Transvaginal repair of ureterovaginal fistula by Latzko technique

Ureterovaginal fistula is an uncommon but serious sequela of unrecognized distal ureteral injury during pelvic operations. Traditionally, it is managed either by endoscopic internal ureteral stenting or by ureteral reimplantation. We report a case of ureterovaginal fistula that failed to respond to ureteral stenting. Because the patient had a history of several laparotomies and intra-abdominal abscesses, she was at high risk for complications with a transabdominal operation. Therefore, we used transvaginal Latzko partial colpocleisis and successfully resolved the ureterovaginal fistula.     

Rectourinary fistula repair using the Latzko technique

PURPOSE: We report our experience with the Latzko technique for rectourinary fistula repair after radical retropubic prostatectomy and cystoprostatectomy. MATERIALS AND METHODS: We performed 7 fistula repairs in 6 patients. The 1-stage procedure was based on a technique for vesicovaginal fistula closure with denudation of the rectal mucosa and multilayer closure of the fistulous tract. RESULTS: Closure was successful in all patients, although 1 had to undergo the procedure twice. There were no postoperative complications. CONCLUSIONS: The Latzko procedure is effective for rectourinary fistula repair and associated with minimal morbidity.     

Two cases of urethrovaginal fistula repaired by Martius labial-rotation flap

Urethrovaginal fistulas are rare. In case 1, a 48-year-old woman had undergone transvaginal drainage for an paraurethral abscess. In case 2, a 33-year-old woman had undergone resection of vaginal varicocele with massive bleeding during pregnancy. Postoperatively both patients complained of total incontinence. Urethroscopy and urethrography revealed an urethrovaginal fistula in each case. Repair ofurethrovaginal fistula using Martius labial-rotation flap was performed and the fistula was closed in both cases. We concluded that repair of urethrovaginal fistula using Martius labial-rotation flap may be useful for patients with urethrovaginal fistula.     

Simple and effective: transvaginal vesico-vaginal fistula repair with a modified Latzko technique

Introduction and hypothesis

The incidence of vesico-vaginal fistulas after hysterectomies for benign indications in developed countries is less than one percent. The objective of this video is to demonstrate an easy-to-follow, step-by-step approach to repairing a small, uncomplicated vesico-vaginal fistula transvaginally using a modified Latzko technique.

Methods

In this video, we present a case of a 46-year-old woman who developed a simple, uncomplicated vesico-vaginal fistula after a total abdominal hysterectomy. To correct her fistula, we used a modified Latzko technique, which is a transvaginal approach to vesico-vaginal fistula repair that involves mobilizing the vaginal mucosa around the fistula and then closing the pubo-vesical fascia and vaginal mucosa in layers.

Results

The patient had successful surgical correction of her vesico-vaginal fistula without recurrence of the fistula.

Conclusions

For small, uncomplicated vesico-vaginal fistulas, a transvaginal approach has an equivalent success rate to that of other approaches with less invasiveness and faster recovery times. Therefore, it is reasonable to use a modified Latzko technique to help restore the quality of life to women affected by small, uncomplicated vesico-vaginal fistulas.

     

Martius flap and anterior vaginal wall sling for correction of urethrovaginal fistula (UVF) associated with stress urinary incontinence (SUI) after vaginal delivery

ObjectiveTo determine the efficacy, safety and urodynamic effects of the Martius flap and the anterior vaginal wall sling in treating post-birth trauma in the form of urethra-vaginal fistula (UVF) associated with stress urinary incontinence (SUI).Patients and methodsBetween July 2006 and August 2011, 19 patients underwent repair of UVF by interposition of a Martius flap and correction of associated SUI by a modified anterior vaginal wall sling. The procedure was carried out 3–17 (mean 7) months after post-birth trauma. Pre-operative evaluation consisted of history, voiding diary, physical examination, routine laboratory work-up, abdominopelvic ultrasonography, intravenous urography (IVU), and cystourethrography. The patients were followed up for a mean of 34 months. Follow-up included history, physical examination, urine analysis and pelvic ultrasonography for the assessment of residual urine. Urodynamic evaluation was performed at 3 months post-operatively.ResultsNone of the patients developed recurrence of UVF. SUI was corrected in 16 patients (84%). In the post-operative period, 3 patients (16%) complained of an overactive bladder (OAB) with urodynamic detrusor overactivity (DO) and an obstructed flow. These problems were managed successfully using anticholinergics and urethral dilation. Three patients (16%) complained of mild SUI, but refused further management. Within 3 years following the intervention, 3 patients complained of a recurrence of SUI which was managed successfully by a rectus sheath sling.ConclusionsPatients with a post-birth trauma in the form of UVF should be examined intra-operatively for the presence of associated SUI following correction of UVF. The use of the Martius flap and anterior vaginal wall sling in treating such patients is safe, efficient and reproducible. An anterior vaginal wall sling should be avoided in distal UVF to avoid recurrence of SUI.     

Complications associated with surgical repair of urethrovaginal fistula

We present 4 patients seen in the last five years with urethrovaginal fistulas involving the mid or proximal urethra. Our experience in the transvaginal repair of these fistulas has been disappointing. The best chance for the development of a functioning continent urethra is by suprapubic bladder flap technique or bladder tube replacement with suprapubic urinary diversion. We suggest that no urethral catheter be placed. Complications following surgical repair have been fistula recurrence, urethral shortening and retraction, persistent reflux, bladder calculi, and bladder cancer.     

Martius flap: an adjunct for repair of complex, low rectovaginal fistula

Background

Complex, rectovaginal fistula (RVF) are uncommon but difficult therapeutic problems. Local repair and flap advancement techniques have a high incidence of recurrence with poor functional outcomes. Transperineal repair with anal sphincter reconstruction, when indicated, and placement of a Martius flap (bulbocavernosus pedicled transplant) result in improved rates of repair and better functional outcomes.

Methods

A consecutive series of patients were retrospectively reviewed from a prospective database between 2002 and 2006. Data were gathered from 2 colon- and rectal-specialty practices. Patient demographics and operative and functional outcomes were documented.

Results

Sixteen patients with a mean age of 39.5 years (17-62) were treated. Etiology of the fistula was obstetric (9), cryptoglandular (5), and Crohn’s disease (2). They had undergone a mean of 1.5 (0-4) prior repairs, and 6 had a preexisting diverting stoma before repair. Preoperatively, anal sphincter disruption was identified in 11 patients, and fecal incontinence was identified in 5 patients all with anal sphincter disruption. Dyspareunia was identified in 1 of 13 sexually active patients preoperatively. At a mean follow-up of 75 weeks (24-190), 1 recurrent fistula was identified (6.2%). Stomas were reversed in all patients. Two patients complained of fecal incontinence postoperatively. Five patients had dyspareunia postoperatively (5/16, 31%). One patient had a labial wound complication requiring local wound care.

Conclusion

Selected complex RVF can be reliably repaired with good functional outcomes using the Martius flap with anal sphincter reconstruction. Persistent or recurrent fecal incontinence and dyspareunia are common sequela of the underlying perineal injury and repair. No acute or delayed morbidity related to the Martius flap was identified.     

Treatment of refractory urethrovaginal fistula using rectus abdominis muscle flap in a six-year-old girl

Urethrovaginal fistula usually occurs after urethrovaginal injury, resulting in urinary incontinence. Several modalities to treat urethrovaginal fistula have been reported. We describe a treatment in which we used a rectus abdominis muscle flap in a 6-year-old girl with refractory urethrovaginal fistula.     

Transvaginal cystocele repair with polypropylene mesh using a tension-free technique

This study describes an original surgical technique for the correction of medium/high-degree cystocele using a tension-free way to apply a polypropylene mesh: the “tension-free cystocele repair” (TCR). About 218 patients were available with a mean follow-up of 38 months. This technique showed an elevated rate of anatomic correction (75.7%), a statistically significant correction of storage symptoms (48.6 vs 32.5%, p < 0.05), voiding symptoms (40.3 vs 8.3%, p < 0.05), and symptoms associated with pelvic organ prolapse (POP; 55.9 vs 11.4%, p < 0.0001), with no negative impact on ano-rectal function and, in particular, on constipation. The percentage of erosions was 12.3%, but in the group where hysterectomy was not performed, we had erosions in only 2.5%. With the exception of the Personal Relationship domain, all of the categories examined by the Prolapse Quality of Life Questionnaire showed a statistically significant improvement, which confirms the positive impact of this surgery as perceived by patients.     

Urethrovaginal fistula repair with Martius labial fat pad graft

Most urethrovaginal fistulas are iatrogenic and, like other urinary fistulas, significantly reduce the quality of the affected individual's life. The Martius labial fat pad graft facilitates the urologic care of these women.     

Rectovaginal fistula repair using a gracilis muscle flap

Introduction and hypothesis

This video demonstrates a technique for using a pedicled gracilis muscle flap to repair rectovaginal fistula.

Methods

We present the case of a 48-year-old woman diagnosed with rectal cancer 2 years earlier. She underwent neoadjuvant chemoradiation followed by ultralow anterior resection. Six weeks after surgery, a fistula was identified at the anastomotic site. Preoperative planning with urogynecology, plastic surgery, and colon and rectal surgery teams deemed a pedicled gracilis muscle flap to be the best approach for this patient due to the rich blood supply and the patient’s prior history of pelvic irradiation. The gracilis muscle is suitable due to the proximity of its vascular pedicle to the perineum, length, and minimal functional donor-site morbidity. We discuss techniques used to interpose a gracilis muscle flap between the rectum and vagina to repair a rectovaginal fistula.

Conclusion

Using the gracilis muscle is a viable option for repairing rectovaginal fistulas, especially in the setting of prior pelvic radiation. A multispecialty approach may be beneficial in complex cases to determine the optimal approach for repair.

     

Transvaginal repair of pouch-vaginal fistula

BACKGROUND: The results of surgery for ileoanal pouch-vaginal fistula have been disappointing. Intra-anal procedures result in fistula healing in, at best, approximately 50 per cent of patients. A transvaginal approach was developed to achieve direct access to the internal opening, enabling closure without damage to the anal sphincter. METHODS: Fourteen patients were treated between January 1992 and December 1998. All had had restorative proctocolectomy for ulcerative colitis and all were defunctioned. Histological review confirmed the diagnosis in all patients. RESULTS: Median age was 40 (range 25-52) years. Median follow-up was 18 (range 6-60) months. The operation was successful in 11 of the 14 patients, after one attempt in six patients, after two attempts in four, and after three attempts in one patient. The operation failed in three patients, who had a permanent ileostomy. The number of bowel actions in the patients who had successful closure ranged from 2 to 10 (median 6) in 24 h, with no faecal incontinence reported. CONCLUSION: This simple technique achieved healing in 11 of 14 patients. This compares favourably with the poor results in 28 patients treated by other procedures in the same hospital, with certain healing in five and definite failure in 20.     

Transvaginal primary repair of a suprasphincteric rectovaginal fistula

Introduction and hypothesis

Rectovaginal fistula repair is one of the most challenging gynecological surgical procedures. This video is intended to serve as a tutorial for surgical repair.

Methods

An 80-year-old woman who developed a traumatic suprasphincteric rectovaginal fistula was managed through layered transvaginal repair without flaps.

Results

Anatomy restoration was completed without complications.

Conclusion

The procedure described in this video was effective and safe. Vaginal route should be considered as a valid surgical approach for rectovaginal fistula repair.

     

Latzko repair for vesicovaginal fistula revisited in the era of minimal-access surgery

Latzko repair is a technique described for repair of post-hysterectomy supratrigonal vesicovaginal fistulas (VVF) and is often practised by gynecologists, but it has not figured in the armamentarium of urologists the world over. Recently urologists have taken to laparoscopic repair of such fistula but laparoscopic repair is technically demanding with a steep learning curve. We reviewed our experience with the technique of Latzko repair. The study is a review of 10 patients operated by this technique between June 2000 and May 2005, with age ranging from 33 to 55 years (average 39 years). Fistula size ranged from 2 mm to 1 cm. There was no recurrence or sexual dysfunction due to shortening of vaginal length. The results were comparable with laparoscopic VVF repair in terms of morbidity, operative time, blood loss, and patient discomfort. Also, the learning curve involved is minimal. Thus this technique deserves wider adoption by the urological community and should be a benchmark for comparison with laparoscopic repair of VVF rather than the abdominal approach. Bearing in mind the simplicity of the procedure, urologists should feel encouraged to adopt this excellent age-old technique that has stood the test of time rather than exploring more-complex operations such as laparoscopic VVF repair and transurethral suture cystorrhaphy.     

Endorectal advancement flap with muscular plication: a modified technique for rectovaginal fistula repair

Aim Endorectal advancement flap is the most used treatment for acquired rectovaginal fistula but is liable to failure. We describe our experience with a modified technique. Method Patients were included who had an acquired rectovaginal fistula. Exclusions included patients with Crohn’s disease with proctitis, malignant or radiation‐related fistula, stricture of the anorectum or those with an external sphincter defect. Surgery included closure of the internal opening with a figure‐of‐eight reabsorbable suture, plication of the anorectal muscular layer and mucosal flap advancement. Total parenteral nutrition was administered postoperatively for seven days. Results Between March 2003 and July 2008, 23 consecutive women (mean age 45.5 [28–78] years) were treated. The cause of fistulation included obstetric injury (n = 5), cryptoglandular disease (n = 11) and Crohn’s disease (n = 7). Thirteen (57%) patients had a previous failed repair. At a mean follow‐up of 14 (2–67) months, success was achieved in 65% (15/23) of patients. The mean Wexner incontinence scores pre‐ and postoperatively were 1.3 (0–15) and 0.6 (0–6), respectively. Conclusion The success rate was promising with no deterioration of anal continence.