OBJECTIVES:Our purpose was to evaluate the anatomic pathology of severe incontinence after fistula closure and assess a surgical technique for correction of this problem. STUDY DESIGN:Twenty-two women with severe urinary incontinence after fistula closure were recruited, and clinical and urodynamic assessment was performed. A technique combining retropubic urethrolysis, pubovaginal sling, and omental graft was performed in women with genuine stress incontinence (GSI), and continence outcome was assessed at 4 weeks and 14 months. RESULTS:On urodynamic assessment, 9 (41%) had severe GSI with normal compliance, 3 (14%) GSI and poor compliance, 9 (41%) GSI and detrusor instability, and 1 (4%) voiding dysfunction with overflow incontinence. Nine women (41%) with pure GSI underwent continence surgery. Continence outcomes were 78% at 4 weeks and 67% at 14 months. CONCLUSION:The anatomic pathology of GSI after fistula surgery is complex. The surgical technique described is promising with low morbidity and improved continence rates at 4 weeks and 14 months compared with previous techniques.