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.     

Laparoscopic repair of vesicovaginal fistula

Introduction In developed countries, the majority of vesicovaginal fistulas develop after gynaecologic surgery, with abdominal hysterectomy accounting for 90% of cases. Several techniques are available for repairing the fistulas. Abdominal approaches give good results even for difficult posterior located fistulas, but are associated with increased morbidity compared with the transvaginal approach. We performed a laparoscopic repair to minimize the surgical morbidity of the transabdominal approach. Methods A 44-year-old female presented with vesicovaginal fistula after abdominal hysterectomy. After a failed trial of conservative treatment with catheter drainage, a transperitoneal laparoscopic repair was performed. Cystoscopy was performed intially to confirm the fistula location and for bilateral ureteric catheterization. A 4-port technique was performed with the patient in the Trendelenburg position with her legs in lithotomy position. Without opening the bladder, the fistula tract was excised with separation of the bladder from the anterior vagina wall. Both the bladder and vagina walls were then closed separately using intracorporeal suturing with an interpositional omentum. Results The operation was uncomplicated. Total operative time was 260 min. Normal diet was resumed on day 1 and patient was discharged on the same day with an indwelling catheter. A cystogram performed 3 weeks post surgery showed resolution of the fistula. Conclusions Laparoscopic repair of vesicovaginal fistula without opening the bladder and using intracorporeal suturing and omentum interpositioning is feasible in selected patients.     

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。     

Large post-hysterectomy and post-radiation vesicovaginal fistulas: repair by ileocystoplasty

PURPOSE: We devised a technique for simultaneous closure of large post-hysterectomy and post-radiation vesicovaginal fistulas, and augmentation of the concomitant shrunken bladder by ileocystoplasty as a 1-step procedure. MATERIALS AND METHODS: Between 1989 and 2000, 4 patients with large vesicovaginal fistulas after radical hysterectomy and radiotherapy for spinocellular cancer of the uterine cervix underwent fistula repair according to the technique described. The premise of utmost importance in the proposed technique is a healthy and not radiation damaged distal ileum. RESULTS: Fistula closure was achieved in 3 patients, while in 1 a 3 mm residual fistula was repaired 5 years later by a Martius skin flap. In all patients the augmented bladder allowed good quality of life with spontaneous voiding, and daytime and nighttime continence. CONCLUSIONS: The technique described seems to have certain advantages. Wide dissection of the bladder from the vagina and pelvic walls is avoided. The bladder defect is closed with a well vascularized ileal segment. Bladder capacity is enlarged simultaneously with good functional results. The procedure can be adapted to cases with concomitant damaged distal ureters.     

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.     

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.     

Bilateral pedicled myocutaneous vertical rectus abdominus muscle flaps to close vesicovaginal and pouch-vaginal fistulas with simultaneous vaginal and perineal reconstruction in irradiated pelvic wounds

Chronic postoperative pouch-vaginal and vesicovaginal fistulas after hysterectomy and irradiation to treat advanced cervical cancer do not respond to conventional treatment because of the low vascularity in the irradiated area. We present the successful repair of these complications in a female patient, in whom several vaginal and abdominal approaches had been tried and had resulted not only in failure but also in tissue loss and fibrosis and persisting fistulas. First, a synchronous vaginoabdominal approach using a vertical myocutaneous distally based rectus abdominis myocutaneous flap was used successfully to close a pouch-vaginal fistula and simultaneously reconstruct the posterior vaginal wall. In a second approach, the persisting vesicovaginal fistula was closed by a right rectus abdominis myocutaneous flap while simultaneously reconstructing the anterior vaginal wall, closing the enterocutaneous stoma and performing an appendicovesicostomy as a continence channel for catheterization. Despite unfavorable local wound situations, including an enterocutaneous stoma through the rectus abdominis and various previous incision lines, the transfer of axially well-vascularized tissue can solve these problem wounds. Consecutive bilateral use of the rectus abdominis flap may be necessary to deal with extensive pelvic wounds. This technique should be considered as one repair modality in irradiated pelvic wounds with fistulas. Previous enterostomy is not a contraindication to the use of this flap.     

Plastic surgical techniques in the repair of vesicovaginal fistulas: A review

A variety of plastic surgical techniques may be used in the repair of vesicovaginal fistulas. The indication for their use include: (a) diameter greater than 4 cm; (b) involvement of the bladder neck/proximal urethra; (c) radiation-induced fistulas; and (d) previous failed repair(s). In the developing world the vast majority of complex fistulas are caused by obstetric trauma; elsewhere they occur mainly following radiotherapy or radical surgery for gynecologic malignancy. The majority of complex fistulas requiring tissue donation may be effectively treated using a vaginal approach and a modified Martius graft. There is probably little or no advantage in encorporating bulbocavernosus muscle fibers in this graft. Although some concern exists regarding the long-term viability of these grafts in radiation-induced fistulas, in view of the relatively simple operative technique, together with the low associated morbidity, modified Martius grafts may be deemed suitable for first-time repairs. The gracilis muscle graft should be considered next in cases of exclusive transvaginal repair. The omental graft is undoubtedly the most versatile: it can be used in both abdominal and combined abdominovaginal procedures. The recently described posterosuperior sliding bladder flaps warrant further evaluation. For most fistulas involving the bladder neck/proximal urethra, there is no clear advantage in bladder flap reconstruction over vaginal flap reconstruction, the latter being augmented by an anti-stress incontinence procedure were appropriate. When continent urinary diversion is required, the Indiana pouch appears preferable to the Kock pouch; ureterosigmoidostomy is, however, technically and culturally more acceptable in these circumstances in the developing world.     

The split labium minus flap graft technique

The split labium minus flap graft technique was used to restore tissue volume and therefore elasticity into the bladder neck area of vagina in eight patients. Three full-thickness vaginal incisions were made, a longitudinal incision extending from external urethral meatus to 3–4 cm beyond the bladder neck, and two transverse incisions, one just below the external urethral meatus and the other at the level of the bladder neck. The vagina, urethra and bladder neck were mobilized widely and the suburethral flaps rotated downwards, leaving a bare area below the urethra. A transverse incision was made across the base of one labium minus (LM) and the incision carried up on each side to the ridge of the LM. The inner wall was dissected clear of the outer wall, creating a flap. This was then rotated into the bare area formed by dislocation of the suburethral vagina. The flap was attached to the pubococcygeus muscles laterally, to the external meatus superiorly and to the vaginal skin inferiorly. All the cut surfaces of the vagina and LM were joined with 00 Dexon sutures. Postoperative pain was minimal. All patients were discharged within 48 h, and there was excellent anatomical restoration at 6 weeks follow-up. The technique works well in patients with adequately large labia minora, and has potential uses for patients who have deficient vaginal tissue in the hammock or bladder neck areas of the vagina.Abbreviations LM Labium minus Editorial Comment: Tethering of the vagina during vaginal repair may cause overcorrection of the support under the bladder neck. Using a full-thickness graft from the labia minora permits the release of the vagina under the urethra and bladder neck and allows for the closure of the vaginal mucosa without tension.     

Vagina reconstruction with perineal axial flaps

Since Nov. 1988, 4 cases of vagina reconstruction were performed using perineal axial flaps with excellent results. The perineal axial flap contains posterior labial artery which penetrates the perineal fascia to the subcutaneous layer at the middle point between the posterior commissura and the root of the thigh, proceeds to the mons pubis along the lateral side about 1.5 cm to the labium majus. The flap 4 x 9 - 5 x 10 cm in size was designed according to the orientation of the artery from the root of the thigh to the labium majus on each side respectively. It was taken up, sutured as sack, and transferred to artificial cavity made between the bladder and rectum Donor sites were closed directly.     

Recto-vaginal/urethral fistula: repair with gracilis muscle transposition

This study was designed to assess the efficacy of gracilis muscle transposition in repairing recto-vaginal and rectourethral fistula. All patients had fecal diversion as a preliminary or concurrent step to fistula repair. Success was defined as healed fistula after stoma closure. Results: Six females and four males underwent gracilis muscle transposition from 1999 to 2006. Gracilis muscle transposition is a viable option for repairing fistulas between the urethra, vagina and the rectum, especially after failed perineal or trans-anal repair. It is associated with low morbidity and good success rate. Underlying Crohn's disease and previous radiation are associated with poor prognosis.     

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.     

Our experience in the Martius method of closing the vesicovaginal fistula

Sometimes after delivery, gynecological or other surgeries, radiological therapy, or destructions of vesico-vaginal septum due to the tumor or trauma, the unnatural communication between the bladder and vagina occurs. Those are fistulas that occur after the delivery (tocogenic) caused by the prolonged delivery or some obstetrics operations. Some fistulas are high, coming from the fundus of the bladder, medium, if they come just behind the trigonum of the bladder, and low, if they are in the level of trigonum and the neck of the bladder. The purpose of this paper is to show the operative technique of elimination of medium and low vesicovaginal fistula and the results of the treatment. Material and method The elimination of the vesicovaginal fistula by original Martius technique is done through vagina. The catheter is inserted through the fistula (figure 1). Than the mucosis of the vagina is cut around the fistula and the vaginal wall is separated from the bladder. The catheter is pulled out and the fistula on the bladder is sown with resorptive stitches. Than the labia maiora nearer to the fistula is cut along from Mons Veneris to the middle and the lipoid tissue is taken with vascular pedicle (figure 2). This tissue is put between the bladder and the vagina and fixed with resorptive stitches. After that the vagina is sown by single stitches. The labia maiora that was cut is also sown by single stitches (figure 3). Than the catheter is inserted in the bladder that should stay there for four weeks. This is the method we used to make surgery in twenty patients with vesicovaginal fistula. The first one had the fistula as the result of the Caesarean section. She was operated twice through the bladder without success. The second patient was a fourteen years old girl that cut herself on the glass and damaged anal sfincter, rectum, vagina and the bladder. The fistula appeared later in the level of trigonum of the bladder. The other eighteen patients got fistula after hysterectomy. All patients were treated as described above and fistulas disappeared. The first patient had another baby a year after the operation by Caesarean section. The other patients have regular miction (figure 4 and 5). Discussion and the conclusion Vesicovaginal fistula are serous complications, for the patients and for the doctors. The only treatment of the vesicovaginal fistula is surgical. If any damage of the bladder occurs during any operation it should be treated immediately, otherwise the fistula will appear. The treatment depends of the localization of the fistula. Low fistulas and some medium and urethrovaginal fistulas should be approached through vagina and according to our experience Martius's method is very efficient. The only important thing is when the fistula is detected to wait at least for two or three months for the fistula to "consolidate" and also to cure the infection.     

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.     

Laparoscopic Management of Recurrent Vesicovaginal Fistula

Vesicovaginal fistula repair is most commonly undertaken via a transvaginal approach. We report a recurrent case of vesicovaginal fistula which was ultimately repaired using a laparoscopic approach. The fistula followed a hysterectomy and persisted despite two operations using the Latzko partial colpocleisis and prolonged catheterization. The fistulous tract was ultimately repaired by closing the vagina and bladder with an interposing omental flap utilizing a laparoscopic approach.     

Perineal subcutaneous dartos pedicled flap as a new technique for repairing urethrorectal fistula

PURPOSE: Urethrorectal fistulas are rare, and the etiology is usually traumatic or iatrogenic (postoperative). Several operative approaches and techniques have been used for fistulous repair but no procedure has proved to be the best or universally acceptable. We present a new technique for repairing urethrorectal fistulas. MATERIALS AND METHODS: We successfully treated 12 male patients 7 to 65 years old who presented with urethrorectal fistula from 1990 to 1997 using the perineal subcutaneous dartos pedicled flap procedure. Urethrorectal fistulas resulted from crush pelvic injury in 6 cases and gunshot in 2, and developed after prostatectomy in 4. The fistula was associated with urethral stricture in 4 cases. A perineal approach was used in all cases of urethrorectal fistula and combined with the transsymphyseal approach in the 4 patients with posterior urethral stricture. We interposed a subcutaneous dartos pedicled flap as a vascularized tissue flap between the repaired rectum and urethra. RESULTS: The results of our technique were excellent in all cases. No leakage or perineal collection developed and there was no fistula recurrence. In 1 patient urethral stricture was managed by visual internal urethrotomy. Loss of the internal and external sphincters resulted in urinary incontinence in 4 cases, involving gunshot injury (2), crush pelvic injury (1) and prostatectomy (1). Followup ranged from 9 to 42 months. CONCLUSIONS: Our technique of a perineal subcutaneous dartos pedicled flap fulfills all principles of the successful repair of urethrorectal fistula. We consider it to be an ideal solution to this urological dilemma.     

Vesicovaginal fistula with secondary vaginal stones

PURPOSE: We report a rare case of a vesicovaginal fistula associated with secondary vaginal stones that was managed totally endoscopically. MATERIALS AND METHODS: A 52-year-old woman presented with urinary incontinence and perineal pain. On subsequent evaluation, we found a vesicovaginal fistula associated with secondary vaginal stones caused by a retained gauze. Management involved vaginoscopy, intracorporeal shock wave lithotripsy for vaginal stones, and removing retained medical gauze. We performed cystoscopy, laparoscopic cystotomy, transabdominal Foley catheterization of the vesicovaginal fistula for traction, injection of diluted adrenaline-saline solution for better dissection, dissection of the bladder from the vagina, tension-free closure of the bladder and vaginal defects, and closure of the cystotomy. RESULTS: Operative time was 155 minutes and blood loss was 60 mL. The patient was discharged on postoperative day 3, and catheterization time was 14 days. At 3-month follow-up, the patient was fully continent. CONCLUSION: To our knowledge, this is the first reported case of a vesicovaginal fistula associated with secondary vaginal stones which was managed totally endoscopically. We believe that this is a feasible and efficacious approach for the management of such cases.     

Posterior bladder flap plasty for repair of vesicourethrovaginal fistula.

Of all types of vesicovaginal fistulas those affecting the trigone and bladder neck, and associated with urethral loss are the most difficult to repair. For these cases a posterior bladder flap procedure is presented that offers a direct approach to close the fistula and form a continent urethra.     

经腹腹腔镜治疗妇科术后膀胱阴道瘘的初步体会

目的总结经腹途径腹腔镜在膀胱阴道瘘修补中的可行性及疗效。方法2012年12月至2017年12月暨南大学附属第一医院因子宫全切除(n=6,均为开放手术)或宫颈癌根治术后(n=1)致膀胱阴道瘘患者共7例,年龄42~57岁,所有瘘口均位于输尿管嵴以上,瘘口直径0.5~3.5 cm,尿瘘病史3个月~5年余,其中2例既往有1~2次经膀胱修补失败病史。采用经腹腹腔镜下膀胱阴道瘘修补术,直视下放置操作通道,其中5例瘘口较大或复发性膀胱阴道瘘采用大网膜填充膀胱与阴道之间的间隙。术后留置尿管2~3周。结果7例患者手术均顺利完成,手术时间150~280 min,出血量50~150 ml,无输血,术后拔除尿管后尿瘘消失。随访6~54个月未出现尿瘘。结论经腹腹腔镜修补高位膀胱阴道瘘微创、有效,尤其是复发性病例,但尚需更多临床资料论证。     

The sandwich design: a new method to close a high-output enterocutaneous fistula and an associated abdominal wall defect

Fistulas draining through large abdominal wall defects are exceptionally difficult to treat and are associated with a very high mortality. This case report describes a new method for closure of these fistulas where prior conservative and surgical treatment had failed. Initial use of a vacuum-assisted closure (VAC) system optimized wound care and led to coverage of the exposed intestines with granulation tissue. The serratus muscle of a composite free latissimus dorsi-serratus flap was used to close the fistula, while the large abdominal wall defect was closed with the musculocutaneous latissimus dorsi flap. Temporary placement of a VAC system between the serratus muscle and the latissimus dorsi muscle immobilized the serratus to the fistula and counteracted changes in abdominal pressure. The layering of muscle, VAC system, and muscle resembles a sandwich. The advantage of the sandwich design is an extraperitoneal approach that provides tension-free closure of the fistula and abdominal wall, with well-vascularized tissue.