individualized study of each single case will reach high healing rates (AU)

An integrative review on women living with obstetric fistula and after treatment experiences.

AIMS AND OBJECTIVES: To review literature on the experiences of women with obstetric fistula, their lived experiences after treatment; and to provide evidence for future research. BACKGROUND: Obstetric fistula is an injury most commonly resulting from a prolonged labour. Long eradicated in developed countries, obstetric fistula remains a public health issue in sub-Saharan Africa and Asia. This is a highly stigmatised health condition, and an understanding of the women's experience is required to inform holistic approaches for care and prevention. DESIGN: A search of literature was conducted on databases of EBSCO host (Academic Search Premier, MEDLINE, PsychINFO, CINAHL), Web of Science; and websites of international organizations such as Women's Dignity Project and EngenderHealth. Keywords, Inclusion and exclusion criteria were defined and 25 articles published between 2004 to January 2015 were identified. METHODS: An integrative review of 25 articles was carried out. RESULTS: Three broad themes were identified: Challenges of living with fistula; treatment and care experiences; and reintegration experiences of women after fistula repair. CONCLUSIONS: Living with a fistula presents multidimensional consequences affecting women, families and communities. Accessing treatment is difficult and there are no standardised treatment packages. Surgical repairs were variable in their success rate. Some authors claim women resume normal lives irrespective of their continence status, whilst others claim they face discrimination despite being continent thereby hindering reintegration. Quality of life is diminished for those remaining incontinent. Post repair psychosocial support services are beneficial for reintegration, but research on programme benefits is limited. Therefore further research is required to support its benefits; and for policy development to meet care provision for women with fistula. RELEVANCE TO CLINICAL PRACTICE: The review provides insights into avenues of improving care provision and delivery by health professionals and policy makers. It also exposes areas that need further research for quality care provision.

First-in-Human Case Study: Pregnancy in Women With Crohn's Perianal Fistula Treated With Adipose-Derived Stem Cells: A Safety Study.

UNLABELLED: The aim of this study was to determine whether treatment with adipose-derived stem cells (ASCs) had any influence on fertility, course of pregnancy, newborn weight, or physical condition of newborns. We performed a retrospective study of patients with a desire to become pregnant after having received intralesional injection of autologous ASCs for the treatment of perianal or rectovaginal fistula associated with Crohn's disease. We collected data on the resulting pregnancies, deliveries, and newborns of these patients. ASCs were expanded in vitro and characterized according to the international guidelines for cell surface markers (clusters of differentiation) and differentiated to adipocytes, chondrocytes, and osteocytes prior to implantation (except first implant in 2002). We analyzed five young women with Crohn's disease treated with ASCs: one for rectovaginal and perianal fistula, two for rectovaginal fistula only, and two for perianal fistula only. All patients received 2 doses of 20 million and 40 million cells at an interval of 3-4 months. Another patient received 2 doses of 6.6 million and 20 million ASCs with 9 months between each dose. Fertility and pregnancy outcomes were not affected by cell therapy treatment. No signs of treatment-related malformations were observed in the neonates by their respective pediatricians. In the patients studied, cell therapy with ASCs did not affect the course of pregnancy or newborn development. SIGNIFICANCE: Local treatment with mesenchymal stem cells derived from adipose tissue seems not to affect the ability to conceive, the course of pregnancy, pregnancy outcomes, or newborns' health in female patients. This is the first publication about pregnancy outcome in women with perianal fistula and Crohn's disease treated with stem cell therapy, and could be of interest for doctors working in cell therapy. This is a very important question for patients, and there was no answer for them until now.

[Ureterovaginal fistulae]. / Fistole ureterovaginali.

Ureterovaginal fistulae are pathological communications between the ureter and the vagina; it commonly occur as a rare but serious sequela of unrecognized distal ureteral injuries during pelvic operations. Patients may present symptoms as leakage of urine from the vagina, flank pain and fever; in some cases it could be possible also the loss of renal function. The purpose of this study is to review the articles from 1991 to 2014 to evaluate the most correct diagnostic procedures and endourological and surgical techniques used in the management of ureterovaginal fistula. Nowadays computered tomography and retrograde pielography are the most commonly diagnostic modalities used to identify fistulous tract and to describe its anatomical position. The major of ureterovaginal fistulae can be successfully managed by conservative methods. Modern endourological treatment will result in resolution of a ureterovaginal fistula if retrograde or anterograde passage of a suitable internal stent is feasible. When stenting failed or in complicated cases, ureteral reimplantation is necessary. Ureteroneocystostomy, psoas hitch and Boari flap are three different possible surgical techniques used to realized an ureteral reimplantation. Both open and mini invasive (laparoscopy and robot assisted) surgical approach have proved successful.

Treatment of ureterovaginal fistula using a Memokath stent.

Ureterovaginal fistula (UVF) is a challenging problem for patients and doctors, especially in patients who have been treated by radiation for malignancy. UVF may occur in conjunction with surgeries involving the uterus. A success rate of 70-100% has been reported for fistula repair with the best results in non-radiated patients. Meanwhile, conservative treatment using ureteral stents in selected patients has resulted in reported success rates of 71%. We present the case of a 24-year-old woman with UVF due to surgery and radiotherapy for cervix cancer. The patient has been successfully treated with the insertion of a Memokath 051 stent (PNN Medical A/S, Denmark), which is a thermoexpandable, nickel-titanium alloy stent. The patient has been totally continent during a follow-up period of 3 years. The Memokath stent has been changed twice within this period due to dysfunction.

A bill of rights for patients with obstetric fistula.

According to the seven categories of vulnerability proposed by Kipnis (cognitive, juridical, deferential, medical, allocational, social, and infrastructural), and the four generally accepted principles of biomedical ethics (respect, beneficence, non-maleficence, and fairness), women with obstetric fistulas are an exceptionally vulnerable population. Therefore, they merit special consideration in both clinical care and research settings. Adoption of a formal bill of rights for patients with fistula similar to the one proposed in the present report should be encouraged at all facilities where these women are treated. Acknowledgment of their rights would help to improve their care and end the abuses they are exposed to in institutional settings.

Transvaginal repair of recurrent pouch-vaginal fistula.

AIM: Pouch-vaginal fistula is an uncommon but unpleasant complication. The chance of successful repair with various surgical procedures is around 50% and the early promise of collagen button plugs was not followed by good long-term results. We report a series of patients who underwent transvaginal repair of pouch-vaginal fistula after failed collagen plugs accompanied by a video to show the operative technique. METHOD: Patients were identified from a prospectively maintained database. Patient demographics, operation notes, complications and ultimate outcome were recorded. RESULTS: Eleven patients, each of whom had previously undergone an attempt to close the fistula with a collagen button plug, underwent transvaginal repair. Nine (81%) were successful at a median follow-up of 14 (6-56) months. The remaining two patients reported symptomatic improvement. CONCLUSION: Pouch-vaginal fistula can be successfully closed by the transvaginal technique after a failed button plug procedure.