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Transvaginal Sims-Simon Multilayered Closure

The Sims-Simon multilayered closure separates bladder and vaginal tissues for independent closure. It aims to preserve vaginal anatomy without partial colpocleisis, but final length and sexual function depend on tissue loss, scarring and the reconstruction. A frequently cited 47/47 success report involved different nonradiogenic GU fistula types, not 47 isolated VVFs.[1]

For the broader VVF clinical algorithm, see the vesicovaginal fistula clinical page. For other transvaginal options, see Conservative VVF Management, Endoscopic VVF Management, and Latzko Repair.

Historical Origins​

The name reflects historical contributions by Sims and Simon to vaginal fistula repair, tissue preparation and closure. Modern modifications are not a single standardized operation. Sims developed techniques through repeated operations on enslaved Black women; that history belongs alongside technical attribution rather than a simplified account of surgical progress.[2][3][4][5]

Fundamental Principle​

Unlike the Latzko (imbrication of denuded tissue over an intact tract), the Sims-Simon is built on anatomic tissue-plane separation and independent layered closure:[6][1][7]

  • Wide mobilization of bladder off vaginal wall to create distinct planes.
  • Freshening or excision of the fistula edges (debated; traditional).
  • Separate closure of bladder wall (one or two layers) and vaginal wall as independent layers.
  • Preservation of vaginal anatomy is a goal — there is no planned colpocleisis, but scarring/shortening can still occur.

Layered vesicovaginal fistula closure: Bladder-vaginal septum, conceptual section

Separate mobilized bladder and vaginal layers permit tension-free closure with offset suture lines; interposition is shown as optional. Freshening/excision and the number of layers are individualized. The diagram does not show ureteral protection, tissue viability assessment or drainage. (Original WARWIKI schematic; see the figure source record and review limits.)

Indications​

Consider separate-layer repair when vaginal access and available tissue permit:[1][8][9][10]

  • Any transvaginally accessible VVF — mid-vaginal, trigonal, or apical (not limited to cuff fistulae).
  • Fistulae where vaginal length matters — especially in sexually active patients.
  • Non-irradiated, benign fistulae — highest success.
  • Selected obstetric fistulae, with reconstruction tailored to urethral involvement, tissue loss and scarring.
  • Fistulae with surrounding scar — mobilize enough viable tissue for closure while avoiding unnecessary excision.

Surgical Technique​

The classic and modified technique:[6][1][7][9]

1. Positioning and exposure​

  • Dorsal lithotomy (or exaggerated lithotomy). Original Sims left-lateral-decubitus with right knee drawn up is now rare but available for difficult posterior-wall exposure.
  • Sims speculum or weighted posterior retractor + lateral retractors.
  • Cystoscopy to assess fistula size and location relative to ureteral orifices; place ureteral stents if near the trigone.
  • Probe / small catheter through the fistula to confirm location.

2. Hydrodissection / vasoconstriction​

  • Hydrodissection may help identify the subepithelial plane. Any vasoconstrictor requires an agreed drug, concentration, total dose and anesthesia protocol; an unspecified dilution is not a dosing instruction.
  • Hydrodissection elevates vaginal epithelium from the underlying pubocervical fascia; provides hemostasis.

3. Circumscribing incision of the vaginal epithelium​

  • Circumferential incision in vaginal epithelium 1–2 cm from the fistula margin.
  • Some surgeons use a U-shaped or inverted-U flap depending on fistula location and preference.

4. Wide mobilization (the defining step)​

Distinguishes Sims-Simon from Latzko:[6][1]

  • Sharply dissect vaginal epithelium off the underlying pubovesical (endopelvic) fascia and bladder wall, creating wide flaps.
  • Extend dissection only as needed for viable, mobile tissue and a tension-free repair; a fixed circumferential distance is not required for every defect.
  • Enter the vesicovaginal space and mobilize the bladder wall off the vaginal wall circumferentially.
  • Identify and protect nearby ureters during dissection and closure, particularly for trigonal defects.

5. Fistula-edge management — the "to trim or not to trim" debate​

  • Edge preparation should remove nonviable tissue without sacrificing tissue needed for reconstruction.
  • Pro-trim arguments: removes epithelialized non-healing tissue; creates fresh wound edges; removes fibrotic / scarred tissue.
  • Anti-trim arguments: enlarges the defect; risks injury to adjacent structures; may not be necessary if mobilization achieves tension-free closure. Shaker randomized 64 women with obstetric VVF, using a Martius flap in both groups. Closure was not significantly different with versus without trimming, while recurrent defects tended to be larger after trimming. This does not prove equivalence for every fistula type.[11]
  • Current practice: debated; varies by surgeon and institution.[6] EAU Robotic Urology Section consensus recommends careful sharp dissection of fistula edges but does not mandate complete excision.[16] The reconstructive endpoint is mobile, vascularized, tension-free tissue rather than a predetermined amount of excision.

6. Layered bladder closure​

After adequate mobilization:[6]

  • Close the bladder with appropriate absorbable suture using secure, tension-free bites. There is no universal requirement to place knots intravesically.
  • A second muscular/fascial layer may be used when tissue permits; avoid added tension or ureteral distortion.
  • Single full-thickness layer is also acceptable.
  • Confirm watertight closure by retrograde-filling the bladder with methylene blue or indigo carmine and inspecting the suture line.

7. Interposition layer (optional)​

  • Terminology overlaps: separate fascial closure is also described in a report labeled modified Latzko. Do not use that report alone to define every Sims-Simon modification.[12]
  • A Martius flap can be added for recurrent or irradiated fistulae.
  • Mörgeli & Tunn used no flaps in their selected series. This supports feasibility, not a rule that interposition is unnecessary in every non-irradiated repair.[1]

8. Vaginal-epithelial closure​

  • Preserve viable vaginal tissue; tailor edges only as needed for closure.
  • Close with interrupted or running 2-0 delayed absorbable.
  • Offset adjacent closure lines where feasible; this is a reconstructive principle rather than a quantified guarantee against recurrence.
  • Vaginal pack as needed.

9. Catheter​

  • Provide reliable postoperative bladder drainage; catheter route, size and duration are individualized.[6][9]

Outcomes​

SeriesnTechniqueFlapSuccessOR time
Mörgeli & Tunn 2021[1]47 modified Sims-Simon procedures within a 50-patient mixed GU cohortModified Sims-SimonNone47/47, not a VVF-only rateSeries median 40 min (20–100)
Goodwin & Scardino 1980[13]24 vaginal VVF/urethrovaginal repairsVaginal repairVariable70% first attempt; 92% with two attempts; mixed anatomyNR
Adinata 2026[14]80Transvaginal multilayerVariable85% overallNR
Dowsuk & Ramart 2025[15]35 women, 40 closuresTransvaginal supratrigonal repairVariable29/35 (82.9%) after first surgery; abstract overall denominator is insufficiently clear to restate as a patient-level rateNR
Angioli 2003 (narrative review)[8]—Different vaginal techniques± MartiusHistorical 91% mean; not specific to Sims-SimonNR

Mörgeli & Tunn included 34 VVF, 11 urethrovaginal, three ureterovaginal and two neobladder-vaginal fistula patients. Forty-seven received modified Sims-Simon repair and all closed; the 14% complication rate belongs to the overall series. These selected nonradiogenic cases do not establish a universal VVF success rate or prove that a flap adds no benefit.[1]

Sims-Simon vs Latzko​

FeatureSims-Simon MultilayeredLatzko Partial Colpocleisis
PrincipleAnatomic tissue-plane separation + layered closureDenuding + imbrication (partial colpocleisis)
Fistula tract excisionTraditionally yes (debated)No
Vesicovaginal-space dissectionWide mobilization requiredMinimal
Closure layersBladder (1–2) + fascia + vaginal epitheliumImbricated fibromuscular tissue + vaginal epithelium
Vaginal anatomyNo planned colpocleisis; scarring/shortening remain possiblePartial colpocleisis; discuss residual length and sexual goals
Applicable fistula locationsAny transvaginally accessiblePrimarily apical / cuff
Ureteral protectionRequired during dissection and closureRequired despite limited dissection
Comparative operative timeCase mix and technique differNo matched evidence establishes a universal advantage
InterpositionSelect by tissue, prior repair and complexitySelect by tissue, prior repair and complexity
Comparative efficacyNo high-quality head-to-head evidence establishes superiorityClosure and continence must be reported separately

The 2026 Cochrane publication is a protocol, which plans comparisons of surgical interventions including partial colpocleisis and multilayer closure; it contains no completed comparative results.[6]

Advantages​

  • Aims to preserve vaginal anatomy without planned colpocleisis.
  • Broad applicability — any vaginal-fistula location, not just the apex.
  • Anatomic reconstruction — restores normal tissue planes between bladder and vagina.
  • May avoid flap harvest in appropriately selected cases, reducing donor-site exposure.[1]
  • Short OR time — median 40 min in experienced hands.[1]
  • High success — up to 100% in selected modern series.[1]

Disadvantages and Limitations​

  • Mobilization near ureters requires careful identification and protection; comparative injury rates versus Latzko are not established.
  • Technically demanding — requires comfort with deep pelvic dissection and layered closure in a confined space.
  • Learning curve — the reported improvement after approximately 20 cases came from one surgeon’s retrospective experience; it is not a validated credentialing threshold or a guarantee of proficiency.[15]
  • Risk of enlarging the defect — when fistula edges are excised, the defect may become larger and harder to close.

Predictors and Limits of Generalization​

Adinata's 2026 retrospective series of 80 women associated successful repair with early intervention (less than four weeks), smaller defects and minimal fibrosis. “First attempt” was not the third independent predictor reported in the abstract. The observational model does not prove that operating earlier causes better outcomes; assess tissue readiness individually.[14]

A 1,185-repair multinational report included mixed urinary and rectovaginal fistulae, heterogeneous adjuncts and incomplete centralized follow-up. Its outcomes do not establish efficacy of a particular Sims-Simon modification, biologic adjunct or postrepair continence procedure.[17]

Postoperative Care​

Maintain unobstructed bladder drainage and assess persistent leakage before catheter removal. Duration and the choice of dye testing/imaging depend on repair complexity and tissue quality; use the source-specific guidance, rather than requiring 14–21 days for every repair. Routine follow-up cystoscopy at a fixed interval is not established for all uncomplicated repairs.[18]

Treat troublesome bladder spasms after checking catheter function, discuss activity and intercourse as healing permits, and document continence, emptying and sexual symptoms separately from anatomical closure.

See Also​

References​

1. Mörgeli C, Tunn R. Vaginal repair of nonradiogenic urogenital fistulas. Int Urogynecol J. 2021;32(9):2449–2454. doi:10.1007/s00192-020-04496-x

2. Wall LL. The controversial Dr. J. Marion Sims (1813–1883). Int Urogynecol J. 2020;31(7):1299–1303. doi:10.1007/s00192-020-04301-9

3. Spettel S, White MD. The portrayal of J. Marion Sims' controversial surgical legacy. J Urol. 2011;185(6):2424–2427. doi:10.1016/j.juro.2011.01.077

4. Vernon LF. J. Marion Sims, MD: why he and his accomplishments need to continue to be recognized — a commentary and historical review. J Natl Med Assoc. 2019;111(4):436–446. doi:10.1016/j.jnma.2019.02.002

5. Ippolito GM, Wilson SN, Howell J. A surgical perspective on the history of vesicovaginal fistula repair in the United States. Neurourol Urodyn. 2024;43(3):655–663. doi:10.1002/nau.25412

6. 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

7. Rafetto AN, Wei N, Linder BJ. Principles and techniques of vesicovaginal fistula repair. Int Urogynecol J. 2026. doi:10.1007/s00192-026-06576-w

8. 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

9. Wall LL. Obstetric vesicovaginal fistula as an international public-health problem. Lancet. 2006;368(9542):1201–1209. doi:10.1016/S0140-6736(06)69476-2

10. Zeleke LB, Welsh A, Abeje G, Khajehei M. Treatment outcomes of obstetrical fistula surgical repair in low- and middle-income countries: a scoping review. Int J Gynaecol Obstet. 2024;167(2):491–500. doi:10.1002/ijgo.15724

11. Shaker H, Saafan A, Yassin M, Idrissa A, Mourad MS. Obstetric vesicovaginal fistula repair: should we trim the fistula edges? A randomized prospective study. Neurourol Urodyn. 2011;30(3):302–305. doi:10.1002/nau.20995

12. 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

13. Goodwin WE, Scardino PT. Vesicovaginal and ureterovaginal fistulas: a summary of 25 years of experience. J Urol. 1980;123(3):370–374. doi:10.1016/s0022-5347(17)55941-8

14. Adinata Y, Hudaya S, Hutasoit YI, et al. Prognostic factors of transvaginal repair for vesicovaginal fistulas: a 5-year single-center study. Int Urogynecol J. 2026. doi:10.1007/s00192-026-06561-3

15. Dowsuk C, Ramart P. Learning curve of transvaginal closure of supratrigonal vesicovaginal fistulas. Int Urogynecol J. 2025. doi:10.1007/s00192-025-06498-z

16. Randazzo M, Lengauer L, Rochat CH, et al. Best practices in robotic-assisted repair of vesicovaginal fistula: a consensus report from the European Association of Urology Robotic Urology Section Scientific Working Group for Reconstructive Urology. Eur Urol. 2020;78(3):432–442. doi:10.1016/j.eururo.2020.06.029

17. Mourad MS, Malallah M, Mahfouz W, et al. Sixteen years of multinational experience in female genital fistula repair: integrating traditional and innovative surgical approaches across 12 countries. Neurourol Urodyn. 2026;45(3):583–590. doi:10.1002/nau.70226

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