Name: Removal of an Intravesical Gellhorn Pessary and Staged Repair of a Residual Large Vesico-Vaginal Fistula (Video) | JoVE Journal
Uploaded: 2026-04-14T13:10:00.000+00:00
Duration: 4 min 22 s
Description: Learn guidewire-assisted removal of an intravesical Gellhorn pessary and staged Latzko colpocleisis repair for vesicovaginal fistula in elderly patients. This minimally invasive approach achieves successful fistula closure.

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5 minutes

This protocol was conducted in accordance with the guidelines of the UT Southwestern Medical Center Human Research Ethics Committee. The video was granted IRB exempt status. Written informed consent was obtained from the patient for surgical management and for the use of operative data and video for research and publication purposes.
1. Surgical removal of the pessary
<ol>
	<li>Preoperative preparation
	<ol>
		<li>Medical clearance was obtained, and anticoagulation therapy was discontinued according to institutional protocol.</li>
		<li>The indication for operative intervention was confirmed based on imaging and cystoscopic findings demonstrating an intravesical pessary with a vesicovaginal fistula.</li>
		<li>Prophylactic antibiotics (cefazolin 2 g IV and gentamicin 80 mg IV) and antifungal medication (fluconazole 200 mg IV) were administered.</li>
		<li>Albumin 5% (250 mL infusion) was prepared for intraoperative volume support if required.</li>
	</ol>
	</li>
	<li>Anesthesia and positioning
	<ol>
		<li>General anesthesia was induced with endotracheal intubation, and a non-depolarizing neuromuscular blocking agent was administered to achieve paralysis.</li>
		<li>Anesthetic depth and physiologic parameters were monitored using standard monitoring, including continuous ECG, pulse oximetry, capnography, and blood pressure monitoring.</li>
		<li>The patient was positioned in a low lithotomy position using Allen boot stirrups, and pneumatic compression devices were applied for venous thromboembolism prophylaxis.</li>
		<li>The abdomen and perineum were prepared and draped in a sterile fashion.</li>
		<li>Neuromuscular blockade was reversed at the conclusion of the procedure.</li>
	</ol>
	</li>
	<li>Operative setup
	<ol>
		<li>The operation field was prepared with the following instrumentation available: Scott retractor, Ring retractor, 5-French open-ended ureteral catheter, Glidewire, Long Allis clamps, Cystoscope (with 30-degree and 70-degree lenses), Thulium laser system, Monopolar electrocautery (Bovie), 15-blade scalpel, Suture scissors, 2-0 Vicryl sutures.</li>
		<li>The thulium laser delivered approximately 0.263 kJ of total energy during activation, and monopolar electrocautery was used with a grounding pad placed on the left lateral thigh with cut and coagulation settings between 30&#8211;60 W.</li>
	</ol>
	</li>
	<li>Initial vaginal exposure
	<ol>
		<li>Vaginal exposure was obtained using a Scott retractor and headlight illumination.</li>
		<li>The vesicovaginal fistula opening at the vaginal apex was identified, and direct communication between the vagina and bladder lumen was confirmed.</li>
	</ol>
	</li>
	<li>Cystoscopic assessment
	<ol>
		<li>A cystoscope was inserted transurethrally to evaluate the bladder. The bladder neck and left ureteric orifice were identified, while the right ureteric orifice could not be identified due to an inflammatory reaction.</li>
		<li>The pessary was confirmed to occupy the majority of the bladder lumen and inflammatory changes of the bladder wall were documented.</li>
		<li>Visualization of at least one ureteric orifice was confirmed prior to manipulation.</li>
	</ol>
	</li>
	<li>Attempted direct pessary division
	<ol>
		<li>Division of the exposed pessary segment was first attempted using electrocautery and subsequently with a thulium laser.</li>
		<li>When these methods were unsuccessful, the exposed pessary segment was incised using a 15-blade scalpel or scissors to obtain partial access. 
		NOTE: Synthetic pessary material resisted energy-based division due to its density and thermal properties, and mechanical disruption was required.</li>
	</ol>
	</li>
	<li>Guidewire-assisted mobilization technique
	<ol>
		<li>A 5-French open-ended ureteral catheter was inserted through a lateral drainage port of the pessary and was advanced through the catheter.</li>
		<li>The intravesical end of the wire was retrieved above the pessary using cystoscopic grasping forceps. The wire was exteriorized through the urethra.</li>
		<li>Controlled traction was applied to both ends of the guidewire. Lateral tilting of the pessary within the bladder was observed. 
		NOTE: Successful lateral displacement allowed visualization of the pessary edge at the fistula opening.</li>
	</ol>
	</li>
	<li>Transvaginal extraction
	<ol>
		<li>The superior and inferior edges of the pessary were grasped using long Allis clamps.</li>
		<li>The pessary was folded along its axis to reduce its transverse diameter, and gradual traction was applied through the vesicovaginal fistula tract until the pessary was delivered completely through the vagina.</li>
		<li>The mobilization process required approximately 10 minutes.</li>
	</ol>
	</li>
	<li>Management of associated vaginal injury
	<ol>
		<li>The anterior vaginal wall was inspected after pessary extraction.</li>
		<li>A small anterior vaginal tear was identified and was oversewn with interrupted 2-0 Vicryl sutures to achieve hemostasis.</li>
	</ol>
	</li>
	<li>Post-extraction cystoscopic reassessment
	<ol>
		<li>Repeat cystoscopy was performed through the urethra and fistula tract to evaluate the bladder.</li>
		<li>Adherent debris was removed from the bladder wall using grasping forceps to reduce the risk of future calculus formation.</li>
		<li>A 70-degree lens was used for enhanced visualization, and the ureteric orifices were reassessed to confirm that no retained pessary fragments remained. 
		NOTE: The bladder was inspected to confirm the absence of retained pessary fragments.</li>
	</ol>
	</li>
	<li>Final safety assessment and immediate postoperative care
	<ol>
		<li>A digital rectal examination was performed to confirm the absence of rectal wall injury.</li>
		<li>Free drainage of urine through the fistula tract was confirmed before removal of surgical retractors.</li>
		<li>Neuromuscular blockade was reversed, and the patient was extubated and transferred to the recovery unit in stable condition.</li>
		<li>The patient was admitted for overnight observation, and intravenous antibiotics were continued.</li>
		<li>Hemodynamic status was monitored due to intraoperative blood pressure variability.</li>
		<li>Estimated blood loss was approximately 50 mL, and the total operative time for pessary removal was 107 minutes.</li>
		<li>The entire pessary was sent to pathology for examination and documentation.</li>
		<li>Due to persistence of the vesicovaginal fistula, a staged transvaginal repair with Latzko colpocleisis was performed 4 months following pessary removal.</li>
	</ol>
	</li>
</ol>
2. Latzko colpocleisis and vesicovaginal fistula repair
<ol>
	<li>Preoperative setup and positioning
	<ol>
		<li>General anesthesia was induced with endotracheal intubation, and physiologic parameters were monitored using standard anesthetic monitoring throughout the procedure.</li>
		<li>The patient was positioned in the lithotomy position with pneumatic compression devices applied for venous thromboembolism prophylaxis</li>
		<li>The perineum and lower abdomen were then prepared and draped in a sterile fashion.</li>
	</ol>
	</li>
	<li>Rectal protection and vaginal exposure
	<ol>
		<li>A rectal pack soaked with povidone-iodine solution was inserted to protect the rectum and improve surgical exposure.</li>
		<li>Vaginal exposure was obtained using a Scott retractor and headlight illumination.</li>
	</ol>
	</li>
	<li>Initial cystoscopic evaluation
	<ol>
		<li>A 17.5-French cystoscope was inserted transurethrally to evaluate the bladder.</li>
		<li>The bladder was inspected, and the ureteral orifices were identified near the margins of the vesicovaginal fistula.</li>
		<li>The fistula dimensions were assessed and measured approximately 3.5&#8211;4 cm.</li>
		<li>Reduced bladder capacity was noted, which was attributed to longstanding intravesical pessary placement and chronic bladder decompression.</li>
		<li>Visualization of both ureteral orifices was confirmed before proceeding with fistula repair.</li>
	</ol>
	</li>
	<li>Intravesical botulinum toxin injection
	<ol>
		<li>A 21-French injection cystoscope was introduced, and botulinum toxin (20 units) was injected into the posterior bladder wall.</li>
		<li>The injections were distributed across 10 sites to reduce postoperative bladder spasms.</li>
	</ol>
	</li>
	<li>Suprapubic catheter placement
	<ol>
		<li>Sterile gauze was placed within the vagina to temporarily occlude the fistula opening, while the bladder was filled maximally using sterile irrigation.</li>
		<li>The patient was positioned in the Trendelenburg position, and a small suprapubic skin incision was made approximately one fingertip above the pubic symphysis.</li>
		<li>A spinal needle was introduced to guide safe bladder entry, after which a suprapubic catheter was inserted into the bladder.</li>
		<li>A 16-French Foley catheter was placed through the suprapubic tract, secured to the skin with suture, and left on continuous drainage. 
		NOTE: Bladder filling improved visualization and reduced the risk of bowel injury during suprapubic access.</li>
	</ol>
	</li>
	<li>Vaginal incision and tissue preparation
	<ol>
		<li>Healthy vaginal tissue distal to the fistula opening was identified.</li>
		<li>A circumferential incision was created approximately 4 cm from the urethral meatus anteriorly and 4 cm from the anal verge posteriorly.</li>
		<li>Epithelial tissue surrounding the fistula was excised to create a denuded surface of the bladder base and adjacent vaginal tissue, and redundant tissue around the fistula tract was removed.</li>
	</ol>
	</li>
	<li>Primary fistula closure and colpocleisis
	<ol>
		<li>Closure was initiated using two running 3-0 PDS sutures. The sutures were started at each lateral corner of the vaginal wall just distal to the fistulous tract.</li>
		<li>Both sutures were advanced toward the midline, completing closure of the vaginal cavity below the fistula.</li>
	</ol>
	</li>
	<li>Integrity testing
	<ol>
		<li>The bladder was filled via the suprapubic catheter using a Toomey syringe, while the repair site was inspected under direct vaginal visualization.</li>
		<li>The absence of fluid leakage confirmed a watertight closure.</li>
		<li>Measured bladder capacity during testing was approximately 90 mL.</li>
	</ol>
	</li>
	<li>Reinforcement of fistula repair
	<ol>
		<li>A running 3-0 V-Loc suture was placed to reinforce the primary closure layer.</li>
		<li>Additional interrupted 3-0 Vicryl sutures were placed beneath this layer to provide further tissue reinforcement.</li>
		<li>Tension-free tissue approximation and adequate hemostasis were confirmed before proceeding.</li>
	</ol>
	</li>
	<li>Post-repair cystoscopic confirmation
	<ol>
		<li>The cystoscope was reintroduced. The bladder was inspected using 30-degree and 70-degree lenses.</li>
		<li>Patency of the ureteral orifices and integrity of the fistula repair were confirmed.</li>
	</ol>
	</li>
	<li>Catheter placement
	<ol>
		<li>An 18-French Foley catheter was inserted transurethrally, and the suprapubic catheter was maintained to allow continuous bladder drainage.</li>
	</ol>
	</li>
	<li>Final closure and completion
	<ol>
		<li>The vaginal incision was closed using running and interrupted 3-0 Vicryl sutures to ensure layered approximation of the vaginal tissues.</li>
		<li>The rectal pack was removed, and a final digital rectal examination confirmed the absence of rectal injury.</li>
		<li>Surgical retractors were removed, and anesthesia was reversed.</li>
		<li>The patient was transferred to recovery in stable condition.</li>
		<li>The total operative time was 117 minutes with an estimated blood loss of 50 mL. No intraoperative complications occurred.</li>
	</ol>
	</li>
</ol>

<ol><li>Arias, B. E., Ridgeway, B., Barber, M. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Complications+of+neglected+vaginal+pessaries%3A+case+presentation+and+literature+review%5BTitle%5D)+AND+%22Int+Urogynecol+J+Pelvic+Floor+Dysfunct%22%5BJournal%5D)">Complications of neglected vaginal pessaries: case presentation and literature review.</a> Int Urogynecol J Pelvic Floor Dysfunct. 19 (8), 1173-1178 (2008).</li>
<li>Curtis, T. J., Chant, C., Quek, S., Giarenis, I., Gray, T. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Fistulae+Secondary+to+Vaginal+Pessary+Use+for+Pelvic+Organ+Prolapse%3A+A+Systematic+Review%5BTitle%5D)+AND+%22Int+Urogynecol+J%22%5BJournal%5D)">Fistulae Secondary to Vaginal Pessary Use for Pelvic Organ Prolapse: A Systematic Review.</a> Int Urogynecol J. 36 (3), 491-521 (2025).</li>
<li>Bodner-Adler, B., Hanzal, E., Pablik, E., Koelbl, H., Bodner, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Management+of+vesicovaginal+fistulas+%28VVFs%29+in+women+following+benign+gynaecologic+surgery%3A+A+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22PLoS+One%22%5BJournal%5D)">Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: A systematic review and meta-analysis.</a> PLoS One. 12 (2), e0171554(2017).</li>
<li>Rogo-Gupta, L., Le, N. B., Raz, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Foreign+body+in+the+bladder+11+years+after+intravaginal+pessary%5BTitle%5D)+AND+%22Int+Urogynecol+J%22%5BJournal%5D)">Foreign body in the bladder 11 years after intravaginal pessary.</a> Int Urogynecol J. 23 (9), 1311-1313 (2012).</li>
<li>Blaivas, J. G., Heritz, D. M., Romanzi, L. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Early+versus+late+repair+of+vesicovaginal+fistulas%3A+vaginal+and+abdominal+approaches%5BTitle%5D)+AND+%22J+Urol%22%5BJournal%5D)">Early versus late repair of vesicovaginal fistulas: vaginal and abdominal approaches.</a> J Urol. 153 (4), discussion 1112-1113 1110-1112 (1995).</li>
<li>Wei, N., Pfeuti, C., Linder, B. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Contemporary+genitourinary+fistula+management%3A+treatment%2C+trends%2C+and+innovations%5BTitle%5D)+AND+%22Curr+Opin+Obstet+Gynecol%22%5BJournal%5D)">Contemporary genitourinary fistula management: treatment, trends, and innovations.</a> Curr Opin Obstet Gynecol. 37 (6), 432-437 (2025).</li>
<li>Goldsberry, W., Metzinger, D. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Robotic+Cystotomy+for+Pessary+Extraction+With+Vesicovaginal+Fistula+Repair%5BTitle%5D)+AND+%22J+Minim+Invasive+Gynecol%22%5BJournal%5D)">Robotic Cystotomy for Pessary Extraction With Vesicovaginal Fistula Repair.</a> J Minim Invasive Gynecol. 24 (5), 722-723 (2017).</li>
<li>Shamout, S., Anderson, K., Baverstock, R., Carlson, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Evaluation+of+surgical+approaches+for+vesicovaginal+fistulae+repair%3A+the+case+for+transvaginal+repair+as+the+gold+standard%5BTitle%5D)+AND+%22Int+Urogynecol+J%22%5BJournal%5D)">Evaluation of surgical approaches for vesicovaginal fistulae repair: the case for transvaginal repair as the gold standard.</a> Int Urogynecol J. 32 (9), 2429-2435 (2021).</li>
<li>Randazzo, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Best+Practices+in+Robotic-assisted+Repair+of+Vesicovaginal+Fistula%3A+A+Consensus+Report+from+the+European+Association+of+Urology+Robotic+Urology+Section+Scientific+Working+Group+for+Reconstructive+Urology%5BTitle%5D)+AND+%22Eur+Urol%22%5BJournal%5D)">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.</a> Eur Urol. 78 (3), 432-442 (2020).</li>
<li>Mörgeli, C., Tunn, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Vaginal+repair+of+nonradiogenic+urogenital+fistulas%5BTitle%5D)+AND+%22Int+Urogynecol+J%22%5BJournal%5D)">Vaginal repair of nonradiogenic urogenital fistulas.</a> Int Urogynecol J. 32 (9), 2449-2454 (2021).</li>
<li>Jung, U. S., Lee, J. H., Kyung, M. S., Kim, K. H., Choi, J. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+removal+of+an+intravesical+foreign+body+after+laparoscopically+assisted+vaginal+hysterectomy%3A+a+case+report+and+review+of+the+literatures%5BTitle%5D)+AND+%22Surg+Laparosc+Endosc+Percutan+Tech%22%5BJournal%5D)">Laparoscopic removal of an intravesical foreign body after laparoscopically assisted vaginal hysterectomy: a case report and review of the literatures.</a> Surg Laparosc Endosc Percutan Tech. 18 (4), 420-422 (2008).</li>
<li>Eilber, K. S., Kavaler, E., Rodríguez, L. V., Rosenblum, N., Raz, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Ten-year+experience+with+transvaginal+vesicovaginal+fistula+repair+using+tissue+interposition%5BTitle%5D)+AND+%22J+Urol%22%5BJournal%5D)">Ten-year experience with transvaginal vesicovaginal fistula repair using tissue interposition.</a> J Urol. 169 (3), 1033-1036 (2003).</li>
<li>Tang, M., Li, P., Wang, C., Zhang, Q., Meng, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Clinical+application+of+single-layer+annular+vaginal+flap+in+transvaginal+repair+for+vesicovaginal+fistula%5BTitle%5D)+AND+%22World+J+Urol%22%5BJournal%5D)">Clinical application of single-layer annular vaginal flap in transvaginal repair for vesicovaginal fistula.</a> World J Urol. 41 (1), 249-255 (2023).</li>
<li>Roberts, B. L., Chang, E. S., Hidalgo, R. J., Wiegand, L. R., Wyman, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Vesicovaginal+fistula+repair+at+the+time+of+colpocleisis%5BTitle%5D)+AND+%22Int+Urogynecol+J%22%5BJournal%5D)">Vesicovaginal fistula repair at the time of colpocleisis.</a> Int Urogynecol J. 32 (7), 1939-1940 (2021).</li>
</ol>

The authors have no conflicts of interest to disclose.

Intravesical migration of vaginal pessaries with subsequent vesicovaginal fistula formation is very rare but presents a complex reconstructive scenario, particularly when the foreign body has been retained for a prolonged period. In the present case, the pessary had remained 
in situ for approximately 2.5 years without manipulation, resulting in extensive inflammatory changes of the bladder wall, contraction of bladder capacity, and distortion of local anatomy. Under these circumstances, staged management was select...

Pelvic organ prolapse (POP) is a prevalent condition among older women, with pessary use representing a cornerstone of conservative management, particularly for those who are poor surgical candidates or prefer to avoid surgery. Pessaries, including the Gellhorn type, are generally safe and effective when accompanied by regular follow-up and appropriate patient education. Despite their utility, pessaries are associated with a spectrum of complications, most commonly vaginal discharge, bleeding, and vaginal erosions1. More severe outcomes, such as vesicovaginal and rectovaginal fistulae, are rare but well-documented, especially in the context of neglected pessary care or prolonged indwelling time.2,3 Intravesical migration of a pessary has been reported only rarely in the literature4. Management requires surgical extraction of the pessary from the bladder, followed by repair of the resultant vesicovaginal fistula.
Case Presentation: 
A 79-year-old G5P5 woman was referred three years after Gellhorn pessary placement for symptomatic bladder and uterine prolapse with recurrent urinary tract infections (UTI) and continuous urinary incontinence secondary to a vesicovaginal fistula. The prolapse was noticed several years prior to her presentation, and pessary placement was favored due to the patient&#8217;s desire for a conservative approach and sexual inactivity. The pessary had not been changed or examined for approximately two years prior to presentation.
Diagnosis, Assessment, and Plan: 
The patient presented with symptoms of bladder pain, severe, continuous incontinence, and recurrent urinary tract infection (UTI). A CT scan of her abdomen and pelvis demonstrated 
an intravesical position of the Gellhorn pessary (Figure 1). Office cystoscopy revealed bladder neck edema, occlusion of the right ureteral orifice, and the dome of the pessary fully occupying the bladder lumen. Vaginoscopy demonstrated the tip of the pessary resting on the posterior vaginal wall with a large fistulous tract connecting to the bladder. The patient was placed on daily nitrofurantoin prophylaxis to prevent UTI while definitive surgical management was planned. She required presurgical clearance due to a complex history of atrial fibrillation and anticoagulant therapy. Several management options were considered in planning her care. 
The first priority was the removal of the Gellhorn pessary. A transvaginal approach was preferred, given her age and comorbidities, with a goal of excision without enlarging the fistula tract. The patient also consented to a possible open cystotomy in case a vaginal extraction was not feasible.
Objectives 
The objective of this report is to demonstrate a transvaginal technique for the removal of a large intravesical pessary using guidewire-assisted mobilization, followed by staged vesicovaginal fistula repair with Latzko colpocleisis. The following protocol outlines the operative steps, technical considerations, and perioperative management used to safely extract the foreign body and achieve definitive fistula closure.

<table><tbody><tr><td>15 blade knife</td><td>Aspen Surgical</td><td>DYNJZ07231</td><td></td></tr><tr><td>Absorbable sutures</td><td>Johnson and Johnson</td><td>J216H</td><td>Vicryl</td></tr><tr><td>Bovie Cautery</td><td>Symmetry Surgical</td><td>ESP1</td><td></td></tr><tr><td>Glidewire</td><td>Olympus</td><td>RF*GA35151A</td><td></td></tr><tr><td>Lonestar retractor</td><td>Medline</td><td>DYNJ83152</td><td></td></tr><tr><td>Telescope (4 mm, 70&amp;deg; direction of view, autoclavable)</td><td>Olympus</td><td>A22003A</td><td>WA2T470A</td></tr><tr><td>Telescope (4 mm, long, 70&amp;deg; direction of view, autoclavable)</td><td>Olympus</td><td>WA20023A</td><td>&amp;nbsp;Long Scope/Male</td></tr><tr><td>Ureteral catheter</td><td>Utah Medical</td><td>4195005</td><td>5-French</td></tr></tbody></table>

removal of an intravesical gellhorn pessary and staged repair of a residual large vesico-vaginal fistula

Removal of an Intravesical Gellhorn Pessary and Staged Repair of a Residual Large Vesico-Vaginal Fistula

This case report demonstrates the removal of an intravesical Gellhorn pessary and management of a large vesicovaginal fistula. A 79-year-old woman with a history of pelvic organ prolapse treated with a Gellhorn pessary three years prior presented with recurrent urinary tract infections and continuous urinary leakage. CT imaging showed the pessary to be intravesical. After surgical clearance, she underwent cystoscopy and vaginoscopy under anesthesia with the goal of transvaginal removal. The pessary was fully embedded in the bladder lumen and could not be mobilized using laser transection, cutting, or grasping techniques. A guidewire was passed through a pessary drainage port and retrieved endoscopically, allowing counter-traction to gradually mobilize the pessary sideways. It was grasped with clamps and removed transvaginally through the large fistula site. Two-month follow-up cystoscopy showed resolution of bladder inflammation. MRI with vaginal contrast demonstrated a persistent large vesicovaginal fistula. Due to age and medical frailty, she underwent Latzko colpocleisis with suprapubic catheter placement for bladder drainage. At four weeks, cystography confirmed fistula closure. At the last follow-up, the patient reported no leakage, normal voiding, and resolution of infections.

The operative time for transvaginal pessary removal was 107 minutes, with an estimated blood loss of 50 mL. A staged vesicovaginal fistula repair with Latzko colpocleisis was subsequently performed with an operative time of 117 minutes and an estimated blood loss of 50 mL. Technical success was defined as complete transvaginal removal of the intravesical pessary without conversion to an abdominal or suprapubic cystotomy and without intraoperative injury to adjacent pelvic organs. This endpoint was achieved in the present...

This case demonstrates transvaginal removal of an intravesical Gellhorn pessary in an elderly woman, following which a residual large vesicovaginal fistula was managed with a Latzko colpocleisis. Long-term follow-up confirmed fistula closure, complete bladder drainage, and resolution of recurrent urinary infections.

This case report demonstrates the removal of an intravesical Gellhorn pessary and management of a large vesicovaginal fistula. A 79-year-old woman with a ...

A 79-year-old woman with an intravesical Gellhorn pessary and vesicovaginal fistula underwent transvaginal pessary removal followed by staged Latzko colpocleisis repair. Chronic inflammation, a large apical fistula, and sexual inactivity favored staged transvaginal extraction and Latzko colpocleisis over more invasive abdominal approaches. After exposing the vaginal area, a cystoscope was inserted transurethrally to evaluate the bladder.The bladder neck and left ureteric orifice were identified while the right ureteric orifice could not be identified due to an inflammatory reaction. The Gellhorn pessary was confirmed to occupy the majority of the bladder lumen and inflammatory changes of the bladder wall were documented. Then a 5 French open-ended ureteral catheter was inserted through a lateral drainage port of the pessary and was advanced further.The intravesical end of the wire was retrieved above the pessary using cystoscopic grasping forceps and the wire was exteriorized through the urethra. Controlled traction was applied to both ends of the guide wire and a lateral tilting of the pessary was observed within the bladder. After grasping the pessary, it was folded along its axis to reduce its transverse diameter and gradual traction was applied through the vesicovaginal fistula tract until the pessary was delivered completely through the vagina.Cystoscopy was repeated through the urethra and fistula tract to evaluate the bladder. Finally, adherent debris was removed from the bladder wall using grasping forceps to reduce the risk of future calculus formation. Computed tomography imaging showed a Gellhorn pessary within the bladder lumen in coronal and sagittal views in a 79-year-old woman who had been treated with the pessary for pelvic organ prolapse three years earlier.Postoperative sagittal T2 weighted MRI obtained 80 days after pessary removal showed a persistent vesicovaginal fistula extending between the bladder and the upper third of the vagina. The fistula was subsequently repaired and colpocleisis was performed. A follow-up voiding cystourethrogram after four weeks confirmed closure of the fistula.Challenges during the treatment included the pessary resisting cutting and obscured anatomy. Guidewire-assisted traction enabled transvaginal extraction and delayed repair allowed inflammation to resolve before definitive closure. The key takeaway from this study is that guidewire-assisted transvaginal extraction and staged Latzko repair offer a reproducible, minimally invasive option for selected intravesical pessary cases.The patient recovered well and long-term follow-up showed fistula closure, complete bladder emptying, resolution of urinary leakage and recurrent infections, and successful catheter removal.

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Medicine

Here, we present an elaborate and efficient protocol to treat isolated short bulbar or posterior urethral strictures with vessel-sparing excision and primary anastomosis.

Vessel-sparing Excision and Primary Anastomosis

This protocol presents the clinical application of a 24 G cannula and 3-0 polypropylene suture as a simple and effective method for the exploration of the vas deferens.

Clinical Application of 24 G Cannula Needle and 3-0 Polypropylene Suture in Vas Deferens Exploration

This protocol introduces the clinical application of seminal vesicle endoscopy combined with holmium laser in the treatment of ejaculatory duct obstruction caused by ejaculatory duct cyst.

Treatment of Ejaculatory Duct Obstruction by Seminal Vesiculoscopy Assisted Flow Modification

This article introduces a surgical method using a pedicled tunica vaginalis to treat long-segment urethral stricture resulting from lichen sclerosus. The tunica vaginalis is an excellent substitute for the urethra, leading to quick postoperative recovery for patients.

Urethroplasty with Pedicled Tunica Vaginalis for the Treatment of Long-segment Anterior Urethral Stricture Caused by Lichen Sclerosus of Glans Penis

Here we introduce a novel approach known as laparoscopic non-mesh cerclage pectopexy with uterine preservation for pelvic organ prolapse (LNMCPUP) for patients who wish to preserve their uterus. Permanent cerclage sutures are used to suspend the uterus to the iliopectineal ligament through the round ligament.

Laparoscopic Non-Mesh Cerclage Pectopexy with Uterine Preservation for Pelvic Organ Prolapse

This article explains a new animal model designed for testing suburethral graft materials. In this model, a mesh tape is implanted through a vaginal incision in ewes, and the animals are observed over a three-month period. This model is essential as it lays the foundation for experimental research on grafts.

A Novel Surgical Technique in a Sheep Model for Suburethral Graft Implantation

Establishing an orthotopic bladder tumor model to evaluate antitumor effects of intravesically delivered saRNA and monitoring tumor growth by ultrasound and bioluminescent imaging.

An Orthotopic Bladder Tumor Model and the Evaluation of Intravesical saRNA Treatment

The goal is to produce an arteriovenous fistula that is simple and reproducible. This method does not use sutures or glue adhesive. Therefore the samples can be used with the least amount of foreign materials for analysis.

Technical Aspects of the Mouse Aortocaval Fistula

Most studies involving the Langendorff apparatus use small animal models due to the increased complexity of systems for larger mammals. We describe a Langendorff system for large animal models that allows for use across a range of species, including humans, and relatively easy data acquisition.

An Isolated Working Heart System for Large Animal Models

During mammalian development, early gestational skin wounds heal without a scar. Here we detail a reliable and reproducible model of fetal scarless wound healing in the cutaneous dorsum of E16.5 (scarless) and E18.5 (scarring) mouse embryos.

A Mouse Fetal Skin Model of Scarless Wound Repair

Learn guidewire-assisted removal of an intravesical Gellhorn pessary and staged Latzko colpocleisis repair for vesicovaginal fistula in elderly patients. This minimally invasive approach achieves successful fistula closure.

Removal of an Intravesical Gellhorn Pessary and Staged Repair of a Residual Large Vesico-Vaginal Fistula

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