Individualized Surgical Repair of Iatrogenic Ureterovaginal Fistula: A Single-Center Experience with 29 Cases

Individualized Surgical Repair of Iatrogenic Ureterovaginal Fistula: A Single-Center Experience with 29 Cases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Individualized Surgical Repair of Iatrogenic Ureterovaginal Fistula: A Single-Center Experience with 29 Cases Xinyan Yan, Haicun Zhou, Weilin Pu, Pingping Zhou, Xiaqin Huo, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9045088/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Iatrogenic ureterovaginal fistula (UVF) is a severe complication primarily arising from gynecologic surgery, most commonly hysterectomy. It leads to continuous urinary leakage, causing significant physical, emotional, and social distress. Optimal management remains challenging due to variations in fistula etiology, anatomy, and timing of diagnosis. This study evaluates the outcomes of a tailored, stepwise surgical approach for UVF based on individual fistula characteristics. Methods A retrospective analysis was conducted on 29 female patients with iatrogenic UVF treated at a single tertiary center between January 2018 and December 2023. Individualized treatment strategies were determined based on fistula size, location, ureteral defect length, and tissue viability. Surgical techniques included ureteroscopic stenting, ureteroneocystostomy, Boari flap, ileal ureter replacement, appendiceal ureteroplasty, and ovarian vein graft. The primary outcome was surgical success, defined as resolution of urine leakage without additional intervention. Secondary outcomes included complications and renal function. Results The overall success rate was 89.7% (26/29) after a median follow-up of 21 months (range, 12–36). Endoscopic stenting was effective in 71.4% of early, small fistulas. Open surgical procedures—including ureteroneocystostomy, Boari flap, and ileal ureter replacement—achieved 100% success within their indications. Complex reconstructions using appendix or ovarian vein had variable outcomes (50–66.7%). Postoperative complications occurred in 6 patients (20.7%), most of which were Clavien-Dindo Grade I or II. Conclusion Management of iatrogenic UVF requires a personalized, stepwise approach. Simple, early fistulas may be managed with endoscopic stenting, but most cases—particularly those involving longer or more complex defects—are best treated with open reconstructive techniques. A structured algorithm based on fistula characteristics facilitates optimal outcomes. Ureterovaginal fistula Iatrogenic injury Ureteral reconstruction Surgical repair Female pelvic surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Ureterovaginal fistula (UVF) represents one of the most distressing complications in female pelvic surgery, characterized by continuous urinary leakage per vagina, leading to significant physical discomfort, psychological distress, and social isolation [ 1 , 2 ]. While obstetric trauma remains a leading cause of urogenital fistulas in developing nations, iatrogenic injury during gynecologic surgery—particularly hysterectomy—constitutes the predominant etiology in developed countries [ 1 , 4 ]. The reported incidence of ureteral injury during gynecologic procedures ranges from 0.3% to 3%, with laparoscopic and radical oncological procedures carrying higher risk [ 2 , 5 ]. The pathophysiology of iatrogenic UVF typically involves unrecognized ureteral injury—either partial transection, devascularization, or crush injury from ligature placement—that progresses to necrosis and subsequent fistula formation between the ureter and vaginal cuff [ 8 ]. Delayed diagnosis or inappropriate initial management can lead to irreversible renal impairment, complex fistulas, and failed repairs, underscoring the need for timely and appropriate intervention [ 7 ]. The optimal treatment strategy for UVF remains incompletely standardized and depends on multiple factors: time of diagnosis, fistula size and location, length of ureteral defect, viability of surrounding tissues, and surgeon expertise [ 1 , 10 ]. Historically, open surgical repair constituted the cornerstone of treatment. However, advancements in minimally invasive techniques and evolving understanding of reconstructive principles have expanded the therapeutic armamentarium, ranging from conservative endoscopic stenting to complex autologous tissue replacement [ 3 , 4 ]. Despite existing literature, there is a paucity of studies that systematically analyze diversified surgical strategies for UVF based on structured fistula classification. This study aims to present our single-center experience with 29 cases of iatrogenic UVF, focusing on a tailored, stepwise approach to repair. We describe clinical presentation, diagnostic workup, and critically evaluate outcomes of various surgical techniques, aiming to provide a pragmatic algorithm for managing this complex condition. Materials and Methods Study Design and Population A retrospective cohort study was conducted on all patients diagnosed and treated for iatrogenic UVF at our center between January 2018 and December 2023. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee (Approval No.: [2021]GSFY054). The need for informed consent was waived due to the retrospective nature of the study. Patient Selection and Data Collection Medical records of patients with a confirmed diagnosis of UVF were reviewed. The diagnosis was established based on clinical history (continuous urinary incontinence following pelvic surgery), physical examination, and confirmed by imaging studies including computed tomography urography (CTU) and/or retrograde pyelography. Cystoscopy with methylene blue test was routinely performed to rule out concomitant vesicovaginal fistula. Data extracted included patient demographics, etiology of the initial surgery, clinical presentation, time to diagnosis, fistula characteristics (laterality, location, estimated length), diagnostic modalities, surgical procedures performed, intraoperative details, postoperative course, and follow-up data. Key patient characteristics are summarized in Table 1. Management Protocol and Surgical Techniques Management Protocol and Surgical Techniques The management strategy was individualized based on comprehensive assessment following a structured algorithm (Fig. 1 ). Treatment selection considered: (1) time from inciting surgery to diagnosis, (2) fistula size and location, (3) estimated length of ureteral defect, (4) degree of ipsilateral renal function impairment, (5) tissue healing capacity and degree of surrounding inflammation, and (6) prior surgical history. Ureteroscopic Double-J Stent Placement This was considered as first-line treatment for patients with early-diagnosed (≤ 14 days), small-caliber fistulas (< 2 cm) where a guidewire could be successfully passed across the fistula site during cystoscopy/ureteroscopy. Stents were maintained for 6–8 weeks followed by repeat imaging. Definitive Surgical Repair Surgical intervention was indicated for large fistulas (> 2 cm), failure of conservative management, late presentation (> 14 days), or when endoscopic access was not feasible. The choice of open procedure was guided by the extent and length of the ureteral defect. Ureteroneocystostomy Performed for distal ureteral defects ≤ 4–5 cm, utilizing extravesical (Lich-Gregoir) or intravesical (Politano-Leadbetter) approaches with psoas hitch when indicated. Boari Flap : Employed for mid-ureteral defects, creating a bladder flap tubularized over a ureteral stent. Figure 1 .Ureterovaginal fistula and Boari flap reconstruction.A Computed Tomography Urography (CTU) shows distal fistula of the left ureter; B Contrast agent was seen in the vagina;C Intraoperative photograph showing a distal ureterovaginal fistula, Necrosis of the distal ureter;D Creation of a Boari bladder flap: the bladder is mobilized and a broad-based flap is raised; E Completed Boari flap anastomosis: the tubularized flap is anastomosed to the proximal ureter over a double-J stent. Appendiceal Ureteroplasty Considered for right-sided defects of moderate length (3–8 cm) in patients with suitable appendix. Figure 2 Appendiceal ureteroplasty for right-sided ureteral defect. A Magnetic Resonance Urography (MRU) show Long-segment defect of the right ureter following injury, Hydronephrosis on the right renal pelvis and proximal ureteral dilation. B Appendix isolated on its mesoappendix, demonstrating adequate length and vascular supply. C Final appearance after appendiceal interposition, restoring ureteral continuity.D Two weeks after the operation, the reexamination of CTU showed that the right ureter had healed well and hydronephrosis had disappeared. Ileal Ureter Replacement Utilized for extensive ureteral loss > 12 cm, with isoperistaltic ileal segment interposition. Figure 3 Ileal ureter replacement for left-sided long-segment defect. A CTU show Extensive left ureteral defect not amenable to bladder-based reconstruction. B Isoperistaltic ileal segment isolated and prepared for interposition. C After the operation, the reexamination of CTU showed that the left-sided ureter had recover well and hydronephrosis had disappeared. Ovarian Vein Graft Employed as an alternative autologous tissue for select cases where bowel interposition was contraindicated.Ovarian vein graft for ureteral reconstruction. A CTU show Extensive left ureteral defect not amenable to bladder-based reconstruction.B-C Harvested ovarian vein with its vascular pedicle. D Ovarian vein graft The defective mulberry was replaced and anastomosed to the residual end of the ureter and the bladder respectively. E After the operation, the reexamination of CTU showed that the left-sided ureter had recover well and hydronephrosis had disappeared. Outcome Measures and Statistical Analysis The primary outcome measure was surgical success rate, defined as resolution of urinary leakage confirmed clinically and radiologically (via CTU or intravenous urography) during follow-up, without need for further surgical intervention. Secondary outcomes included operative time, estimated blood loss, intraoperative and postoperative complications graded according to the Clavien-Dindo classification [ 12 ], and changes in renal function. Descriptive statistics were used for data analysis. Continuous variables were presented as mean ± standard deviation or median with range, as appropriate. All analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Results Patient Characteristics and Fistula Details A total of 29 female patients with a mean age of 49.0 ± 9.8 years (range: 32–71 years) were included in the study. Table 1 summarizes baseline demographic and clinical characteristics. The most common etiology was gynecologic surgery for malignancy (n = 16, 55.2%), followed by surgery for benign conditions (n = 8, 31.0%). All patients presented with continuous urinary leakage per vagina (100%). The median time from inciting surgery to UVF diagnosis was 14 days (range: 5–45 days), with 14 patients (48.3%) diagnosed within the first 2 weeks postoperatively. Treatment Outcomes The distribution of surgical procedures and their outcomes are presented in Table 3. A total of 29 patients underwent 32 procedures (3 patients required repeat intervention after initial failed management). N/A not applicable, SD standard deviation The overall success rate after a single procedure was 89.7% (26/29) over a median follow-up of 21 months (range: 12–36 months). Ureteroscopic stenting was successful in 5 patients (71.4%). Two failures occurred due to early stent occlusion (n = 1) and persistent leakage (n = 1), both subsequently managed successfully with ureteroneocystostomy. All open surgical procedures utilizing bladder (ureteroneocystostomy, Boari flap) or ileum (ileal ureter replacement) demonstrated 100% success rates. Among the two failures in complex reconstructions, one occurred after appendiceal ureteroplasty (anastomotic stricture at 4 months requiring reoperation with ileal ureter) and one after ovarian vein graft (stricture at 6 months successfully managed with endoscopic dilation and long-term stenting). Postoperative Complications and Follow-up Postoperative complications occurred in 6 patients (20.7%) (Table 4). Most were Clavien-Dindo grade I or II, including urinary tract infection (n = 3), transient ileus (n = 2), and wound infection (n = 1). Two cases of anastomotic stricture (one after appendiceal and one after ovarian vein repair) were classified as grade IIIb complications requiring surgical intervention. Renal function remained stable throughout follow-up, with mean serum creatinine of 79.8 ± 16.2 µmol/L postoperatively compared with 82.4 ± 18.6 µmol/L preoperatively. Postoperative imaging demonstrated resolution of hydronephrosis in most patients, with only one patient (following ovarian vein graft) exhibiting persistent mild hydronephrosis managed conservatively. Discussion This study reinforces the principle that successful management of UVF hinges on a precise, individualized approach tailored to specific fistula characteristics. Our overall success rate of 89.7% aligns favorably with contemporary literature, which reports success rates between 85% and 95% for various repair techniques in the modern era [2, 6, 7]. Endoscopic Management Our findings confirm that endoscopic stenting, while minimally invasive, has a limited but important role and is best reserved for highly selected cases—typically small, recent fistulas without significant tissue loss or ischemia [1, 10]. The 71.4% success rate in our cohort aligns with recent series reporting 70-85% success in appropriately selected patients [2, 7]. Two important observations emerge from our experience with endoscopic management: first, successful stent placement across the fistula site is prerequisite and should not be forced; second, even with successful stenting, close radiographic follow-up is essential to detect delayed failures. We recommend stent removal at 6-8 weeks with repeat imaging 4-6 weeks thereafter to confirm durable fistula closure. Minimally Invasive Surgical Approaches Recent literature demonstrates a paradigm shift toward minimally invasive reconstruction for UVF [3-5]. Valecha et al. reported that robot-assisted laparoscopic repair offers superior magnified 3D visualization and improved dexterity, leading to enhanced dissection and suturing, particularly beneficial in complex and recurrent fistulae [5]. Similarly, Tătaru et al. demonstrated in a systematic review that single-port robotic approaches for ureteral reconstruction are feasible with low morbidity, though comparative data remain limited [3]. Bajoria et al. reported excellent outcomes with laparoscopic ureteroneocystostomy in 13 UVF patients, with mean operative time of 140 minutes and no major complications [2]. Bladder-Based Reconstruction Open surgical reconstruction, particularly ureteroneocystostomy and the Boari flap procedure, continues to provide definitive and highly reliable outcomes. These techniques benefit from utilizing well-vascularized bladder tissue, ensuring tension-free anastomosis, and remain the gold standard for distal and mid-ureteral defects [9, 15]. Kumar et al. reported 100% success in 12 patients undergoing robot-assisted ureteral reimplantation and Boari flap procedures following gynecologic injuries, with no recurrences at mean follow-up of 35 months [9]. The consistently excellent outcomes with these approaches suggest they should remain the first-line surgical options for most distal and mid-ureteral fistulas. Both procedures can be performed through a Pfannenstiel incision with extraperitoneal approach, minimizing morbidity while providing excellent exposure. Intestinal Reconstruction For the most complex scenarios involving long-segment ureteral loss (>12 cm), ileal interposition yields excellent results, consistent with its established role as a robust solution for extensive defects [16]. Kocot et al. reported long-term success rates exceeding 90% with ileal ureter replacement, though the potential for metabolic complications (hyperchloremic metabolic acidosis) and mucous production necessitates careful patient selection [16]. We routinely perform preoperative bowel preparation and employ antirefluxing techniques when feasible, though the necessity of antireflux mechanisms in ileal ureter replacement remains debated. Alternative Autologous Tissues The use of alternative tissues such as the appendix and ovarian vein represents more novel approaches. Appendiceal ureteroplasty is an elegant solution for right-sided defects, but its success is highly dependent on a healthy, well-vascularized appendix and meticulous technique [17]. Our single failure in this subgroup occurred early in the series and likely reflected suboptimal tissue handling. Careful preoperative evaluation of the appendix (when feasible) and intraoperative assessment of vascular supply are essential. The appendix offers the advantage of a caliber similar to the ureter and absence of mucous production, but its limited length restricts applicability to defects <8 cm. The ovarian vein graft represents an innovative autologous option with theoretical advantages: it is readily available within the same surgical field, avoids bowel anastomosis, and preserves peritoneal integrity. However, our variable success rates (66.7%) suggest caution is warranted. The ovarian vein may be prone to late stenosis due to its thin wall and lack of inherent peristalsis, suggesting it should be considered when other options are exhausted or contraindicated [17]. Some authors have reported improved outcomes with ovarian vein grafts when combined with omental wrapping to enhance vascular supply. Treatment Algorithm A key strength of our management protocol was its stepwise and individualized nature. Based on our cumulative experience and aligned with contemporary recommendations [1, 4, 10], we propose the following algorithmic approach: 1.Early diagnosis (≤14 days) + small fistula (<2 cm) + guidewire passage feasible → Ureteroscopic stenting 2.Failed stenting or late diagnosis + distal/mid ureteral defect ≤4-5 cm → Ureteroneocystostomy ± psoas hitch (consider laparoscopic/robotic approach if expertise available) 3.Mid ureteral defect 5-12 cm + adequate bladder capacity → Boari flap 4.Extensive defect >12 cm → Ileal ureter replacement 5.Right-sided defect 3-8 cm + suitable appendix → Consider appendiceal ureteroplasty 6.Complex reoperative field + bowel contraindicated → Consider ovarian vein graft (with caution) This approach minimizes unnecessary morbidity while ensuring definitive repair for complex cases. Decision-making should always consider patient factors, surgeon expertise, and institutional resources. The increasing adoption of robotic platforms may further expand minimally invasive options for these complex reconstructions [3, 5]. Study Limitations Limitations of this study include its retrospective design, relatively small sample size for some surgical subgroups, and inherent selection bias in treatment allocation. The single-center nature may limit generalizability, though it ensures consistency in surgical technique and perioperative care. Follow-up duration (median 21 months) may not capture very late complications such as anastomotic strictures or metabolic disturbances. Additionally, we lacked standardized patient-reported outcome measures to assess quality of life impact.Larger, prospective, multi-institutional studies would be valuable to validate a standardized treatment algorithm. Future research should focus on comparative effectiveness of different techniques, long-term functional outcomes, and patient-centered endpoints. The role of robotic-assisted minimally invasive reconstruction for UVF represents an evolving area warranting further investigation. Conclusions The management of iatrogenic ureterovaginal fistula requires a sophisticated, individualized approach.Atreatment strategy tailored to fistula characteristics—employing endoscopic stenting for select simple cases and advancing to complex reconstruction using bladder, intestinal, or other autologous tissues for larger defects—leads to successful outcomes in approximately 90% of patients [ 2 , 6 , 7 ]. Ureteroneocystostomy and Boari flap procedures remain the cornerstone of repair for most distal and mid-ureteral fistulas, with minimally invasive approaches offering comparable success and reduced morbidity [ 3 , 5 , 9 ]. Ileal interposition provides a robust option for extensive defects [ 16 ]. Alternative tissues such as appendix and ovarian vein have selective applicability with variable outcomes. Surgeons managing this condition must be proficient in a range of techniques to offer optimal patient care in an era of rapidly evolving reconstructive options [ 1 , 4 , 10 ]. Declarations Acknowledgements The authors thank the patients who participated in this study and the surgical and nursing staff of the Department of Urology and Gynecology for their dedicated care. Authors’ Contributions XY and HZ contributed to study design and patient recruitment. WP and PH performed data analysis. XH and WC participated in surgical procedures. HZ and XY drafted the manuscript. All authors reviewed and approved the final version. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data Availability The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethics Approval and Consent to Participate All procedures performed in this study were in accordance with the ethical standards of the Institutional Review Board of the Maternal and Child Health Hospital of Gansu Province (also known as Gansu Province Central Hospital), Lanzhou, China. The study was approved under the ethics approval number [2021]GSFY054. Given the retrospective nature of the study and the use of anonymized patient data, the need for informed consent from individual participants was waived by the ethics committee. Consent for Publication This manuscript does not contain any identifiable personal or clinical details, images, or videos of individual participants that could compromise anonymity. Therefore, consent for publication is not applicable . Should any such material be included in future revisions or related submissions, appropriate written informed consent for publication will be obtained and documented. Competing Interests The authors declare that they have no competing interests. Clinical trial number Clinical trial number: not applicable References Wei N, Pfeuti C, Linder BJ. Contemporary genitourinary fistula management: treatment, trends, and innovations. Curr Opin Obstet Gynecol. 2025 Dec 1;37(6):432-437. Sema MH, Singh V, Bhandari K, et al. Surgical Outcomes of Lower Genitourinary Fistula Repair: A Prospective Cohort Study From an Indian Tertiary Hospital. Cureus. 2025 Nov 27;17(11):e97910. Tătaru VS, Vartolomei MD, Ferro M, et al. Current status of single port robotic-assisted reconstructive urology: a systematic review, meta-analysis and structured summary of the available literature. J Robot Surg. 2025;19(1):349. Valecha D, Saba D. Changing Trends in the Management of Genitourinary Fistulae: From Conventional to Robot Assisted Repair. ICS 2025 Annual Meeting; September 2025; Abstract 687. Bajoria S, Bhunia A, Mandal SN, Sharma PK. 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Tables Table 1 Baseline demographic and clinical characteristics of patients with iatrogenic ureterovaginal fistula (N=29) Characteristic Value Age (years), mean ± SD 49.0 ± 9.8 BMI (kg/m²), mean ± SD 24.6 ± 3.2 Parity, median (range) 2 (1-5) Initial surgical procedure, n (%) Abdominal radical hysterectomy (cervical/endometrial cancer) 16 (55.2) Abdominal hysterectomy (benign) 4 (13.8) Laparoscopic hysterectomy (benign) 4 (13.8) Laparoscopic pelvic reconstructive surgery (pelvic organ prolapse) 1 (3.5) Pelvic radiotherapy (cervical/endometrial cancer) 4 (13.8) Prior pelvic surgery history, n (%) 8 (27.6) Time to diagnosis (days), median (range) 14 (5-45) Presenting symptoms, n (%) Continuous vaginal leakage 29 (100) Abdominal/flank pain 12 (41.4) Fever 5 (17.2) Hematuria 4 (13.8) Table 2 Fistula characteristics and diagnostic findings Characteristic Value Laterality, n (%) Left 11 (37.9) Right 13 (44.8) Bilateral 5 (17.2) Fistula location, n (%) Distal ureter (10 cm from UVJ) 2 (6.9) Estimated defect length (cm), mean ± SD 4.8 ± 2.1 Diagnostic modality, n (%) CT urography 24 (82.8) Retrograde pyelography 19 (65.5) Intravenous urography 8 (27.6) Preoperative serum creatinine (μmol/L), mean ± SD 82.4 ± 18.6 Preoperative hydronephrosis, n (%) None 8 (27.6) Mild (Grade I) 12 (41.4) Moderate (Grade II) 7 (24.1) Severe (Grade III) 2 (6.9) Table 3 Surgical procedures and perioperative outcomes Surgical procedure n Operative time (min), mean ± SD Estimated blood loss (mL), mean ± SD Hospital stay (days), mean ± SD Success rate, n (%) Ureteroscopic stenting 7 35 ± 12 N/A 2.1 ± 0.8 5 (71.4) Ureteroneocystostomy 7 118 ± 24 95 ± 32 5.3 ± 1.2 7 (100) With psoas hitch (4) 125 ± 18 105 ± 28 5.5 ± 1.0 4 (100) Without psoas hitch (3) 108 ± 26 82 ± 35 5.0 ± 1.4 3 (100) Boari flap 3 156 ± 31 148 ± 45 7.3 ± 1.5 3 (100) Ileal ureter replacement 4 218 ± 42 215 ± 68 10.5 ± 2.3 4 (100) Appendiceal ureteroplasty 2 165 ± 28 120 ± 42 8.0 ± 1.4 1 (50) Ovarian vein graft 3 142 ± 35 135 ± 38 7.7 ± 1.2 2 (66.7) Overall 29 26 (89.7) Table 4 Postoperative follow-up results and renal function changes Parameter Value Follow-up duration (months), median (range) 21 (12-36) Complications (Clavien-Dindo), n (%) Grade I-II 4 (13.8) Grade IIIa 0 (0) Grade IIIb 2 (6.9) Grade IV-V 0 (0) Renal function (serum creatinine, μmol/L) Preoperative, mean ± SD 82.4 ± 18.6 Postoperative, mean ± SD 79.8 ± 16.2 Postoperative hydronephrosis, n (%) None 24 (82.8) Mild (Grade I) 4 (13.8) Moderate-severe 1 (3.4) Requiring long-term stenting, n (%) 1 (3.4) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 06 May, 2026 Reviewers agreed at journal 04 May, 2026 Reviewers invited by journal 24 Apr, 2026 Editor assigned by journal 23 Apr, 2026 Editor invited by journal 20 Mar, 2026 Submission checks completed at journal 19 Mar, 2026 First submitted to journal 19 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9045088","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":634325808,"identity":"e4100b27-8c34-4cec-8ae7-1e6dd979f3cf","order_by":0,"name":"Xinyan Yan","email":"","orcid":"","institution":"Gansu Provincial Maternal and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xinyan","middleName":"","lastName":"Yan","suffix":""},{"id":634325814,"identity":"f0263c1d-0b9c-414e-9e67-7c0ef3c1106a","order_by":1,"name":"Haicun Zhou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBAC+/b2gw8+GPzn4WdvIFKLAc+ZZMMZFcwykj0HiNUi4WAmzXOG2cbgRgKRWswlGBKkedvYeCRnPt54g6HGJpqgFsvZjQcM57bx8PBLpxVbMBxLy20gqOfOgYSEt20SPJKzc8wkGBsOE6HlRoLBAd42Ax6Dm2eI1AL0tWEjz5kEHoMbPERqkew5k8w4o+IAj2QP0C8JxPiFn739+I8PBgfs+dkPb7zxocaGCL8gO1IigRTlEC2k6hgFo2AUjIKRAQChXUG9fFP03gAAAABJRU5ErkJggg==","orcid":"","institution":"Gansu Provincial Maternal and Child Health Hospital","correspondingAuthor":true,"prefix":"","firstName":"Haicun","middleName":"","lastName":"Zhou","suffix":""},{"id":634325818,"identity":"50ff7290-abcc-413a-8180-ed44e57d685e","order_by":2,"name":"Weilin Pu","email":"","orcid":"","institution":"Gansu Provincial Maternal and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Weilin","middleName":"","lastName":"Pu","suffix":""},{"id":634325830,"identity":"10eb56f3-7c07-4ac1-8396-4be123784f2d","order_by":3,"name":"Pingping Zhou","email":"","orcid":"","institution":"Gansu Provincial Maternal and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Pingping","middleName":"","lastName":"Zhou","suffix":""},{"id":634325831,"identity":"8e77c5f3-80ce-4eb1-9d91-3660253e6c3a","order_by":4,"name":"Xiaqin Huo","email":"","orcid":"","institution":"Gansu Provincial Maternal and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaqin","middleName":"","lastName":"Huo","suffix":""},{"id":634325839,"identity":"3baf29ac-6046-4eb5-a1e0-4b1ec178ac32","order_by":5,"name":"Wenqiang Cai","email":"","orcid":"","institution":"Gansu Provincial Maternal and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wenqiang","middleName":"","lastName":"Cai","suffix":""},{"id":634325851,"identity":"89c64ce8-4e25-49c1-985d-141d0d94c5f5","order_by":6,"name":"Ke Shen","email":"","orcid":"","institution":"Gansu Provincial Maternal and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ke","middleName":"","lastName":"Shen","suffix":""},{"id":634325855,"identity":"8e6c3b83-6003-4aa9-a28f-e8385cea3278","order_by":7,"name":"Yan Wang","email":"","orcid":"","institution":"Gansu Provincial Maternal and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2026-03-06 02:09:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9045088/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9045088/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108837107,"identity":"3d9acb58-a2de-403f-a06e-4bf3bfddfdab","added_by":"auto","created_at":"2026-05-09 00:05:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":9234896,"visible":true,"origin":"","legend":"\u003cp\u003eUreterovaginal fistula and Boari flap reconstruction.A CTU shows distal fistula of the left ureter; B Contrast agent was seen in the vagina;C Intraoperative photograph showing a distal ureterovaginal fistula，Necrosis of the distal ureter；D Creation of a Boari bladder flap: the bladder is mobilized and a broad-based flap is raised; E Completed Boari flap anastomosis: the tubularized flap is anastomosed to the proximal ureter over a double-J stent.\u003c/p\u003e","description":"","filename":"fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-9045088/v1/04fa0c40757bc024e29bd6c1.png"},{"id":109203371,"identity":"555bca25-dcdf-46fe-9bec-064330d19367","added_by":"auto","created_at":"2026-05-13 14:30:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":10905368,"visible":true,"origin":"","legend":"\u003cp\u003eAppendiceal ureteroplasty for right-sided ureteral defect. A MRU show Long-segment defect of the right ureter following injury，Hydronephrosis on the right renal pelvis and proximal ureteral dilation. B Appendix isolated on its mesoappendix, demonstrating adequate length and vascular supply. C Final appearance after appendiceal interposition, restoring ureteral continuity.D Two weeks after the operation, the reexamination of CTU showed that the right ureter had healed well and hydronephrosis had disappeared.\u003c/p\u003e","description":"","filename":"fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-9045088/v1/c060ab35afa5f7946e1d5e18.png"},{"id":108837109,"identity":"c534b31a-f89a-4ee6-bbe5-d9e8bba0023d","added_by":"auto","created_at":"2026-05-09 00:05:41","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":5370338,"visible":true,"origin":"","legend":"\u003cp\u003eIleal ureter replacement for left-sided long-segment defect. A CTU show Extensive left ureteral defect not amenable to bladder-based reconstruction. B Isoperistaltic ileal segment isolated and prepared for interposition. C After the operation, the reexamination of CTU showed that the left-sided ureter had recover well and hydronephrosis had disappeared.\u003c/p\u003e","description":"","filename":"fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-9045088/v1/58c60be1161176bd1f55766b.png"},{"id":108977142,"identity":"0f89a7a5-138e-45b8-b365-061894a5ddb7","added_by":"auto","created_at":"2026-05-11 11:30:34","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":10879699,"visible":true,"origin":"","legend":"\u003cp\u003eOvarian vein graft for ureteral reconstruction. A CTU show Extensive left ureteral defect not amenable to bladder-based reconstruction.B-C Harvested ovarian vein with its vascular pedicle. D Ovarian vein graft The defective mulberry was replaced and anastomosed to the residual end of the ureter and the bladder respectively. E After the operation, the reexamination of CTU showed that the left-sided ureter had recover well and hydronephrosis had disappeared.\u003c/p\u003e","description":"","filename":"FIG4.png","url":"https://assets-eu.researchsquare.com/files/rs-9045088/v1/4408a8f1761d082290737698.png"},{"id":109205955,"identity":"42a29152-0324-45a3-bcd0-3ae483938af6","added_by":"auto","created_at":"2026-05-13 15:09:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":34805859,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9045088/v1/b33fc69e-3e94-428b-a40c-18d95b8b32d7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Individualized Surgical Repair of Iatrogenic Ureterovaginal Fistula: A Single-Center Experience with 29 Cases","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUreterovaginal fistula (UVF) represents one of the most distressing complications in female pelvic surgery, characterized by continuous urinary leakage per vagina, leading to significant physical discomfort, psychological distress, and social isolation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While obstetric trauma remains a leading cause of urogenital fistulas in developing nations, iatrogenic injury during gynecologic surgery\u0026mdash;particularly hysterectomy\u0026mdash;constitutes the predominant etiology in developed countries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The reported incidence of ureteral injury during gynecologic procedures ranges from 0.3% to 3%, with laparoscopic and radical oncological procedures carrying higher risk [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe pathophysiology of iatrogenic UVF typically involves unrecognized ureteral injury\u0026mdash;either partial transection, devascularization, or crush injury from ligature placement\u0026mdash;that progresses to necrosis and subsequent fistula formation between the ureter and vaginal cuff [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Delayed diagnosis or inappropriate initial management can lead to irreversible renal impairment, complex fistulas, and failed repairs, underscoring the need for timely and appropriate intervention [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe optimal treatment strategy for UVF remains incompletely standardized and depends on multiple factors: time of diagnosis, fistula size and location, length of ureteral defect, viability of surrounding tissues, and surgeon expertise [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Historically, open surgical repair constituted the cornerstone of treatment. However, advancements in minimally invasive techniques and evolving understanding of reconstructive principles have expanded the therapeutic armamentarium, ranging from conservative endoscopic stenting to complex autologous tissue replacement [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite existing literature, there is a paucity of studies that systematically analyze diversified surgical strategies for UVF based on structured fistula classification. This study aims to present our single-center experience with 29 cases of iatrogenic UVF, focusing on a tailored, stepwise approach to repair. We describe clinical presentation, diagnostic workup, and critically evaluate outcomes of various surgical techniques, aiming to provide a pragmatic algorithm for managing this complex condition.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Population\u003c/h2\u003e \u003cp\u003eA retrospective cohort study was conducted on all patients diagnosed and treated for iatrogenic UVF at our center between January 2018 and December 2023. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee (Approval No.: [2021]GSFY054). The need for informed consent was waived due to the retrospective nature of the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePatient Selection and Data Collection\u003c/h3\u003e\n\u003cp\u003eMedical records of patients with a confirmed diagnosis of UVF were reviewed. The diagnosis was established based on clinical history (continuous urinary incontinence following pelvic surgery), physical examination, and confirmed by imaging studies including computed tomography urography (CTU) and/or retrograde pyelography. Cystoscopy with methylene blue test was routinely performed to rule out concomitant vesicovaginal fistula.\u003c/p\u003e \u003cp\u003eData extracted included patient demographics, etiology of the initial surgery, clinical presentation, time to diagnosis, fistula characteristics (laterality, location, estimated length), diagnostic modalities, surgical procedures performed, intraoperative details, postoperative course, and follow-up data. Key patient characteristics are summarized in Table\u0026nbsp;1.\u003c/p\u003e\n\u003ch3\u003eManagement Protocol and Surgical Techniques\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eManagement Protocol and Surgical Techniques\u003c/div\u003e \u003cp\u003eThe management strategy was individualized based on comprehensive assessment following a structured algorithm (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Treatment selection considered: (1) time from inciting surgery to diagnosis, (2) fistula size and location, (3) estimated length of ureteral defect, (4) degree of ipsilateral renal function impairment, (5) tissue healing capacity and degree of surrounding inflammation, and (6) prior surgical history.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eUreteroscopic Double-J Stent Placement\u003c/strong\u003e \u003cp\u003eThis was considered as first-line treatment for patients with early-diagnosed (\u0026le;\u0026thinsp;14 days), small-caliber fistulas (\u0026lt;\u0026thinsp;2 cm) where a guidewire could be successfully passed across the fistula site during cystoscopy/ureteroscopy. Stents were maintained for 6\u0026ndash;8 weeks followed by repeat imaging.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDefinitive Surgical Repair\u003c/strong\u003e \u003cp\u003eSurgical intervention was indicated for large fistulas (\u0026gt;\u0026thinsp;2 cm), failure of conservative management, late presentation (\u0026gt;\u0026thinsp;14 days), or when endoscopic access was not feasible. The choice of open procedure was guided by the extent and length of the ureteral defect.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eUreteroneocystostomy\u003c/strong\u003e \u003cp\u003ePerformed for distal ureteral defects\u0026thinsp;\u0026le;\u0026thinsp;4\u0026ndash;5 cm, utilizing extravesical (Lich-Gregoir) or intravesical (Politano-Leadbetter) approaches with psoas hitch when indicated.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eBoari Flap\u003c/b\u003e: Employed for mid-ureteral defects, creating a bladder flap tubularized over a ureteral stent. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.Ureterovaginal fistula and Boari flap reconstruction.A Computed Tomography Urography (CTU) shows distal fistula of the left ureter; B Contrast agent was seen in the vagina;C Intraoperative photograph showing a distal ureterovaginal fistula, Necrosis of the distal ureter;D Creation of a Boari bladder flap: the bladder is mobilized and a broad-based flap is raised; E Completed Boari flap anastomosis: the tubularized flap is anastomosed to the proximal ureter over a double-J stent.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAppendiceal Ureteroplasty\u003c/strong\u003e \u003cp\u003eConsidered for right-sided defects of moderate length (3\u0026ndash;8 cm) in patients with suitable appendix. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e Appendiceal ureteroplasty for right-sided ureteral defect. A Magnetic Resonance Urography (MRU) show Long-segment defect of the right ureter following injury, Hydronephrosis on the right renal pelvis and proximal ureteral dilation. B Appendix isolated on its mesoappendix, demonstrating adequate length and vascular supply. C Final appearance after appendiceal interposition, restoring ureteral continuity.D Two weeks after the operation, the reexamination of CTU showed that the right ureter had healed well and hydronephrosis had disappeared.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eIleal Ureter Replacement\u003c/strong\u003e \u003cp\u003eUtilized for extensive ureteral loss\u0026thinsp;\u0026gt;\u0026thinsp;12 cm, with isoperistaltic ileal segment interposition. Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e Ileal ureter replacement for left-sided long-segment defect. A CTU show Extensive left ureteral defect not amenable to bladder-based reconstruction. B Isoperistaltic ileal segment isolated and prepared for interposition. C After the operation, the reexamination of CTU showed that the left-sided ureter had recover well and hydronephrosis had disappeared.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eOvarian Vein Graft\u003c/strong\u003e \u003cp\u003eEmployed as an alternative autologous tissue for select cases where bowel interposition was contraindicated.Ovarian vein graft for ureteral reconstruction. A CTU show Extensive left ureteral defect not amenable to bladder-based reconstruction.B-C Harvested ovarian vein with its vascular pedicle. D Ovarian vein graft The defective mulberry was replaced and anastomosed to the residual end of the ureter and the bladder respectively. E After the operation, the reexamination of CTU showed that the left-sided ureter had recover well and hydronephrosis had disappeared.\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eOutcome Measures and Statistical Analysis\u003c/h3\u003e\n\u003cp\u003eThe primary outcome measure was surgical success rate, defined as resolution of urinary leakage confirmed clinically and radiologically (via CTU or intravenous urography) during follow-up, without need for further surgical intervention. Secondary outcomes included operative time, estimated blood loss, intraoperative and postoperative complications graded according to the Clavien-Dindo classification [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and changes in renal function.\u003c/p\u003e \u003cp\u003eDescriptive statistics were used for data analysis. Continuous variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median with range, as appropriate. All analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient Characteristics and Fistula Details\u003c/h2\u003e \u003cp\u003eA total of 29 female patients with a mean age of 49.0\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8 years (range: 32\u0026ndash;71 years) were included in the study. Table\u0026nbsp;1 summarizes baseline demographic and clinical characteristics.\u003c/p\u003e \u003cp\u003eThe most common etiology was gynecologic surgery for malignancy (n\u0026thinsp;=\u0026thinsp;16, 55.2%), followed by surgery for benign conditions (n\u0026thinsp;=\u0026thinsp;8, 31.0%). All patients presented with continuous urinary leakage per vagina (100%). The median time from inciting surgery to UVF diagnosis was 14 days (range: 5\u0026ndash;45 days), with 14 patients (48.3%) diagnosed within the first 2 weeks postoperatively.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTreatment Outcomes\u003c/h3\u003e\n\u003cp\u003eThe distribution of surgical procedures and their outcomes are presented in Table\u0026nbsp;3. A total of 29 patients underwent 32 procedures (3 patients required repeat intervention after initial failed management).\u003c/p\u003e\n\u003ch3\u003eN/A not applicable, SD standard deviation\u003c/h3\u003e\n\u003cp\u003eThe overall success rate after a single procedure was 89.7% (26/29) over a median follow-up of 21 months (range: 12\u0026ndash;36 months). Ureteroscopic stenting was successful in 5 patients (71.4%). Two failures occurred due to early stent occlusion (n\u0026thinsp;=\u0026thinsp;1) and persistent leakage (n\u0026thinsp;=\u0026thinsp;1), both subsequently managed successfully with ureteroneocystostomy.\u003c/p\u003e \u003cp\u003eAll open surgical procedures utilizing bladder (ureteroneocystostomy, Boari flap) or ileum (ileal ureter replacement) demonstrated 100% success rates. Among the two failures in complex reconstructions, one occurred after appendiceal ureteroplasty (anastomotic stricture at 4 months requiring reoperation with ileal ureter) and one after ovarian vein graft (stricture at 6 months successfully managed with endoscopic dilation and long-term stenting).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative Complications and Follow-up\u003c/h2\u003e \u003cp\u003ePostoperative complications occurred in 6 patients (20.7%) (Table\u0026nbsp;4). Most were Clavien-Dindo grade I or II, including urinary tract infection (n\u0026thinsp;=\u0026thinsp;3), transient ileus (n\u0026thinsp;=\u0026thinsp;2), and wound infection (n\u0026thinsp;=\u0026thinsp;1). Two cases of anastomotic stricture (one after appendiceal and one after ovarian vein repair) were classified as grade IIIb complications requiring surgical intervention.\u003c/p\u003e \u003cp\u003eRenal function remained stable throughout follow-up, with mean serum creatinine of 79.8\u0026thinsp;\u0026plusmn;\u0026thinsp;16.2 \u0026micro;mol/L postoperatively compared with 82.4\u0026thinsp;\u0026plusmn;\u0026thinsp;18.6 \u0026micro;mol/L preoperatively. Postoperative imaging demonstrated resolution of hydronephrosis in most patients, with only one patient (following ovarian vein graft) exhibiting persistent mild hydronephrosis managed conservatively.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study reinforces the principle that successful management of UVF hinges on a precise, individualized approach tailored to specific fistula characteristics. Our overall success rate of 89.7% aligns favorably with contemporary literature, which reports success rates between 85% and 95% for various repair techniques in the modern era [2, 6, 7].\u003c/p\u003e\n\u003ch3\u003eEndoscopic Management\u003c/h3\u003e\n\u003cp\u003eOur findings confirm that endoscopic stenting, while minimally invasive, has a limited but important role and is best reserved for highly selected cases\u0026mdash;typically small, recent fistulas without significant tissue loss or ischemia [1, 10]. The 71.4% success rate in our cohort aligns with recent series reporting 70-85% success in appropriately selected patients [2, 7]. Two important observations emerge from our experience with endoscopic management: first, successful stent placement across the fistula site is prerequisite and should not be forced; second, even with successful stenting, close radiographic follow-up is essential to detect delayed failures. We recommend stent removal at 6-8 weeks with repeat imaging 4-6 weeks thereafter to confirm durable fistula closure.\u003c/p\u003e\n\u003ch3\u003eMinimally Invasive Surgical Approaches\u003c/h3\u003e\n\u003cp\u003eRecent literature demonstrates a paradigm shift toward minimally invasive reconstruction for UVF [3-5]. Valecha et al. reported that robot-assisted laparoscopic repair offers superior magnified 3D visualization and improved dexterity, leading to enhanced dissection and suturing, particularly beneficial in complex and recurrent fistulae [5]. Similarly, Tătaru et al. demonstrated in a systematic review that single-port robotic approaches for ureteral reconstruction are feasible with low morbidity, though comparative data remain limited [3]. Bajoria et al. reported excellent outcomes with laparoscopic ureteroneocystostomy in 13 UVF patients, with mean operative time of 140 minutes and no major complications [2].\u003c/p\u003e\n\u003ch3\u003eBladder-Based Reconstruction\u003c/h3\u003e\n\u003cp\u003eOpen surgical reconstruction, particularly ureteroneocystostomy and the Boari flap procedure, continues to provide definitive and highly reliable outcomes. These techniques benefit from utilizing well-vascularized bladder tissue, ensuring tension-free anastomosis, and remain the gold standard for distal and mid-ureteral defects [9, 15]. Kumar et al. reported 100% success in 12 patients undergoing robot-assisted ureteral reimplantation and Boari flap procedures following gynecologic injuries, with no recurrences at mean follow-up of 35 months [9]. The consistently excellent outcomes with these approaches suggest they should remain the first-line surgical options for most distal and mid-ureteral fistulas. Both procedures can be performed through a Pfannenstiel incision with extraperitoneal approach, minimizing morbidity while providing excellent exposure.\u003c/p\u003e\n\u003ch3\u003eIntestinal Reconstruction\u003c/h3\u003e\n\u003cp\u003eFor the most complex scenarios involving long-segment ureteral loss (\u0026gt;12 cm), ileal interposition yields excellent results, consistent with its established role as a robust solution for extensive defects [16]. Kocot et al. reported long-term success rates exceeding 90% with ileal ureter replacement, though the potential for metabolic complications (hyperchloremic metabolic acidosis) and mucous production necessitates careful patient selection [16]. We routinely perform preoperative bowel preparation and employ antirefluxing techniques when feasible, though the necessity of antireflux mechanisms in ileal ureter replacement remains debated.\u003c/p\u003e\n\u003ch3\u003eAlternative Autologous Tissues\u003c/h3\u003e\n\u003cp\u003eThe use of alternative tissues such as the appendix and ovarian vein represents more novel approaches. Appendiceal ureteroplasty is an elegant solution for right-sided defects, but its success is highly dependent on a healthy, well-vascularized appendix and meticulous technique [17]. Our single failure in this subgroup occurred early in the series and likely reflected suboptimal tissue handling. Careful preoperative evaluation of the appendix (when feasible) and intraoperative assessment of vascular supply are essential. The appendix offers the advantage of a caliber similar to the ureter and absence of mucous production, but its limited length restricts applicability to defects \u0026lt;8 cm.\u003c/p\u003e\n\u003cp\u003eThe ovarian vein graft represents an innovative autologous option with theoretical advantages: it is readily available within the same surgical field, avoids bowel anastomosis, and preserves peritoneal integrity. However, our variable success rates (66.7%) suggest caution is warranted. The ovarian vein may be prone to late stenosis due to its thin wall and lack of inherent peristalsis, suggesting it should be considered when other options are exhausted or contraindicated [17]. Some authors have reported improved outcomes with ovarian vein grafts when combined with omental wrapping to enhance vascular supply.\u003c/p\u003e\n\u003ch3\u003eTreatment Algorithm\u003c/h3\u003e\n\u003cp\u003eA key strength of our management protocol was its stepwise and individualized nature. Based on our cumulative experience and aligned with contemporary recommendations [1, 4, 10], we propose the following algorithmic approach:\u003c/p\u003e\n\u003cp\u003e1.Early diagnosis (\u0026le;14 days) + small fistula (\u0026lt;2 cm) + guidewire passage feasible\u0026nbsp;\u0026rarr; Ureteroscopic stenting\u003c/p\u003e\n\u003cp\u003e2.Failed stenting or late diagnosis + distal/mid ureteral defect \u0026le;4-5 cm\u0026nbsp;\u0026rarr; Ureteroneocystostomy \u0026plusmn; psoas hitch (consider laparoscopic/robotic approach if expertise available)\u003c/p\u003e\n\u003cp\u003e3.Mid ureteral defect 5-12 cm + adequate bladder capacity\u0026nbsp;\u0026rarr; Boari flap\u003c/p\u003e\n\u003cp\u003e4.Extensive defect \u0026gt;12 cm\u0026nbsp;\u0026rarr; Ileal ureter replacement\u003c/p\u003e\n\u003cp\u003e5.Right-sided defect 3-8 cm + suitable appendix\u0026nbsp;\u0026rarr; Consider appendiceal ureteroplasty\u003c/p\u003e\n\u003cp\u003e6.Complex reoperative field + bowel contraindicated\u0026nbsp;\u0026rarr; Consider ovarian vein graft (with caution)\u003c/p\u003e\n\u003cp\u003eThis approach minimizes unnecessary morbidity while ensuring definitive repair for complex cases. Decision-making should always consider patient factors, surgeon expertise, and institutional resources. The increasing adoption of robotic platforms may further expand minimally invasive options for these complex reconstructions [3, 5].\u003c/p\u003e\n\u003ch3\u003eStudy Limitations\u003c/h3\u003e\n\u003cp\u003eLimitations of this study include its retrospective design, relatively small sample size for some surgical subgroups, and inherent selection bias in treatment allocation. The single-center nature may limit generalizability, though it ensures consistency in surgical technique and perioperative care. Follow-up duration (median 21 months) may not capture very late complications such as anastomotic strictures or metabolic disturbances. Additionally, we lacked standardized patient-reported outcome measures to assess quality of life impact.Larger, prospective, multi-institutional studies would be valuable to validate a standardized treatment algorithm. Future research should focus on comparative effectiveness of different techniques, long-term functional outcomes, and patient-centered endpoints. The role of robotic-assisted minimally invasive reconstruction for UVF represents an evolving area warranting further investigation.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe management of iatrogenic ureterovaginal fistula requires a sophisticated, individualized approach.Atreatment strategy tailored to fistula characteristics\u0026mdash;employing endoscopic stenting for select simple cases and advancing to complex reconstruction using bladder, intestinal, or other autologous tissues for larger defects\u0026mdash;leads to successful outcomes in approximately 90% of patients [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Ureteroneocystostomy and Boari flap procedures remain the cornerstone of repair for most distal and mid-ureteral fistulas, with minimally invasive approaches offering comparable success and reduced morbidity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Ileal interposition provides a robust option for extensive defects [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Alternative tissues such as appendix and ovarian vein have selective applicability with variable outcomes. Surgeons managing this condition must be proficient in a range of techniques to offer optimal patient care in an era of rapidly evolving reconstructive options [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the patients who participated in this study and the surgical and nursing staff of the Department of Urology and Gynecology for their dedicated care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXY and HZ contributed to study design and patient recruitment. WP and PH performed data analysis. XH and WC participated in surgical procedures. HZ and XY drafted the manuscript. All authors reviewed and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in this study were in accordance with the ethical standards of the Institutional Review Board of the Maternal and Child Health Hospital of Gansu Province (also known as Gansu Province Central Hospital), Lanzhou, China. The study was approved under the ethics approval number [2021]GSFY054. Given the retrospective nature of the study and the use of anonymized patient data, the need for informed consent from individual participants was waived by the ethics committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript does not contain any identifiable personal or clinical details, images, or videos of individual participants that could compromise anonymity. Therefore, \u003cstrong\u003econsent for publication is not applicable\u003c/strong\u003e. Should any such material be included in future revisions or related submissions, appropriate written informed consent for publication will be obtained and documented.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWei N, Pfeuti C, Linder BJ. Contemporary genitourinary fistula management: treatment, trends, and innovations. Curr Opin Obstet Gynecol. 2025 Dec 1;37(6):432-437.\u003c/li\u003e\n\u003cli\u003eSema MH, Singh V, Bhandari K, et al. Surgical Outcomes of Lower Genitourinary Fistula Repair: A Prospective Cohort Study From an Indian Tertiary Hospital. Cureus. 2025 Nov 27;17(11):e97910.\u003c/li\u003e\n\u003cli\u003eTătaru VS, Vartolomei MD, Ferro M, et al. Current status of single port robotic-assisted reconstructive urology: a systematic review, meta-analysis and structured summary of the available literature. J Robot Surg. 2025;19(1):349.\u003c/li\u003e\n\u003cli\u003eValecha D, Saba D. Changing Trends in the Management of Genitourinary Fistulae: From Conventional to Robot Assisted Repair. ICS 2025 Annual Meeting; September 2025; Abstract 687.\u003c/li\u003e\n\u003cli\u003eBajoria S, Bhunia A, Mandal SN, Sharma PK. Laparoscopic repair of urogenital fistula: A single-center experience and review of literature. Int J Reconstruct Urol. 2025;3(1):95-100.\u003c/li\u003e\n\u003cli\u003eThompson JC, Halder GE, Jeppson PC, et al. Repair of Vesicovaginal Fistulae: A Systematic Review. Obstet Gynecol. 2024;143(2):229-241.\u003c/li\u003e\n\u003cli\u003eVikram S, Om Kumar Y, Arjun Singh S, et al. Genitourinary fistula: epidemiology, changing trends in etiology and management: a tertiary care institute\u0026apos;s perspective. Urologia. 2024;91:243\u0026ndash;248.\u003c/li\u003e\n\u003cli\u003eTzelepis K, Giannakodimos I, Samara AA, et al. Complex postoperative ureterovaginal and vesicovaginal fistula following a non-oncological hysterectomy: a report of a challenging complication. J Surg Case Rep. 2024;2024:692.\u003c/li\u003e\n\u003cli\u003eKumar S, Modi P, Mishra A, et al. Robot-assisted laparoscopic repair of injuries to bladder and ureter following gynecological surgery and obstetric injury: A single-center experience. Urol Ann. 2021;13(4):405-411.\u003c/li\u003e\n\u003cli\u003eNigro N, Shahinyan G, Lin S, Bhalla RG, Flynn BJ. A comprehensive review of urinary tract fistulas: the evolution of etiologies, surgical techniques, and contemporary outcomes. Ther Adv Urol. 2025;17:17562872251317344.\u003c/li\u003e\n\u003cli\u003edel Amo E, Vicens A, Rodriguez A, Cecchini L. Hysteropexy mesh giant calcification removal and robotic ureteral reimplantation due to ureterovaginal fistula. ICS 2025 Annual Meeting; September 2025; Abstract 182.\u003c/li\u003e\n\u003cli\u003eDindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205-213.\u003c/li\u003e\n\u003cli\u003eShrestha DB, Budhathoki P, Karki P, et al. Vesico-vaginal fistula in females in 2010\u0026ndash;2020: a systemic review and meta-analysis. Reprod Sci. 2022;29:3346\u0026ndash;3364.\u003c/li\u003e\n\u003cli\u003eLee Z, Lee M, Koster H, et al. Robotic ureteroplasty with buccal mucosa graft for the management of complex ureteral strictures: a comprehensive review. Urology. 2021;149:13-20.\u003c/li\u003e\n\u003cli\u003eZhao LC, Weinberg AC, Lee Z, et al. Robotic ureteral reconstruction using buccal mucosa grafts: a multi-institutional experience. Eur Urol. 2021;79(3):405-412.\u003c/li\u003e\n\u003cli\u003eKocot A, Kalogirou C, Vergho D, Riedmiller H. Long-term results of ileal ureteric replacement: a 25-year single-centre experience. BJU Int. 2017;120(2):273-279.\u003c/li\u003e\n\u003cli\u003eXu YM, Li YD, Feng C, Song LJ, Hua J. Use of the ovarian vein in the reconstruction of complex ureteral defects: a report of 13 cases. Urology. 2011;78(3):710-714.\u003c/li\u003e\n\u003cli\u003eLi X, Huang M, Zhang J, et al. Lingual mucosal graft ureteroplasty for long proximal ureteral stricture: 5-year single-center experience. Eur Urol. 2022;81(3):296-302.\u003c/li\u003e\n\u003cli\u003eMiklos JR, Moore RD, Chinthakanan O. Laparoscopic and Robotic-assisted Vesicovaginal Fistula Repair: A Systematic Review of the Literature. J Minim Invasive Gynecol. 2021;28(4):831-841.\u003c/li\u003e\n\u003cli\u003eAbdel-Karim A, Elmissiry M, Moussa A, et al. Laparoscopic repair of female genitourinary fistulae: 10-year single-center experience. Int Urogynecol J. 2020;31(7):1357-1362.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Baseline demographic and clinical characteristics of patients with iatrogenic ureterovaginal fistula (N=29)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"501\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (years), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e49.0 \u0026plusmn; 9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBMI (kg/m\u0026sup2;), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24.6 \u0026plusmn; 3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eParity, median (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (1-5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eInitial surgical procedure, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAbdominal radical hysterectomy (cervical/endometrial cancer)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (55.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAbdominal hysterectomy (benign)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLaparoscopic hysterectomy (benign)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLaparoscopic pelvic reconstructive surgery (pelvic organ prolapse)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePelvic radiotherapy (cervical/endometrial cancer)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePrior pelvic surgery history, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (27.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTime to diagnosis (days), median (range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 (5-45)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePresenting symptoms, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eContinuous vaginal leakage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAbdominal/flank pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (41.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (17.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHematuria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 2\u003c/strong\u003e Fistula characteristics and diagnostic findings\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"501\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLaterality, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (37.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (44.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (17.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFistula location, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDistal ureter (\u0026lt;5 cm from UVJ)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18 (62.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMid ureter (5-10 cm from UVJ)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (31.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eProximal ureter (\u0026gt;10 cm from UVJ)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEstimated defect length (cm), mean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.8 \u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnostic modality, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCT urography\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24 (82.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRetrograde pyelography\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19 (65.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIntravenous urography\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (27.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative serum creatinine (\u0026mu;mol/L), mean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e82.4 \u0026plusmn; 18.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative hydronephrosis, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (27.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMild (Grade I)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (41.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate (Grade II)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (24.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSevere (Grade III)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 3\u003c/strong\u003e Surgical procedures and perioperative outcomes\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical procedure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOperative time (min), mean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEstimated blood loss (mL), mean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHospital stay (days), mean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSuccess rate, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUreteroscopic stenting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35 \u0026plusmn; 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.1 \u0026plusmn; 0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUreteroneocystostomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e118 \u0026plusmn; 24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e95 \u0026plusmn; 32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.3 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWith psoas hitch\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e125 \u0026plusmn; 18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e105 \u0026plusmn; 28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.5 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWithout psoas hitch\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e108 \u0026plusmn; 26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e82 \u0026plusmn; 35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.0 \u0026plusmn; 1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBoari flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e156 \u0026plusmn; 31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e148 \u0026plusmn; 45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.3 \u0026plusmn; 1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIleal ureter replacement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e218 \u0026plusmn; 42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e215 \u0026plusmn; 68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.5 \u0026plusmn; 2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAppendiceal ureteroplasty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e165 \u0026plusmn; 28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e120 \u0026plusmn; 42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.0 \u0026plusmn; 1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOvarian vein graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e142 \u0026plusmn; 35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e135 \u0026plusmn; 38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.7 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e29\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e26 (89.7)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e Postoperative follow-up results and renal function changes\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"501\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFollow-up duration (months), median (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (12-36)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eComplications (Clavien-Dindo), n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGrade I-II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGrade IIIa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGrade IIIb\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGrade IV-V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRenal function (serum creatinine, \u0026mu;mol/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreoperative, mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e82.4 \u0026plusmn; 18.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePostoperative, mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e79.8 \u0026plusmn; 16.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative hydronephrosis, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24 (82.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMild (Grade I)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate-severe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRequiring long-term stenting, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ureterovaginal fistula, Iatrogenic injury, Ureteral reconstruction, Surgical repair, Female pelvic surgery","lastPublishedDoi":"10.21203/rs.3.rs-9045088/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9045088/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIatrogenic ureterovaginal fistula (UVF) is a severe complication primarily arising from gynecologic surgery, most commonly hysterectomy. It leads to continuous urinary leakage, causing significant physical, emotional, and social distress. Optimal management remains challenging due to variations in fistula etiology, anatomy, and timing of diagnosis. This study evaluates the outcomes of a tailored, stepwise surgical approach for UVF based on individual fistula characteristics.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis was conducted on 29 female patients with iatrogenic UVF treated at a single tertiary center between January 2018 and December 2023. Individualized treatment strategies were determined based on fistula size, location, ureteral defect length, and tissue viability. Surgical techniques included ureteroscopic stenting, ureteroneocystostomy, Boari flap, ileal ureter replacement, appendiceal ureteroplasty, and ovarian vein graft. The primary outcome was surgical success, defined as resolution of urine leakage without additional intervention. Secondary outcomes included complications and renal function.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe overall success rate was 89.7% (26/29) after a median follow-up of 21 months (range, 12\u0026ndash;36). Endoscopic stenting was effective in 71.4% of early, small fistulas. Open surgical procedures\u0026mdash;including ureteroneocystostomy, Boari flap, and ileal ureter replacement\u0026mdash;achieved 100% success within their indications. Complex reconstructions using appendix or ovarian vein had variable outcomes (50\u0026ndash;66.7%). Postoperative complications occurred in 6 patients (20.7%), most of which were Clavien-Dindo Grade I or II.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eManagement of iatrogenic UVF requires a personalized, stepwise approach. Simple, early fistulas may be managed with endoscopic stenting, but most cases\u0026mdash;particularly those involving longer or more complex defects\u0026mdash;are best treated with open reconstructive techniques. A structured algorithm based on fistula characteristics facilitates optimal outcomes.\u003c/p\u003e","manuscriptTitle":"Individualized Surgical Repair of Iatrogenic Ureterovaginal Fistula: A Single-Center Experience with 29 Cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-09 00:05:37","doi":"10.21203/rs.3.rs-9045088/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"56927930580462150635663998792076309657","date":"2026-05-06T14:17:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325973946618579712508594011051597484867","date":"2026-05-04T17:40:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-24T09:32:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-23T09:16:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-20T05:44:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-19T05:27:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-03-19T04:12:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d2bbaad1-8fe6-42e8-a71d-967133f39bea","owner":[],"postedDate":"May 9th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"56927930580462150635663998792076309657","date":"2026-05-06T14:17:20+00:00","index":59,"fulltext":""},{"type":"reviewerAgreed","content":"325973946618579712508594011051597484867","date":"2026-05-04T17:40:28+00:00","index":58,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-09T00:05:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-09 00:05:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9045088","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9045088","identity":"rs-9045088","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}