Removal of an Intravesical Gellhorn Pessary and Staged Repair of a Residual Large Vesico-Vaginal Fistula
April 14th, 2026
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.
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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Overview
This case report details the removal of an intravesical Gellhorn pessary and the management of a large vesicovaginal fistula in a 79-year-old woman. The patient presented with recurrent urinary tract infections and continuous urinary leakage, ultimately requiring a multidisciplinary surgical approach for successful management and fistula closure.
Key Study Components
Area of Science
- Urology
- Gynecology
- Pelvic reconstructive surgery
Background
- Gellhorn pessaries are used to manage pelvic organ prolapse.
- Long-term pessary use can lead to complications such as erosion, migration, and fistula formation.
- Vesicovaginal fistulas result in continuous urinary leakage and recurrent infections.
- Management of embedded intravesical devices is complex, especially in elderly, frail patients.
Purpose of Study
- To demonstrate a technique for removing an intravesical Gellhorn pessary embedded in the bladder.
- To describe the management of a large vesicovaginal fistula in a medically frail patient.
- To highlight outcomes following minimally invasive surgical intervention.
Methods Used
- Preoperative imaging with CT and MRI to localize the pessary and assess fistula size.
- Cystoscopy and vaginoscopy under anesthesia for direct visualization and attempted removal.
- Use of a guidewire through the pessary drainage port to provide counter-traction for mobilization.
- Transvaginal removal of the pessary through the fistula site using clamps.
- Latzko colpocleisis and suprapubic catheter placement for fistula closure and bladder drainage.
Main Results
- The embedded Gellhorn pessary was successfully removed transvaginally using a guidewire and clamps.
- Initial follow-up showed resolution of bladder inflammation but persistence of the fistula.
- Latzko colpocleisis with suprapubic catheterization led to fistula closure confirmed by cystography.
- The patient experienced no further leakage, normal voiding, and resolution of infections at last follow-up.
Conclusions
- Guidewire-assisted counter-traction is effective for removing embedded intravesical pessaries.
- Latzko colpocleisis is a viable option for fistula closure in elderly, frail patients.
- Multidisciplinary management can achieve favorable outcomes in complex urogenital cases.
Frequently Asked Questions
Executive Industry Relevance
Complex device-related urogenital injuries, such as embedded pessaries and large vesicovaginal fistulas, present significant challenges for translational research and device safety evaluation in biopharma R&D. This case highlights the need for robust preclinical models and quantitative endpoints to assess device-tissue interactions, complication risk, and repair strategies. Insights from such cases inform risk mitigation, mechanistic de-risking, and portfolio prioritization for device and surgical innovation pipelines.
Strategic Applications in Biopharma R&D
Early Discovery & Target Validation
- Supports mechanistic de-risking of device-tissue interface complications in preclinical models.
- Enables identification of biological pathways involved in chronic inflammation and fistula formation.
- Informs target validation for interventions aimed at reducing device-related tissue injury.
Screening & Assay Development
- Guides development of quantitative assays for tissue response to implanted devices.
- Facilitates standardization of endpoints for device migration, erosion, and fistula risk.
- Enables reproducible evaluation of removal techniques and repair strategies in model systems.
Translational & Preclinical Research
- Aligns preclinical models with clinically relevant complications such as fistula persistence and repair outcomes.
- Supports translational biomarker identification for tissue healing and device integration.
- Provides continuity from discovery of device complications to preclinical validation of mitigation strategies.
Pipeline & Workflow Integration
This case informs the continuum from device discovery and safety assessment through preclinical modeling of complications and translational evaluation of repair techniques.
- Discovery Biology: Clarifies mechanisms of device-induced tissue injury and chronic inflammation.
- Screening: Establishes quantitative endpoints for device migration, erosion, and removal feasibility.
- Analytics: Enables measurement of fistula size, tissue response, and repair success using imaging and cystography.
- Translational Research: Bridges clinical complication profiles with preclinical model development and biomarker alignment.
- Enterprise Reuse: Provides a framework for evaluating new device designs and repair strategies across R&D portfolios.
Operational & Enterprise Impact
- Scientific Value: Enhances predictive confidence in device safety and complication risk.
- Operational Value: Promotes standardization and reproducibility in device complication modeling and repair assessment.
- Strategic Value: Informs go/no-go decisions for device development and surgical innovation programs.
- Portfolio Impact: Supports risk-adjusted prioritization of device and repair technology candidates.
Implementation Considerations
- Requires multidisciplinary expertise in urology, gynecology, and surgical device evaluation.
- Demands advanced imaging and endoscopic instrumentation for quantitative assessment.
- Necessitates standardized protocols for complication modeling and repair outcome measurement.
- Must adapt endpoints and techniques for diverse patient populations and device types.
- Limited by the complexity of replicating chronic device complications in preclinical systems.