Vesico-vaginal fistula is a global healthcare problem that has a high prevalence in sub-Saharan Africa, where obstetric complications lead to the development of this condition. Despite this, comparatively few fistula repairs are performed in well-resourced countries, where iatrogenic injury is the leading aetiological factor. As a consequence, much of our knowledge results from the experience of relatively few fistula surgeons in areas of high prevalence borne out of large case series or retrospective cohorts rather than high level evidence. At present, debate surrounds the exact timing of repair and the most appropriate surgical approach for this condition. Certain fistulae can be selected for conservative management, while those that do not demonstrate factors associated with spontaneous closure can be selected for surgery. Fistula surgeons should be aware of several potential repair options and the principles of contemporary fistula surgery, as the first attempt at repair is likely to be the best opportunity to achieve a successful outcome. We review the available literature and provide evidence on the optimal timing of repair, the appropriate surgical approach and the use of tissue interpositioning in fistula surgery.