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Transvaginal Latzko Repair (Partial Colpocleisis)

The Latzko repair (Wilhelm Latzko, 1942) is a transvaginal partial colpocleisis for vesicovaginal fistula (VVF). It removes the surrounding vaginal epithelium and imbricates the underlying fibromuscular tissue, without formal fistula-tract excision. Selected series report high closure rates with differing endpoints; continence remains a separate outcome.[1][2][3][4]

For the broader VVF clinical algorithm, see the vesicovaginal fistula clinical page. For conservative and endoscopy-guided alternatives, see Conservative VVF Management and Endoscopic VVF Management.

Principle​

Latzko originally described the technique for post-hysterectomy VVFs at the vaginal cuff. Rather than dissecting the bladder off the vagina and closing each layer separately (multilayer closure), the Latzko denudes vaginal epithelium circumferentially around the fistula and imbricates the surrounding fibromuscular tissue in multiple layers, obliterating the upper vagina over the fistula site. The tract is left in situ and is sealed by apposition of the raw, denuded surfaces.[1][5]

Indications​

  • Post-hysterectomy (vaginal cuff) VVFs. The classic and most common indication; the apex is where the technique sits most naturally.[5][6][2]
  • Small to moderate-sized fistulae that can be visualized and accessed transvaginally.
  • Selected fistulae near the ureteral orifices. Limited dissection may be useful, but identify and protect the ureters.[7]
  • Radiation-induced VVF. Used in 35.7% of cases in one large series (n = 210 radiation VVFs), particularly when ureteral proximity is a concern.[7]
  • Complex or recurrent fistulae. Versatile across concurrent prolapse repair, complex urologic surgery, and the postpartum setting.[5][8]
  • Repeat repairs. Angioli’s review describes repeat vaginal repair after a first vaginal failure as an option, without isolating repeat Latzko outcomes.[3] A third Latzko after two failures has been described in one radiation-associated case with platelet-rich plasma injections and Martius interposition.[9] Reassess tissue quality, anatomy and alternatives before another attempt.[7] EAU 2026 gives a Weak recommendation for an abdominal approach to persistent urogenital fistulas; Angioli's earlier review considers repeat vaginal repair acceptable after a first vaginal failure.[12][3]

Contraindications / poor fit​

  • Fistula too low (mid-vaginal or distal) for adequate apical denuding and imbrication.
  • Ureteral reimplantation required.
  • Bladder augmentation required.
  • Very large fistula preventing tension-free closure.
  • Concurrent abdominal pathology requiring transabdominal access.[1]
  • Particular concern about vaginal shortening in a sexually active patient (see below).

Surgical Technique​

The classic technique and modifications proceed in this order:[5][6]

1. Positioning and exposure​

  • Dorsal lithotomy (high or exaggerated for optimal exposure).
  • Weighted posterior vaginal retractor and lateral retractors.
  • Identify the fistula and pass a small catheter or probe through the tract to confirm location; when a pediatric Foley is used, gentle downward traction can improve exposure of a high fistula.[5]
  • Cystoscopy to assess fistula size, location relative to the ureteral orifices, and to place ureteral stents if needed for protection.

2. Hydrodissection​

  • Hydrodissect the vaginal epithelium from the underlying fascia. The published technique describes local vasopressin; if used, the concentration and dose require an agreed anesthetic or medication protocol rather than an unspecified dilution.
  • Dual purpose: hydrodissection to elevate vaginal epithelium from underlying fascia, plus hemostasis.[5]

3. Circumscribing incision and denuding​

  • Circumferential incision in vaginal epithelium 2–3 cm from the fistula margin.
  • Sharply dissect the vaginal epithelium within this circle off the underlying pubovesical (endopelvic) fascia, leaving a ring of denuded raw fibromuscular tissue around the fistula.
  • The fistula tract is not excised, the defining feature of the Latzko compared with multilayer closure.[1][5]

4. Purse-string closure of the fistula​

  • Place a fine absorbable purse-string suture in the fibromuscular tissue just outside the epithelialized tract.
  • Remove the catheter used to identify the tract as the purse-string is tied, avoiding entrapment; this is distinct from postoperative bladder drainage.[5]

5. Imbrication (layered closure)​

  • Place interrupted imbricating sutures over the purse-string and additional layers appropriate to the available tissue; the described technique uses one to two subsequent imbricating layers. Avoid leaving a channel at the base.
  • Each successive layer imbricates the previous, creating a multilayered tension-free closure.
  • Sutures incorporate anterior and posterior vaginal fibromuscular tissue, bringing the walls together over the fistula site (partial colpocleisis).[5][7]

6. Vaginal epithelial closure​

  • Close the remaining vaginal epithelium over the repair with interrupted or running absorbable sutures.
  • Vaginal pack as needed.[5][6]

7. Catheter​

  • Provide continuous bladder drainage; individualize duration as outlined below.[1][3]

Modified Latzko Techniques​

ModificationDetailOutcome
Apical-VVF modification (Luo & Shen)Includes the firm transverse apical scar in the epithelial incision without catheterizing the fistula; closes perivesical tissue in three to four layers.[17]108/108 final closure (see Outcomes); seven assessed by telephone at mean 40.7 months. The review records fever (n = 6), hematuria (n = 3) and vaginal bleeding (n = 3), with no Clavien–Dindo grade II or higher complications.[2][17]
Modified Latzko with separate pubovesical-fascia closure (Cardenas-Trowers)Mobilizes vaginal mucosa around the fistula, then closes pubovesical fascia and vaginal mucosa as separate layers.Adds a distinct fascial layer to the repair.[6]
Latzko + Martius flap interpositionLabial fat-pad flap interposed between bladder and vaginal walls for additional blood supply and bulk.In one radiation-associated case, a third Latzko with Martius interposition closed the fistula after two failed Latzko repairs and two platelet-rich plasma injections.[9]

Outcomes​

SeriesnFistula typeSuccessFollow-up
Luo & Shen 2019[2]108Apical (after gynecologic surgery)100/108 (92.6%) did not recur after one repair; eight recurred and closed after repeat modified Latzko (108/108 final closure)[17]Mean 40.7 mo (range 12–84); seven assessed by telephone
Mohr 2014[4]60 vaginal Latzko repairsVVF82% continence6 mo
Pushkar 2009[7]210 vaginal repairs, including 75 LatzkoRadiation-induced VVFPrimary repair effective in 101/210; eventual fistula closure in 169/210 in the entire vaginal cohortSeries accumulated over more than 40 years
Angioli 2003 (narrative review)[3]—Non-irradiated VVFHistorical vaginal-route mean 91%; includes different vaginal techniques and case mixesVariable
Kieserman-Shmokler 2019[5]Technique/video reportDiverse selected casesDescribes operative steps; no comparative efficacy estimateVariable

Points from these series:

  • In the radiation study, 48.1% primary and 80.4% final closure refer to all 210 vaginal repairs and not to the 75 Latzko cases.[7]
  • Repeat Latzko repair has been described, including a third attempt with a Martius flap and prior platelet-rich plasma injections in one radiation-associated case.[9]

Advantages and Evidence Limits​

A 2024 systematic review of 46 studies of VVF, urethrovaginal and bladder neck–vaginal fistula repair found that high-quality evidence to guide technique is lacking. Route of surgery (vaginal or abdominal) was determined mainly by surgeon preference and showed no difference in repair success. Interpositional flaps, trimming of fistula edges, fibrin glue and fascial sling did not significantly improve fistula cure. Layered closure and intraoperative antibiotics seemed to improve success, although the data were insufficient.[15]

Latzko avoids formal tract excision and extensive vesicovaginal dissection. In Mohr's nonrandomized comparison, vaginal repair had shorter operations, less blood loss and shorter hospitalization than abdominal repair.[3][4][5]

Protect nearby ureters and assess the final repair; Pushkar et al. describe Latzko upper colpocleisis as preferable when ureteral injury is a concern, without reporting a comparative injury rate.[7]

Disadvantages and Concerns​

Vaginal shortening​

The principal concern. The Latzko is by definition a partial colpocleisis (obliteration of the upper vagina) that shortens the canal. The functional consequence varies; discuss baseline length, scarring and the patient’s sexual goals. A comparative transvaginal versus transabdominal study found significantly improved sexual function among the 64 sexually active patients at 6 months, with no difference in FSFI between operative routes.[4][10][11] The IUGA/ICS 2026 obstetric fistula consensus states that Latzko repair has been reported to shorten the vagina and may not suit a woman with a short vagina, and that flap splitting carries a smaller risk of reducing vaginal capacity (statement 36, consensus).[16] It considers the two techniques equally effective for closure on similar published outcomes, although no comparative studies exist.[16]

  • Tract not excised. Deliberate tissue preservation.

  • Other possible complications. Persistent or new urinary incontinence, UTI or urosepsis, ureteric obstruction, vaginal stenosis and dyspareunia have been described after VVF repair.[12]

  • Not suitable for all fistula locations. The classic Latzko targets apical or cuff fistulae; mid-vaginal or distal fistulae may not be amenable.

  • Tract not excised. Deliberate tissue preservation; it does not eliminate the possibility of recurrence.

Latzko vs Multilayer Closure​

FeatureLatzko (Partial Colpocleisis)Multilayer Closure
Fistula tract excisionNoDebated (some excise; some freshen edges)
Vesicovaginal-space dissectionMinimalWide mobilization required
Closure layersImbrication of denuded fibromuscular tissueSeparate bladder (1–2 layers) + vaginal wall
Vaginal shorteningReported after Latzko; assess baseline vaginal length.[16]No quantified comparison with Latzko; flap splitting is described as less likely to reduce vaginal capacity in obstetric fistula repair, but no direct comparative studies exist.[16]
Ureteral considerationsIdentify/protect ureters despite limited dissectionIdentify/protect ureters during mobilization
Comparative efficacyNo high-quality evidence establishes superiorityCase mix and endpoint definitions differ
Access requirementAdequate vaginal access and tissue for imbricationAdequate exposure and tissue for separate-layer closure

The 2026 Cochrane protocol plans to evaluate surgical interventions including partial colpocleisis and multilayer closure. It provides no completed comparative results.[1] For the right apical fistula, non-excision is the design of the operation.

Postoperative Care​

  • Maintain reliable bladder drainage and treat troublesome spasms after checking catheter function. For simple obstetric repair, WHO recommends 7–10 days, while the 2026 IUGA/ICS obstetric-fistula consensus recommends a minimum of 10–14 days.[13][16] EAU gives a Weak recommendation to drain until healing is confirmed; its expert-opinion ranges are 10–14 days for simple or postsurgical fistulae and 14–21 days for complex or radiation-associated fistulae.[12] Individualize duration and assess healing before removal.[12][13][16]
  • Assess closure when planning catheter removal using dye testing or imaging as appropriate; for obstetric repairs, the 2026 IUGA/ICS consensus advises a routine dye test at removal.[16] Routine follow-up cystoscopy at a fixed interval is not established for every uncomplicated Latzko repair.
  • If leakage persists, investigate its source. After obstetric repair with a positive dye test following at least 14 days of drainage, an extra catheter week converted dye testing to negative in 29/52 women; see the postoperative drainage evidence.[14]
  • Discuss activity and resumption of intercourse according to tissue healing and patient goals, and assess continence and sexual function separately from closure.

Radiation-Induced VVF​

Pushkar reported 216 radiation-associated VVF cases, including 210 vaginal repairs and 75 Latzko procedures. The 101/210 initial and 169/210 eventual closures belong to the entire vaginal cohort.[7] The authors describe selected staged or repeat repair and use of Latzko or Martius tissue. For radiation-associated fistula repair, EAU 2026 gives a Weak recommendation to use an interposition graft despite limited comparative evidence.[12] Before another repair after radiotherapy, evaluate for recurrent malignancy and reassess tissue, urinary function and goals.[7][12]

See Also​

References​

1. Okada Y, Matsushita T, Hasegawa T, et al. Surgical interventions for treating vesicovaginal fistula in women. Cochrane Database Syst Rev. 2026;1:CD015413. Protocol. doi:10.1002/14651858.CD015413

2. Luo DY, Shen H. Transvaginal repair of apical vesicovaginal fistula: a modified Latzko technique — outcomes at a high-volume referral center. Eur Urol. 2019;76(1):84–88. doi:10.1016/j.eururo.2019.04.010

3. Angioli R, Penalver M, Muzii L, et al. Guidelines of how to manage vesicovaginal fistula. Crit Rev Oncol Hematol. 2003;48(3):295–304. doi:10.1016/s1040-8428(03)00123-9

4. Mohr S, Brandner S, Mueller MD, Dreher EF, Kuhn A. Sexual function after vaginal and abdominal fistula repair. Am J Obstet Gynecol. 2014;211(1):74.e1–6. doi:10.1016/j.ajog.2014.02.011

5. Kieserman-Shmokler C, Sammarco AG, English EM, Swenson CW, DeLancey JO. The Latzko: a high-value, versatile vesicovaginal fistula repair. Am J Obstet Gynecol. 2019;221(2):160.e1–4. doi:10.1016/j.ajog.2019.05.021

6. Cardenas-Trowers O, Heusinkveld J, Hatch K. Simple and effective: transvaginal vesicovaginal fistula repair with a modified Latzko technique. Int Urogynecol J. 2018;29(5):767–769. doi:10.1007/s00192-017-3471-8

7. Pushkar DY, Dyakov VV, Kasyan GR. Management of radiation-induced vesicovaginal fistula. Eur Urol. 2009;55(1):131–137. doi:10.1016/j.eururo.2008.04.044

8. Roberts BL, Chang ES, Hidalgo RJ, Wiegand LR, Wyman AM. Vesicovaginal fistula repair at the time of colpocleisis. Int Urogynecol J. 2021;32(7):1939–1940. doi:10.1007/s00192-021-04787-x

9. Kołodyńska A, Streit-Ciećkiewicz D, Kot A, Kuliniec I, Futyma K. Radiation-induced recurrent vesicovaginal fistula — treatment with adjuvant platelet-rich plasma injection and Martius flap placement: case report and review of literature. Int J Environ Res Public Health. 2021;18(9):4867. doi:10.3390/ijerph18094867

10. Kim-Fine S, Antosh DD, Balk EM, et al. Relationship of postoperative vaginal anatomy and sexual function: a systematic review with meta-analysis. Int Urogynecol J. 2021;32(8):2125–2134. doi:10.1007/s00192-021-04829-4

11. Occhino JA, Trabuco EC, Heisler CA, Klingele CJ, Gebhart JB. Changes in vaginal anatomy and sexual function after vaginal surgery. Int Urogynecol J. 2011;22(7):799–804. doi:10.1007/s00192-011-1386-3

12. European Association of Urology. Non-neurogenic Female LUTS guideline, section 4.8: urinary fistula. 2026 edition. Full guideline section.

13. World Health Organization. Duration of catheterization after simple obstetric fistula repair. 2018. Official recommendation.

14. Chang OH, Ganesh P, Wilkinson JP, Pope RJ. Extended bladder catheterization for women with positive dye tests after obstetric vesicovaginal fistula repair surgery. Int J Gynaecol Obstet. 2020;149:61–65. doi:10.1002/ijgo.13088.

15. Thompson JC, Halder GE, Jeppson PC, et al. Repair of vesicovaginal fistulae: a systematic review. Obstet Gynecol. 2024;143(2):229–241. doi:10.1097/AOG.0000000000005468

16. Maljaars LP, Corcos J, Ghoniem G, et al. Consensus statements on the definition of surgical success following obstetric urinary pelvic floor fistula repair: an IUGA-ICS proposal. Int Urogynecol J. 2026. doi:10.1007/s00192-025-06413-6

17. Srivastava M, Mittal A, Panwar VK, Bahurupi Y, Mandal AK. "Transvaginal repair of supratrigonal, juxtacervical, vault, and apical vesicovaginal fistulae: a systematic review and meta-analysis." Urol Res Pract. 2025;51(3):117–130. doi:10.5152/tud.2025.24184