Skip to main content

Transvaginal Sims-Simon Multilayered Closure

The Sims-Simon multilayered closure is the principal alternative to the Latzko partial colpocleisis for transvaginal vesicovaginal fistula (VVF) repair. It is a true anatomic, layered dissection-and-closure technique that separates the bladder from the vagina, closes each tissue layer independently, and preserves vaginal length — in contrast to the Latzko, which obliterates the upper vagina. In the largest modern series of a modified Sims-Simon, 100% success (47/47) was achieved without any tissue interposition, with median operative time of 40 min.[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​

SurgeonContribution
J. Marion Sims (1813–1883)Between 1845–49 developed the first reproducible VVF repair. Innovations: Sims speculum, lateral (Sims) position, silver-wire sutures (replacing tissue-necrotizing silk), the principle of freshening / scarifying the fistula edges, and postoperative continuous bladder drainage via a self-retaining catheter. Original technique was a single-layer closure with silver wire sutures secured by lead clamps.[2][3][4]
Gustav Simon (1824–1876)Refined the technique in the 1860s–70s. Critical contributions: wide mobilization of bladder off vagina, separate layered closure of bladder and vaginal walls, and tension-free closure through extensive tissue mobilization. Transformed VVF repair from a single-layer edge approximation into a true multilayer anatomic reconstruction.

The combined "Sims-Simon" technique synthesizes Sims' principles (edge preparation, positioning, catheter drainage) with Simon's principles (wide dissection, tissue-plane separation, layered closure).[1][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.
  • Vaginal length preserved — no colpocleisis.

Indications​

Broader applicability than the Latzko:[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.
  • Obstetric fistulae — the predominant technique used in LMICs.
  • Fistulae with surrounding scar — wide mobilization permits excision of fibrotic tissue and creation of healthy edges for closure.

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​

  • Inject dilute vasoconstrictor (1:200,000 epinephrine or dilute vasopressin) circumferentially into the subepithelial plane.
  • 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.
  • Dissection extends well beyond fistula margins (≥1–2 cm in all directions) for tension-free closure.
  • Enter the vesicovaginal space and mobilize the bladder wall off the vaginal wall circumferentially.
  • This step carries the highest risk of ureteral injury, particularly for trigonal fistulae.

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

  • Sims' original principle: excise / freshen edges to expose raw, bleeding tissue ("scarification").[2][3]
  • 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 RCT (obstetric VVF) found no significant difference in closure rates between trim and no-trim groups.[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]

6. Layered bladder closure​

After adequate mobilization:[6]

  • First layer (bladder mucosa / urothelium): interrupted or running 3-0 / 4-0 delayed absorbable (Vicryl, Monocryl); knots tied on the intravesical (mucosal) side; watertight, tension-free.
  • Second layer (detrusor / muscularis): interrupted 3-0 imbricating layer over the first, inverting the closure line and adding strength.
  • 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)​

  • Modified Sims-Simon may add a separate pubovesical-fascia closure as a third tissue barrier.[12]
  • A Martius flap can be added for recurrent or irradiated fistulae.
  • The Mörgeli & Tunn series demonstrated no flaps required to achieve 100% success in non-irradiated patients.[1]

8. Vaginal-epithelial closure​

  • Trim flaps of excess tissue.
  • Close with interrupted or running 2-0 delayed absorbable.
  • Offset the vaginal suture line from the bladder suture line — non-overlapping suture lines reduce recurrence risk.
  • Vaginal pack as needed.

9. Catheter​

  • Transurethral Foley 14–18 Fr for 14–21 days.[6][9]

Outcomes​

SeriesnTechniqueFlapSuccessOR time
Mörgeli & Tunn 2021[1]47Modified Sims-SimonNone100% (47/47)Median 40 min (20–100)
Goodwin & Scardino 1980[13]24 (transvaginal)Layered closureVariable70% first attempt; 92% with 2 attemptsNR
Adinata 2026[14]80Transvaginal multilayerVariable85% overallNR
Dowsuk & Ramart 2025[15]35Transvaginal multilayerVariable82.9% first attempt; 97.5% overallNR
Angioli 2003 (literature review)[8]—Vaginal layered closure± Martius91% mean (non-irradiated)NR

The Mörgeli & Tunn series is notable: all 47 patients treated with the modified Sims-Simon achieved closure with a single operation, without tissue interposition flaps, and with only 14% mostly-minor complications. Median OR time 40 min (range 20–100).[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 shorteningMinimal to noneYes (partial colpocleisis)
Applicable fistula locationsAny transvaginally accessiblePrimarily apical / cuff
Ureteral-injury riskHigher (wide dissection)Lower
OR timeMedian 40 min (modified Sims-Simon)Variable, generally short
Need for interpositionNot required in non-irradiatedNot required in non-irradiated
Success (non-irradiated)82–100%82–100%

The Cochrane systematic review on VVF surgical interventions identified the comparison of partial colpocleisis (Latzko) vs multilayer closure as a high-priority comparison, though high-quality head-to-head comparative data remain limited.[6]

Advantages​

  • Preserves vaginal length — no colpocleisis (matters for sexually active patients).
  • Broad applicability — any vaginal-fistula location, not just the apex.
  • Anatomic reconstruction — restores normal tissue planes between bladder and vagina.
  • No interposition flap required in most non-irradiated cases — avoids donor-site morbidity.[1]
  • Short OR time — median 40 min in experienced hands.[1]
  • High success — up to 100% in selected modern series.[1]

Disadvantages and Limitations​

  • Wide mobilization — extensive vesicovaginal-space dissection carries higher ureteral-injury risk than the Latzko, particularly for trigonal fistulae.[6]
  • Technically demanding — requires comfort with deep pelvic dissection and layered closure in a confined space.
  • Learning curve — at least 20 cases to achieve >80% success in a transvaginal-supratrigonal-VVF series, highlighting the importance of surgical experience.[15]
  • Risk of enlarging the defect — when fistula edges are excised, the defect may become larger and harder to close.

Predictors of Success​

A recent transvaginal-VVF study identified three independent predictors of successful repair:[14]

  • Early repair (<3 mo from injury).
  • Smaller fistula size.
  • First repair attempt (vs revision).

Postoperative Care​

  • Continuous Foley 14–21 days.
  • Anticholinergics for detrusor spasm.
  • Avoid straining, heavy lifting, and intercourse for 6–8 wk.
  • Dye test before catheter removal.
  • Follow-up cystoscopy at 6 wk to 3 mo.

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. 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