经膀胱途径修补膀胱阴道瘘的临床分析

目的探讨经膀胱途径修补膀胱阴道瘘手术时机的选择以及治疗效果。 方法回顾性分析2012年1月至2018年4月中山大学附属第三医院及外院会诊手术共21例膀胱阴道瘘患者的临床资料。患者年龄24～66岁,病程3个月至30年。所有患者均行膀胱镜检,单个瘘口16例、2个瘘口4例、3个瘘口1例,瘘口大小0.3～1.5 cm,瘘口位于输尿管口旁6例,膀胱底后壁9例,输尿管间嵴后方6例。 结果21例均行膀胱阴道瘘修补术,其中16例经膀胱途径,4例经膀胱联合经腹途径,1例经膀胱联合阴道途径。除子宫内膜癌术后辅助放疗引起者行膀胱联合阴道途径修补术后2个月仍出现少量漏尿外,其余20例经膀胱途径修补术均取得成功,随访1～65个月均无漏尿及输尿管损伤等并发症发生。 结论经膀胱途径修补膀胱阴道瘘是一种安全有效的方法,对于复杂性瘘,术中根据瘘口具体情况联合经腹或阴道进行修补,可以提高治愈率、减少并发症的发生。     

Delayed presentation and successful repair of a recurrent vesicovaginal fistula after hysterectomy and primary abdominal repair

Urogenital fistulae are an uncommon consequence of gynecologic surgery. Vesicovaginal fistulae due to gynecologic surgery generally appear 1–6 weeks after surgery and recurrent fistulae within 3 months of their repair. The pathogenesis of vesicovaginal fistula formation remains unclear. We present the case of a 36-year-old woman with a spontaneously recurring vesicovaginal fistula 21 months after abdominal repair of a vesicovaginal fistula caused by a laparoscopic-assisted vaginal hysterectomy. During the repair of the fistula and excision of the vaginal cuff, two small fluid-filled cysts between the bladder mucosa and the vaginal epithelium were encountered. Vesicovaginal fistulae can occur spontaneously and remote from surgery. The finding of small fluid-filled cysts in the cuff suggests that rupture of a similar cyst may have led to the formation of the fistula. Abbreviations LAVH Laparoscopically assisted vaginal hysterectomy     

带蒂膀胱瓣修补膀胱阴道瘘38例疗效分析

目的：探讨带蒂膀胱肌瓣修补膀胱阴道瘘的临床疗效。方法：对我院38例行带蒂膀胱肌瓣覆盖修补膀胱阴道瘘患者进行回顾性分析。初次修补患者22例,二次以上修补患者16例;单纯瘘口修补术25例,修补并输尿管膀胱再植术13例。结果：38例患者中有37例获得随访,1例失访。一次手术成功率94.59％（35／37）;1例手术失败,行二次修补治愈;1例术后出现膀胱缝合口漏尿,留置导尿2周后消失。术后随访患者均未出现阴道漏尿,6例患者出现轻度。肾积水,13例患者出现轻度尿失禁。结论：利用带蒂膀胱瓣覆盖修补瘘口是治疗膀胱阴道瘘的有效方法。     

带蒂腹直肌瓣修补膀胱阴道瘘39例疗效分析

目的:探讨带蒂腹直肌瓣修补膀胱阴道瘘的临床疗效。方法:回顾性分析2006年1月～2011年1月对39例较大瘘口的膀胱阴道瘘患者行带蒂腹直肌瓣修补,其中初次修补34例,2次以上修补5例;单纯瘘口修补30例,瘘口修补并输尿管膀胱再植9例。结果:39例患者中有38例获得随访,1例失访。一次手术成功率97.4%(37例);1例(2.6%)行二次修补治愈。术后随访6～36个月,均未出现阴道漏尿。结论:利用带蒂腹直肌瓣覆盖修补瘘口是治疗膀胱阴道瘘的有效方法。     

经腹径路手术治疗膀胱阴道瘘的临床分析

目的:探讨经腹径路手术治疗膀胱阴道瘘的临床疗效。方法:回顾性分析14例女性膀胱阴道瘘患者资料。患者平均年龄41.36岁。临床表现不同程度阴道漏尿,或伴血尿及膀胱刺激症状。膀胱镜检、膀胱尿道造影及CT三维重建术前确诊。先后行经腹径路膀胱阴道瘘修复手术,其中采取经膀胱径路9例,膀胱外径路5例。结果:14例术后随访9～103个月,平均46.26个月。2例术后出现再次膀胱阴道瘘,行二次修补手术后未再复发,1例出现切口感染,经对症处理后愈合,其余患者均未出现尿瘘复发及其他严重并发症。结论:经腹径路手术治疗膀胱阴道瘘,术中视野暴露充分,易于获取带蒂支持组织,尤其对于复杂性膀胱阴道瘘及合并输尿管等组织损伤可疑患者,是一种可行的手术治疗方式。     

妇产科手术后并发膀胱阴道瘘的诊治(附20例报告）

目的：探讨妇产科手术后并发膀胱阴道瘘的诊断、手术时机及手术途径。方法：20例妇产科手术后并发膀胱阴道瘘的患者经膀胱镜检查和膀胱亚甲蓝试验确诊。除1例经停留导尿管后自行闭合、2例恶性肿瘤复发未行手术外．17例于损伤发生后3个月行膀胱阴道瘘修补术，其中8例经阴道途径，9例经腹部途径。结果：17例手术均成功，随访无复发。结论：对膀胱阴道瘘手术时机和手术途径的选择不能一概而论．应根据患者的一般情况、瘘管性质及手术者的经验来选择。     

Management of giant vesicovaginal and vesicourethrovaginal fistulas

We herein report on 15 patients with giant vesicovaginal (7) and vesicourethrovaginal (8) fistulas repaired since July 1979. All fistulas were repaired by a suprapubic approach with or without a concomitant vaginal approach. All 7 patients with giant vesicovaginal fistulas underwent a standard racket incision of the bladder with excision of the fistula, closure of the vagina and bladder, and an omental interposition, and were cured. Four patients with giant vesicourethrovaginal fistulas had a similar successful closure but only 2 were cured of the incontinence, while 2 remained totally incontinent owing to failure of the bladder outlet sphincteric mechanism. The latter 2 patients were managed by a Tanagho bladder flap urethral reconstruction: 1 remained totally incontinent and finally underwent diversion, while 1 was improved but not cured totally. Four patients were managed by repair of the fistula simultaneously with a Tanagho bladder flap: 2 had no previous abdominal repairs and both achieved continence postoperatively, while 2 had numerous attempts at repair (including abdominal approaches) before referral and only 1 was cured. Giant vesicovaginal fistulas can be repaired successfully in almost all patients. Although vesicourethrovaginal fistulas can be closed as readily there is a high likelihood of sphincteric inadequacy in patients with extensive urethral involvement. A bladder flap urethral reconstruction is valuable in these patients, particularly in the absence of prior suprapubic procedures.     

Surgical repair of vesicovaginal fistulae--a ten-year retrospective study.

OBJECTIVE: Vesicovaginal fistulae in the western world generally occur as complications to pelvic surgery or radiation therapy of pelvic cancers. We have reviewed our results of vesicovaginal fistula closure procedures over a 10-year period. PATIENTS AND METHODS: From 1985 to 1996, 55 patients were referred to our department due to vesicovaginal fistulae. Five patients had fistulae due to malignant recurrence and one patient was considered inoperable. Thus, 49 patients were operated on. Thirty patients had fistulae resulting from pelvic surgery. Nineteen of the 25 patients admitted with fistulae secondary to radiation therapy of pelvic cancers were operated on. RESULTS: Of the 30 patients with postoperative fistulae, 23 had an abdominal repair and 7 a vaginal repair. A success rate of 90% was achieved after a first closure procedure, as 3 patients within a month experienced a recurrence. These three recurrences were all successfully closed in a second operation, augmenting the success rate to 100% in this group of patients. In the group of patients with fistulae caused by irradiation, a urinary diversion was performed in 12 patients, and in 7 patients a primary attempt to close the fistula was made, either by an abdominal approach (2 patients) or by a vaginal approach (5 patients). The fistula recurred in 6 of these 7 patients. Despite several additional attempts to close the recurrent fistulae, only one patient was successfully operated on. CONCLUSION: It seems that vesicovaginal fistulae resulting from pelvic surgery, in our hands, can be managed successfully either by an abdominal or vaginal approach. For patients with vesicovaginal fistulae resulting from radiation therapy, a urinary diversion appears to be the method of choice.     

Vesicovaginal fistula repair without intentional cystotomy using the laparoscopic robotic approach: a case report.

BACKGROUND AND OBJECTIVES: Fistulas inaccessible from the vagina may require abdominal repair; we sought to evaluate the robotic-assisted laparoscopic approach for this procedure. METHODS: A 41-year-old nulliparous woman presented with urinary incontinence following an abdominal hysterectomy, and office evaluation identified a vesicovaginal fistula. After discussion with the patient regarding the surgical options, the robotic approach was chosen to facilitate precise dissection, fine visualization, and suturing. A stent was placed from the bladder into the vagina, and no intentional cystotomy was made. The bladder was dissected away from the anterior vaginal wall at the fistula site, and the defects were closed independently with interposition of a fatty epiploica from the sigmoid colon. Total operative time was approximately 4 hours, and robotic time was about 2.5 hours. RESULTS: At 3 months after surgery, the patient had no recurrent symptoms. CONCLUSIONS: The robotic-assisted laparoscopic approach is a viable option for successful repair of a vesicovaginal fistula in a patient in whom a vaginal approach is not indicated.     

Laparoscopic repair of vesicovaginal fistula

PURPOSE: Vesicovaginal fistula may be a complication of urogynecologic surgery. We describe the technique of laparoscopic repair of vesicovaginal fistula as performed at our 2 institutions. MATERIALS AND METHODS: Since August 1998 laparoscopic repair of vesicovaginal fistula was performed in 15 select patients who had clear indications to undergo surgical treatment through an abdominal approach. Hysterectomy had previously been performed in 14 patients (93%). Conservative treatment was initially attempted for more than 2 months in all cases. Four patients had undergone a previous surgical fistula closure attempt with unsuccessful results. Our technique involved cystoscopy, catheterization of the vesicovaginal fistula, laparoscopic cystotomy, opening and excision of the fistulous tract, dissection of the bladder from the vagina, cystotomy closure and colpotomy with interposition of a flap of healthy tissue. Demographic as well as perioperative and outcome data were recorded. RESULTS: Average patient age was 38 years. None of the cases required open conversion. Mean operative time was 170 minutes (range 140 to 240). Mean hospital stay was 3 days (range 2 to 5). The mean duration of bladder catheterization was 10.4 days (range 9 to 15) At a mean followup of 26.2 months (range 3 to 60) 14 patients (93%) were cured. CONCLUSIONS: We believe that laparoscopic repair of vesicovaginal fistula is a feasible and efficacious minimally invasive approach for the management of this entity.     

Vaginal flap urethral reconstruction: an alternative to the bladder flap neourethra

Vaginal flap urethral reconstruction was done in 10 women who sustained total or partial loss of the urethra, and extensive damage to the vesical neck and trigone due to operative complications. In all patients a neourethra was constructed by rolling a vaginal flap into a tube and covering the anastomosis with a labial pedicle fat pad graft and vaginal flap. Five patients underwent a concomitant pubovaginal sling procedure, 3 had a modified Pereyra operation and 1 had a modified Kelly plication. Postoperatively, 9 of the 10 patients had a satisfactory neourethra but 3 required a generous meatotomy to facilitate micturition. Two patients required temporary intermittent self-catheterization. Of the 10 patients 6 were completely continent after a single reconstruction, which included an anti-incontinence repair. Of the patients with postoperative incontinence 2 subsequently were cured with a pubovaginal sling and 1 had a vesicovaginal fistula that was successfully repaired transvaginally. These results support our contention that a vaginal flap urethral reconstruction combined with an appropriate anti-incontinence operation offers a viable and simple alternative to bladder flap urethral reconstruction.     

Reparación laparoscópica de la fístula vesicovaginal (O’Connor laparoscópico)

IntroductionThe most frequent cause of vesicovaginal fistula in developed countries is hysterectomy, while in the third world it is related to time in labour. Any surgical iatrogenic trauma implies encountering added difficulties of various kinds when repairing the condition.Material and methodWe report the first case of vesicovaginal fistula to be resolved laparoscopically in our department. The patient is a woman 50 years of age who had undergone an abdominal hysterectomy 8 months previously, and who presented a syndrome compatible with vesicovaginal fistula. She was referred to our division after an unsuccessful attempt at vaginal repair. We will now describe the laparoscopic vesicovaginal fistula repair procedure.ResultsThe surgical procedure lasted approximately 3 hours and 30 minutes. The patient began oral intake 48 hours after surgery, normal intestinal transit was restored by the 5th day, a cystography was performed on the 7th day, and the patient was discharged on the 8th day. The patient remains asymptomatic after more than a year and a half.ConclusionsLaparoscopic resolution of vesicovaginal fistula is perfectly feasible and safe. If we consistently reproduce the principles applied in the open surgery, it offers the same success rate with the lowest possible morbidity.     

Laparoscopic transabdominal transvesical repair of supratrigonal vesicovaginal fistula

Introduction and hypothesis

We investigated the clinical efficacy of early laparoscopic repair of supratrigonal vesicovaginal fistula.

Methods

Laparoscopic repair of vesicovaginal fistula was performed and retrospectively studied in 18 consecutive patients who had clear indications for iatrogenic supratrigonal vesicovaginal fistula following hysterectomy or obstetric trauma during delivery. All patients underwent laparoscopic surgery via the transabdominal transvesical route. Wide mobilization of the bladder and vaginal wall, complete excision of devitalized tissue, tension-free closure, omental interposition, and efficient postoperative bladder drainage provides dependable support for definitive closure of the path. Success was defined as the disappearance of the fistula.

Results

Average patient age was 36.7 years; none required open conversion. Mean operative time was 135  (range 75–175) min. Mean duration of bladder catheterization was 15 (range 14–16) days. All patients were cured at the first attempt, with no surgical reintervention or recurrence at a mean follow-up of 22.7 (range 3–45) months.

Conclusions

We believe that laparoscopic repair of supratrigonal vesicovaginal fistula is an excellent alternative to the traditional abdominal approach and provides excellent results.     

A new dimension in vesicovaginal fistula management: an 8-year experience at Ramathibodi hospital

OBJECTIVE: Vesicovaginal fistula is mostly iatrogenic in origin and causes devastating medical, social, psychogenic and hygienic consequences. The aetiology has changed since the nineteenth century, becoming more associated with hysterectomy rather than other obstetric procedures, which were common in the past. We studied the causes, clinical presentations and management of vesicovaginal fistula in our institute during 1998 to 2005. METHODS: From 1998 to 2005, 45 patients were treated in our hospital, of whom 35 were referred from other hospitals after failed surgery. All the medical records were reviewed. Fistulae, clinical presentation, clinical findings, means of treatment and clinical outcome as well as complications were noted. RESULTS: The most common cause of a fistula in our study was post laparoscopic hysterectomy that comprised 28 cases (62.2%). Transabdominal hysterectomy caused fistula in 10 cases (22.2%) and vaginal hysterectomy only four cases (8.8%). Most cases of vesicovaginal fistulae after laparoscopic hysterectomy presented with early urinary leakage, of which 35.7% presented within 1 week and 50% in the second week. Most of the patients after transabdominal hysterectomies (90%) had leakage in the second week. All patients were treated with surgical repair, 19 cases by a transvaginal approach and 26 cases by a transabdominal repair. Seventeen cases in the transvaginal group and 25 cases in the transabdominal group were dry after the first operation. The rest of both groups were dry after the second operation. After 38 months of follow-up, no complication or incontinence was noted. CONCLUSION: Vesicovaginal fistula is still a serious iatrogenic consequence and causes suffering in the physical, emotional and social functioning of patients. The study found that the condition is now more frequently associated with laparoscopic hysterectomy. Successful closure of the fistula requires an accurate and timely repair using procedures that exploit basic surgical principles. With the appropriate surgical expertise, all patients can be cured of this distressing condition.     

Congenital vesicovaginal fistula with transverse vaginal septum presenting as menouria��a rare case report and brief review

Menouria due to congenital vesicovaginal fistula is rare entity. We report a case of a 22-year-old female who presented with menouria. On evaluation, she had congenital vesicovaginal fistula and obstructing complete vaginal septum. McIndoe vaginoplasty and fistula repair through vaginal route was performed.     

经阴膀胱阴道瘘修补术的改良及其初步结果

目的：描述一种改良的经阴膀胱阴道瘘修补术并报告其初步临床应用结果。方法：在经阴膀胱阴道瘘修补术中,采用Foley导尿管牵引技术为手术提供良好的视野暴露,同时为组织层次的分离提供有效的对抗牵引力量和可靠的依托平台,使手术程序简化,难度降低,提高组织分离的准确性,减少组织切除量,完成瘘口的三层无张力关闭。本组共有12例膀胱阴道瘘患者接受改良的经阴膀胱阴道瘘修补术,其中三角区上方瘘9例,三角区瘘3例,5例曾经历过一次以上失败的修补术。结果：12例患者均一次手术成功,手术时间20～80min,出血量均〈100ml,住院时间5～14d,留置导尿管时间13-23d。随访3～36个月,未发现瘘复发,3例有泌尿系感染经抗菌素治愈,1例表现出压力性尿失禁经做中段尿道吊带术治愈。结论：以Foley导尿管牵引技术为特点的改良经阴膀胱阴道瘘修补术是一种创伤小,成功率高的手术方式。     

Ten-year experience with transvaginal vesicovaginal fistula repair using tissue interposition

PURPOSE: The success rate of vesicovaginal fistula repair is improved by tissue interposition. The Martius flap produces reliable results but it has increased morbidity. A peritoneal flap is easily created with minimal morbidity and it can be used for proximal fistulas. We describe our 10-year experience with tissue interposition for transvaginal repair of vesicovaginal fistulas. MATERIALS AND METHODS: From January 1991 to July 2001, 207 cases of vesicovaginal fistulas were repaired transvaginally. Tissue interposition was used for complex (greater than 2 cm. and/or radiation induced) fistulas and/or failed previous repairs. A peritoneal flap was used for proximal fistulas and a Martius flap was used for distal fistulas. A full-thickness labial flap was reserved for cases of insufficient vaginal epithelium. RESULTS: A total of 207 patients underwent transvaginal repair of a vesicovaginal fistula. Etiology of the fistula was hysterectomy in 91% of cases (abdominal in 83% and vaginal in 8%), radiation in 4% and 5% other (obstetric trauma, anterior colporrhaphy or an indwelling catheter) in 5%. In 159 patients (77%) at least 1 previous repair had failed. Repair in 120 patients (58%) was done with tissue interposition, including a peritoneal, Martius and full-thickness labial flap in 83, 34 and 3, respectively. The cure rate after initial repair with a peritoneal, Martius and labial flap was 96%, 97% and 33%, respectively. There were no intraoperative complications. CONCLUSIONS: A peritoneal flap for transvaginal repair of vesicovaginal fistulas has minimal morbidity, results in a success rate comparable to that of the Martius flap and is especially useful for proximal fistulas when previous repair has failed.     

Urological injuries in conjunction with gynecologic surgery-10 years' experience

A 10-year evaluation (1983–1992) of 23 patients (mean age 49 years) with urologic injuries in conjunction with gynecologic surgery is presented. There were nine vesicovaginal fistulas, eight ureteral injuries, three bladder lesions, two posterior urethrovaginal fistulas and one vesicocervical fistula. The total incidence of urologic injuries from all major gynecologic operations (n=16 400) was 0.09% and that of abdominal hysterectomies (n=4082) 0.17%. Vesicovaginal fistulas and ureteral injuries comprised two-thirds (17/23) of all injuries. All vesicovaginal fistulas followed abdominal hysterectomy, whereas almost half (3/8) of ureteral injuries were recognized after radical hysterectomy. Of nine vesicovaginal fistulas two were cured by prolonged transurethral catheter drainage: the other seven underwent successful transabdominal repair at first attempt. All the eight ureteral injuries were cured successfully at the first attempt, five of them by ureteroneocystostomy and the others with ureteral stent placement. One of the urethrovaginal fistulas was repaired successfully at the first attempt, the other required a second repair. At follow-up (mean 4 years) all patients were doing well. Urologic injuries after gynecologic surgery are extremely rare (0.09% in our series) but when they occur they can be consistently repaired by modern surgical techniques.Editorial Comment: This report of a 10-year experience with various types of fistula and ureteral injury indicates a very low incidence as well as a very high success rate in their management. Of note is the high frequency of fistulas following urethral diverticulectomy (18%). Care must be taken when closing the anterior vaginal wall in this procedure. There must be no tension and adequately vascularized tissue must be present. The preparation of flaps is usually possible as the dissection of the diverticulum proceeds, with the goal of having enough tissue to allow a vest-over closure in one or two layers. If there is any doubt about the closure a bulbocavernosus fat pad graft should be prepared and placed as an additional layer prior to closure of the vaginal wall.     

Vesicovaginal fistula caused by abdominal hysterectomy and sacrocolpopexy with polypropylene mesh (GYNEMESH): a case report

A 45-year-old woman underwent abdominal simple hysterectomy and sacrocolpopexy with polypropylene mesh (GYNEMESH) for uterine prolapse at the department of Gynecology in October 2006. One month after the operation, she visited our department with a complaint of urinary incontinence. Cystography and magnetic resonance imaging revealed a vesicovaginal fistula. A foley catheter was indwelt for the purpose of conservative treatment, but failed. Considering possible infection and inflammation remaining, we decided to perform abdominal repair of the vesicovaginal fistula about three months after the operation. Transabdominal repair of the vesicovaginal fistula was performed in February 2007. During the operation, a fistula 3 mm in diameter was confirmed just adjacent to the distal edge of the polypropylene mesh which had been fixed between the bladder and the anterior wall of vagina. Eleven days after the operation, cystography revealed no evidence of the vesicovaginal fistula. There has been no sign of recurrence at three years after the operation.     

Complications of neglected vaginal pessaries: case presentation and literature review

Vaginal pessaries are often used as first-line management of pelvic organ prolapse in women who are poor surgical candidates or who decline surgical repair. Mostly, pessaries are well tolerated but when neglected may lead to serious complications including vesicovaginal and rectovaginal fistulas. An 89-year-old woman presented with a large vesicovaginal fistula resulting from a Gellhorn pessary that had been neglected for 3 years. The base of the pessary had migrated completely inside the bladder and the fistulous opening measured 4 cm. The pessary was extracted under anesthesia using a Schuchardt incision to increase exposure. After 6 weeks of vaginal estrogen treatment, the fistula was successfully repaired using the Latzko partial colpocleisis technique. Neglect of a vaginal pessary can lead to serious complications. Patient education, local estrogen treatment, excellent fitting, and careful follow-up are of paramount importance in prevention of such complications.