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.     

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。     

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.     

Vesicovaginal fistula repair with genito-gluteal fold fat pad flap.

We report our experience of supratrigonal vesicovaginal fistula (VVF) repair cases developed after gynaecologic surgery. Two patients presented with urinary incontinence after hysterectomy and adjuvant radiation therapy for cervical carcinoma. Cystoscopy findings showed vesicovaginal fistula near the bladder neck area. In a transvaginal approach, we excised the fistulous tract and transferred the genito-gluteal fold fat pad flap for interpositioning. Postoperative cystography showed no evidence of leakage and no recurrence was found after a 1 year follow-up period. This flap technique is particularly useful for a vaginal cuff area fistula in terms of ease of dissection, lower donor site morbidity and large flap dimension. Also the fat pad provides neovascularity and lymphatic drainage, fills dead space, and enhances granulation tissue formation.     

Functional outcomes of primary and secondary repairs of vesicovaginal fistulae via vaginal cuff scar excision

Hospital and office charts of patients who underwent vaginal cuff scar excision for vesicovaginal fistula (VVF) repair from February 1998 to December 2002 at our institution were reviewed. Preoperative demographics and fistula characteristics were gathered. Intraoperative data included use of tissue flaps, blood loss, OR time and anesthetic type. Postoperative review included time to discharge, successful repair and postoperative urinary or sexual dysfunction. Forty fistula repairs were identified. Ninety-three percent occurred after a hysterectomy and no subjects had a history of radiation. Forty-two percent had failed at least one surgical repair of their fistula and 12% had failed two or more attempted repairs. Twenty percent of the fistulae measured 1 cm or more in diameter and the remaining 80% were 5 mm or less. Peritoneal flaps and martius flaps were performed in 32% and 5%, respectively. Postoperatively, 100% of subjects were evaluated at 3 weeks when the suprapubic catheter was removed and 93% were evaluated at 3 months or later. All subjects were cured of their fistulae at last contact. At 3 months postoperatively, 94% percent denied any urinary dysfunction and 85% had resumed sexual intercourse. Two sexually active subjects reported mild deep dyspareunia. Transvaginal cuff scar excision is an effective method for the primary and secondary repair of vesicovaginal fistulae and does not appear to cause postoperative irritative voiding symptoms or dyspareunia.Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy or position of the United States Army, Department of Defense or the United States governmentThis article was presented at the 24th annual meeting of the American Urogynecologic Society, September 11–13, 2003. Hollywood, FL, USA Editorial Comment: Vesicovaginal fistula (VVF) is a most distressing problem for both the patient and surgeon alike. The most expeditious, safest, and least morbid repair with the greatest likelihood of success should be employed. These authors have previously described this approach for VVF repair and, now, in this article have published on functional outcomes. There is very little in the literature on long-term functional outcomes following VVF repair and therefore this represents an important contribution. Although the use of anonymous, complete validated questionnaires as an outcome measure would have been ideal, especially as regards urinary and sexual function, these authors report that functional outcomes following vaginal cuff excision repair of VVF are satisfactory. It is important to remember that the vast majority of patients presenting with VVF were healthy, presumably without significant urinary or sexual dysfunction, and underwent an elective surgery which created the problem. This paper suggests that these patients can be restored to a satisfactory level of urinary and sexual function following repair.     

Transvesical vesicovaginal fistula repair: a revival

Vesicovaginal fistulae are usually traumatic in nature, following obstetric or gynecologic trauma. Here, our experience with vesicovaginal fistula repair in 68 cases, performed transvesically (58 cases) or transperitoneally-transvesically, with pedicled omental interposition in 10 cases over the last 8 years is described. The size of fistulae ranged from 1 to 5 cm, and most were situated near or above the trigone. Two cases required ureteric reimplantation. Recurrent fistulae were found in 4 cases. We attribute our success to the simple access, the construction of a vascularized flap, the tension-free grid-iron closure, and the utilization of Vicryl suture.     

Laparoscopic repair of vesicovaginal fistula

Vesicovaginal fistula (VVF) may be a complication of prolonged repair or urogynecologic surgery. Failing conservative management, it may be repaired using an abdominal or vaginal approach. We herein report laparoscopic repair of VVF following vaginal hysterectomy and detail the operative steps.     

Vesicovaginal fistula

Urinary fistula to the vagina has been described since the beginning of the written record. In developed nations, these fistulas are usually unfortunate complications of gynecologic or other pelvic surgery and radiotherapy. Historically, birth trauma accounted for most vesicovaginal fistulas, and it remains the major cause of urinary fistulas in many underdeveloped nations. Once a vesicovaginal fistula is suspected, a thorough vaginal examination should be performed to identify its size and location, especially in relation to the trigone and eliminate a ureterovaginal fistula which can be associated in up to 10% of cases. Numerous methods for the treatment of vesicovaginal fistulae have been described. Abdominal, and vaginal approaches are used for the repair of vesicovaginal fistulae. The approach selected is dependent on many factors, but is probably best determined by the experience and training of the surgeon. The techniques of the vaginal approach involve tension-free closure of the fistula with or without excision of the tract, creation of an anterior vaginal wall flap and appropriate use of vascularized interposition grafts. The abdominal approach may be used to treat all types of vesicovaginal fistulae and is the preferred approach when concomittant ureteral reimplantation is required. Postoperative care is similar for both vaginal and abdominal vesicovaginal fistula repair. Adequate uninterrupted bladder drainage is the most critical aspect of postoperative management. A voiding cystourethrogram is performed at 10 postoperative days to confirm closure of the fistula.     

Vaginal repair of ureterovaginal fistula may be suitable for selected cases

Ureterovaginal fistula (UVF) is an uncommon but devastating complication of gynecologic surgery. Management includes ureteral stenting for 6–8 weeks. For stent failure, ureteroneocystostomy (UNC) through an open, laparoscopic, or robotic abdominal approach is the classic alternative. Originally pioneered for repair of vesicovaginal fistulas (VVF), the use of the vaginal approach in UVF is scarcely reported in the literature. We report the successful repair of UVF performed exclusively through the vaginal approach in two women after robotic hysterectomy. In select clinical scenarios, this approach may be applied, as it provides a minimally invasive option for managing UVF after failure of ureteral stenting.     

Transperitoneal Transvesical Laparoscopic Repair of Vesicovaginal Fistulae: Experience of a Tertiary Care Centre in Northern India

Objective

To present our experience of treating supratrigonal vesicovaginal fistulae by laparoscopic technique and their long-term follow-up.

Material and Methods

Between January 2008 and June 2012, 28 cases of supratrigonal fistulas were repaired by laparoscopic transperitoneal transvesical technique with interposition flap. The obstetric fistula was present in 18 and gynecologic fistula in 10 patients. Single supratrigonal fistula was present in 26 patients and in 2 patients there were 2 fistulae lying side to side. The vaginal opening was closed as single layer interrupted suture and cystotomy closed as single layer continuous suture by 3-0 polygalactin. The omentum was used as interposition flap in all except 2 cases in whom postero-superior vesical fold of peritoneum was used. The open conversion was required in 2 cases. The urethral catheter was removed in 4 weeks following a micturating cystogram.

Result

The mean fistula size was 1.2 cm (range 0.8-2.5 cm). Open conversion was performed in 2 cases of whom one had excess carbon-dioxide retention and cardiac arrhythmia and in another case the needle of 3-0 polygalactin was avulsed and lost in peritoneal cavity which was recovered following laparotomy. All patients were continent following the catheter removal. The median follow-up is 24 months. None developed any complication related to laparoscopic repair till last follow-up.

Conclusion

Laparoscopic repair of supratrigonal vesicovaginal fistulae is an effective and safe minimally invasive treatment with excellent result.Key Words: Transperitoneal approach, Laparoscopic surgery, Vesicovaginal fistulae     

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.     

Large cystocele with spontaneous vesicovaginal fistula

Vesicovaginal fistulae (VVF) caused by cystoceles are very rare. To date, there are no documented cases in English literature. A 77-year-old woman presented with near total incontinence. On physical examination, she was found to have severe vaginal atrophy and pressure necrosis of the anterior vaginal wall, which caused partial thickness erosion and breakdown of the mucosa. A fistula had formed but there was no obvious full thickness necrosis. She underwent a combined vesicovaginal fistula repair with pubovaginal sling.     

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.     

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.     

Our experience with salvage genitourinary fistulae repair: technique and outcomes

Objectives The objectives are to present the long-term results of vaginal reconstructive operations using the labial fat pad flap (Martius flap) interposition. Patients and methods Eight women, 27–65 years old (mean 40), suffering from urinary fistulae (five urethrovaginal and three vesicovaginal) who failed primary repair underwent salvage vaginal reconstruction for damaged urethra or bladder. Urethral or bladder and vaginal defect was closed and a Martius fat flap was interposed between urethra or bladder and vaginal wall flap to secure a watertight separation of the structures. A Martius flap was also used successfully for salvage vaginal reconstruction in three more women, two with extensive injury of their urethra and bladder neck and one with vaginal leakage, after a rectosigmoid neobladder diversion following cystectomy. Results The repair was successful in all eight patients with urinary fistulae and in the one with rectovaginal leakage. The patient with the traumatically injured urethra and bladder neck developed an anastomotic stricture treated with urethral dilatations and internal urethrotomy. The older one developed a vesicovaginal fistula due to bladder neck closure, and this was repaired with a second transvaginal closure. Conclusion Martius labial fat flap is an easy to prepare, well-vascularized tissue that can be most helpful in achieving a long-lasting favorable outcome in vaginal reconstructive surgery.     

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.     

Early Versus Late Repair of Vesicovaginal Fistulas: Vaginal and Abdominal Approaches

We reviewed retrospectively 24 consecutive women who presented with a vesicovaginal fistula repaired by a single surgeon between 1989 and 1993. All patients underwent preoperative investigation, including cystoscopy, excretory urography and bilateral retrograde pyelography. Followup ranged from 6 months to 5 years. Postoperatively, 96 percent of the women were cured. Two patients had persistent symptomatic detrusor instability and 1 had mild stress incontinence. In 1 woman a vaginal repair failed and she was subsequently cured after an abdominal repair. Five patients presented 6 to 12 months after fistula formation. Among the other 17 patients the average interval from pelvic surgery to vesicovaginal fistula repair was 10.8 weeks. Indications for abdominal repair were indurated vaginal epithelium approximately 2 cm. in circumference around the fistula, a vault fistula with poor vaginal exposure and fistulas involving the ureters. Surgical timing and route of repair are best tailored to the individual patient.     

Do we need new surgical techniques to repair vesico-vaginal fistulas?

Introduction and hypothesis  

The urogenital fistula is a devastating condition for women. Despite advances in medical care, the vesicovaginal fistula continues to be a distressful problem. Complex vesicovaginal fistulae repair may need tissue interposition. It can be achieved by vaginal or abdominal approach and depends on the surgeon's experience and local factors like size, location, and previous radiotherapy. The aim of this study was to demonstrate that using traditional approaches is possible and reasonable to treat any sort of vesicovaginal fistula.     

女性尿路生殖道瘘诊疗分析(附27例报告)

目的:总结女性尿路生殖道瘘临床诊疗经验,探讨复杂性女性尿路生殖道瘘的治疗方法。方法:本组27例,年龄16~56岁,平均41.2岁。其中膀胱阴道瘘9例,输尿管阴道瘘15例,输尿管子宫瘘1例,尿道阴道瘘2例。妇科盆腔手术所致23例,会阴部或盆腔外伤所致3例,放疗所致1例。9例膀胱阴道瘘中,3例行耻骨上经膀胱修补,2例经阴道修补,3例复杂性瘘经腹修补并移植带蒂大网膜,1例放疗后复杂性瘘行输尿管皮肤造口术。15例输尿管阴道瘘中,6例行输尿管镜下输尿管双J管留置术,9例行输尿管膀胱再植术。1例输尿管子宫瘘行耻骨上辅助经脐单孔腹腔镜(SA-LESS)输尿管膀胱再植术。2例尿道阴道瘘均经阴道行修补术,其中1例采用改进三层错位缝合术修补。结果:24例一次治愈,成功率为88.89%(24/27);3例二次手术治愈。平均手术时间75(45~135)min,平均术中出血量60(15~150)ml。术后随访4个月~13年,27例患者均未再出现漏尿,无尿失禁、尿道及阴道狭窄,无继发性肾功能损害。结论:女性尿路生殖道瘘修补手术方法因人因病而定。术前充分准备,选择恰当的手术修补时机、正确的手术修补途径、术中精细操作是提高尿路生殖道瘘手术成功的关键。对复杂性尿瘘,可采用改进三层错位缝合术、辅助带蒂瓣片或网膜技术修补瘘口,促进愈合。     

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.