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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.[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.[2][3][4][5] Sims developed techniques through repeated operations on enslaved Black women (see the History of Prolapse Surgery & Urogynecology).[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:[1][7][18]

  • Wide mobilization of the bladder off the vaginal wall creates distinct planes.
  • Fistula-edge management varies across layered repairs. The cited 47-case modified Sims–Simon series circumcised and removed the tract; routine trimming remains debated.[1][11]
  • Separate closure of the bladder wall (one or two layers) and the vaginal wall produces independent layers.
  • Preservation of vaginal anatomy is a goal. No colpocleisis is planned, but scarring or 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]

  • Transvaginally accessible VVF, after route selection. Mid-vaginal, trigonal or apical defects can be considered when exposure and viable tissue permit. For persistent urogenital fistulae, the 2026 EAU guideline weakly recommends an abdominal approach (open, laparoscopic or robotic) according to availability and competence; it separately weakly favors vaginal repair for urethrovaginal fistulae.[18]
  • Fistulae where vaginal length matters. Especially in sexually active patients.
  • Non-irradiated, benign fistulae. Repair success is higher than for irradiated fistulae.[18]
  • After primary radiotherapy. A new fistula may signal tumour recurrence; evaluate for recurrence before reconstruction.[18]
  • 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.

Poor fit for a vaginal approach​

A fixed high vault fistula that cannot be exposed adequately from below needs another route. Suspected ureteric involvement may require upper-tract evaluation and a repair plan that includes ureteral reconstruction.[18]

Surgical Technique​

The classic and modified technique:[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 the ureteral orifices; consider protective ureteral stents when an orifice is close to the planned closure. If a concomitant ureterovaginal fistula is suspected, obtain contrast-enhanced CT with a late excretory phase and/or MRI to define ureteric integrity before choosing the repair route .[18]
  • Probe / small catheter through the fistula to confirm location.
  • When adequate exposure cannot be obtained and an abdominal approach is not available, a relaxing incision at the 5 or 7 o'clock position of the vaginal introitus (or both) has been described to improve visualization; this can increase postoperative pain, which should be discussed with the patient beforehand.[23]
  • A pediatric Foley catheter (6 or 8 Fr) placed through the fistula tract, directly or over a guidewire, with its balloon inflated for gentle traction has been described to bring a deep or apical fistula into view; gentle dilation, a ureteral stent, or a Fogarty catheter are described alternatives when the tract is too small for the Foley.[24]

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:[1][18]

  • 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.
  • 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.
  • When mobilization is difficult, additional circumferential vaginal incisions at a distance from the fistula have been described as a bailout to gain tissue excursion for a low-tension closure; after hemostasis these incisions are left open to heal by secondary intention.[20]

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.[11]
  • Current practice: edge trimming remains debated and varies by surgeon and institution.[11][18] A 2020 EAU Robotic Urology Section consensus describes careful sharp edge dissection for robotic repair. The EAU female-LUTS guideline reports that one randomized obstetric-VVF trial found no difference in closure rates with versus without trimming.[16][18] The reconstructive endpoint is mobile, vascularized, tension-free tissue rather than a predetermined amount of excision.

6. Layered bladder closure​

After adequate mobilization:[1][7]

  • Close the bladder with appropriate absorbable suture using secure, tension-free bites. Knots may be placed extravesically.
  • A second muscular or 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.
  • One described sequence places interrupted extramucosal bladder-edge sutures, then an imbricating muscular layer, tests the closure at that point with methylene blue or sterile milk while avoiding overdistention, and then attempts an additional interrupted pubocervical-fascial layer when usable tissue is available.[20]
  • 3-0 polyglactin or 3-0 chromic are described examples of suitable absorbable suture. Permanent suture should not be used because of infection and stone risk; delayed absorption of an intravesical knot has been associated with calcification or infection while exposed to urine. Absorbable knot position varies by closure technique.[21]

7. Interposition layer (optional)​

  • Terminology overlaps: separate fascial closure is also described in a report labeled modified Latzko.[12]
  • For radiation-associated fistula repair, the 2026 EAU guideline weakly recommends an interposition graft.[18] A Martius flap may be considered when viable tissue can reach the repair; interposition for a recurrent nonirradiated fistula is individualized.[7][18]
  • Mörgeli & Tunn used no flaps in their selected series.[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.
  • Vaginal pack as needed.

9. Catheter​

  • Provide reliable postoperative bladder drainage; catheter route and size are individualized.[9] For simple obstetric fistulae, WHO recommends 7–10 days of drainage, while the 2026 IUGA/ICS consensus recommends a minimum of 10–14 days; EAU 2026 weakly recommends drainage until healing, with expert ranges of 10–14 days for simple or postsurgical fistulae and 14–21 days for complex or postradiation fistulae.[27][25][18]

Vaginal flap / flap-splitting variant​

One described alternative combines several of the above steps into a single technique. The fistula tract is left in place rather than excised, which its authors say limits defect enlargement, dissection toward the ureter and bleeding edges. The defect is closed horizontally as a first layer starting about 0.5 cm from the defect margin, the perivesical fascia and detrusor are imbricated as a perpendicular second layer, tested by filling the catheter with 200 mL saline (methylene blue optional), and a U-shaped vaginal flap mobilized at least 2–3 cm beyond the repair is advanced over the closure as a separate final layer. A pediatric or Fogarty catheter placed through the tract aids identification and gentle traction.[22]

Outcomes​

SeriesnTechniqueFlapReported outcomeOR time
Mörgeli & Tunn 2021[1]47 modified Sims-Simon procedures within a 50-patient mixed GU cohortModified Sims-SimonNone47/47 index-tract closures; cohort median follow-up 12 weeks [IQR 8–47], with persistent incontinence in 11/50 (22%); one second, previously unrecognized fistula required another repairVaginal-procedure median 40 min (range 20–100)
Goodwin & Scardino 1980[13]24 vaginal VVF/urethrovaginal repairsVaginal repairVariable70% first attempt; 92% with two attempts; mixed anatomyNR
Adinata 2026[14]80 womenTransvaginal repair—68/80 (85%) during 3-month follow-upNR
Dowsuk & Ramart 2026[15]35 women, 40 transvaginal repair proceduresSupratrigonal VVF—29/35 (82.9%) after first surgery; 97.5% overall reported with an unclear denominator; mean follow-up 2.6 ± 2.3 yearsNR
Angioli 2003 (narrative review)[8]—Different vaginal techniques± MartiusHistorical 91% mean for nonradiated VVF repaired vaginallyNR

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. The selected nonradiogenic series provides no general VVF success estimate or comparison of flap 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 closure in one or two layers plus vaginal epithelium; an additional muscular or fascial layer when usable tissue permitsImbricated 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

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 laparotomy) was determined mainly by surgeon preference; these low-quality, nonrandomized comparisons provide insufficient evidence to determine whether repair success differs by route. Interpositional flaps, trimming of fistula edges, fibrin glue and fascial sling did not significantly improve fistula cure. Two randomized trials (803 women) comparing perioperative antibiotic strategies found no significant difference in fistula closure; one found fewer postoperative UTIs with intraoperative prophylaxis than with none. In a separate 58-woman trial of complex VVF, four-layer closure reached 96.4% at three weeks versus 71.4% with three layers, but evidence remains insufficient to determine the preferred closure method.[19]

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​

  • The operation aims to preserve vaginal anatomy without planned colpocleisis.
  • Flexible vaginal location. Layered repair can be considered for accessible mid-vaginal, trigonal or apical fistulae when exposure and viable mobile tissue permit tension-free closure.[18]
  • Anatomic reconstruction. It restores normal tissue planes between bladder and vagina.
  • Flap harvest may be avoided in appropriately selected cases, reducing donor-site exposure.[1]
  • Short operating time. The median was 40 min in the Mörgeli and Tunn series.[1]
  • High closure rate. Mörgeli and Tunn reported 47/47 closures in selected nonradiogenic fistulas.[1]

Disadvantages and Limitations​

  • Mobilization near ureters requires careful identification and protection; comparative injury rates versus Latzko are not established. In the mixed Mörgeli cohort, ureteral stricture occurred in 1/50 (2%) and caused renal fornix rupture.[1]
  • Technically demanding. The operation 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.[15]
  • Risk of enlarging the defect. Excising the fistula edges may make the defect larger and harder to close.
  • Urethrovaginal repairs. Counsel about postoperative stress incontinence, urethral stricture and shortening, and arrange follow-up for these complications.[18]

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.[14] The 2026 EAU guideline weakly recommends tailoring repair timing until edema, inflammation, tissue necrosis or infection have resolved.[18]

A 1,185-repair multinational report included mixed urinary and rectovaginal fistulae, heterogeneous adjuncts and incomplete centralized follow-up.[17]

Postoperative Care​

Maintain unobstructed bladder drainage and assess persistent leakage before catheter removal. A Sims-Simon case report described renal forniceal rupture after postoperative intramural ureteral edema; for new flank pain after vaginal VVF repair, its authors advise prompt renal ultrasound and CT if symptoms persist despite inconclusive ultrasound.[26] Duration and the choice of dye testing or imaging depend on repair complexity and tissue quality; use the source-specific guidance, rather than requiring 14–21 days for every repair. If postoperative cystography is chosen, it can theoretically miss a persistent fistula when no micturition phase is included or when the fistula is at the bladder neck.[18] 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. For obstetric VVF repair, the 2026 IUGA/ICS consensus advises a dye test at catheter removal and separate assessment of residual incontinence with postvoid residual and cough testing.[25] FIGO's 2025 obstetric-fistula expert protocol measures voided volume and postvoid residual three times over 24–48 hours, identifies retention when residual is >100 mL or >50% of voided volume, and uses a one-hour pad test after adequate emptying.[28]

No Sims-Simon-specific VTE recommendation exists; this is vaginal reconstructive surgery, so apply the general risk framework (age, obesity, prior VTE, malignancy, prolonged operation or immobility) on the VTE Prophylaxis page rather than a fixed regimen.

See Also​

Videos​

Vaginal Repair of VVF and Urethrovaginal Fistula
Operative video
Vesicovaginal Fistula: Vaginal Repair with Martius Graft
Dr. Deeksha Pandey, Urogynecology for Beginners

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.

19. 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

20. Karram MM. Vaginal Repair of Vesicovaginal Fistula. In: Baggish MS, Karram MM, eds. Atlas of Pelvic Anatomy and Gynecologic Surgery. 5th ed. Elsevier; 2021:1091-1097.

21. Ingber M, Rackley RR. Vesicovaginal and Urethrovaginal Fistula Repair. In: Goldman HB, ed. Complications of Female Incontinence and Pelvic Reconstructive Surgery. 2nd ed. Springer (Humana Press); 2017:231-238.

22. Vollstedt A, Hoang Roberts L, Sirls LT. Vesicovaginal Fistula Repair: Vaginal Approach. In: Martins FE, Holm HV, Sandhu JS, McCammon KA, eds. Female Genitourinary and Pelvic Floor Reconstruction. Springer; 2023:761-784.

23. Clifton M, Goldman HB. Transvaginal Repair of Vesicovaginal Fistula. In: Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2025:439-444.

24. Jones L, Rosenblum N. Transvaginal Repair of VVF. In: Cardozo L, Staskin D, eds. Textbook of Female Urology and Urogynecology. Vol 2: Surgical Perspectives. 5th ed. CRC Press; 2023:1146-1151.

25. 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;37(5):1193–1205. doi:10.1007/s00192-025-06413-6

26. Rendtorff R, Knispel HH, Tunn R. "Rupture of the Left Renal Fornix after Vaginal Repair of Postpartum Vesicovaginal Fistula." Geburtshilfe Frauenheilkd. 2014;74(4):376–378. doi:10.1055/s-0034-1368365

27. World Health Organization. WHO recommendation on duration of bladder catheterization after surgical repair of simple obstetric urinary fistula. Geneva: WHO; 2018. PMID:29634170. Official guideline.

28. Browning A, Trautvetter L, Slinger G, et al. "FIGO good practice recommendations to standardize the assessment of outcomes following vesicovaginal fistula surgery." Int J Gynaecol Obstet. 2025;168(2):497–501. doi:10.1002/ijgo.16017