A 35 year old female, presented with 3 months history of continuous dribbling of urine per-vaginum that she noticed in the immediate post-operative period following sub-total hysterectomy for still birth in a ruptured uterus due to prolonged obstructed labour of more than 24 hours. Her hematological, bio-chemical and radiological investigations were normal. Cystoscopic examination revealed a 2 cm vesico-vaginal fistula (VVF) located in the trigonal area within the safe zone, i.e., her both the ureteric openings were placed more than 1 cm away from the fistulous margins.

A 30 year old female presented with 4 months history of urinary incontinence following sub-total hysterectomy for the same reasons as mentioned above. She had 1.5 cm VVF located in the trigonal area in risky zone, i.e., her left ureteric opening was placed within 1 cm of the left margin of the fistula and required re-implantation of left ureter.

A 40 year old female, presented with 1 year history of continuous leakage of urine per-vaginum that she experienced in the immediate post-operative period following sub- total hysterectomy for similar reasons. Cystoscopic examination demonstrated a 3 cm VVF located in trigonal area within the risky zone, i.e., her both ureteric openings were abutting the left and right margins of the fistula and required bilateral ureteric re-implantation.

All the three VVFs were defined, dissected and closed using a combined transabdominal- transvesical approach (Swift Joly technique).₅ The cervical stumps were removed and the bladder and the vagina were closed at right angle to each other (bladder vertically and vaginal vault transversally) in two layers (inner continuous and outer interrupted) using 2 0 vicryl on round body needle. The right fallopian tube was held with a pair of Bab-cock forceps near its fimbrial and medial ligated end. The serosal covering of its mesentery was incised keeping 1 cm fringe of the serosa on both sides of the fallopian tube. The tube was mobilized till its vascular pedicle (Fig.1) and was split open at its anti-mesenteric border in its whole length from fimbrial end to the blind medial ligated end (fallopian tube flap). Its mucosal lining was excised after infiltration with 1:200,000 adrenaline solution in the sub-mucosa. The flap measured approximately 5-7 cm in length and 3-5 cm in width. The fallopian tube flap was brought down and its front margin was sutured with the anterior wall of the vagina, approximately 1 cm away from the suture line of the vaginal vault, taking partial thickness suture bites of continuous 2-0 vicryl on round-body needle (Fig.2). In all three patients following tubes were used, a) intra-abdominal pelvic drain (24 F), b) infant feeding tubes for cannulation of transplanted ureters (8 F), c) suprapubic cystostomy tube (28 F), and d) Foley’s catheter (18 F) for following purposes: (a) to prevent pelvic collection and haematoma, (b) for renal decompression, (c) to provide an alternate route for free drainage of urine in case the Foley’s catheter is blocked, and (d) to ascertain continuous bladder decompression, and all these tubings were removed on 5^th, 10^th, 15^th, and 20^th post-operative day, respectively.

The associated pelvic displacement of the ovary was tagged with silk sutures and recorded for its future identification/localization.