Management of vesicovaginal fistula. Experience with 75 cases

Vesicovaginal fistula has become a complication of gynecologic, obstetric, and urologic surgical procedures more frequently than of difficult vaginal delivery. It still occurs occasionally as the result of an infectious process, malignant disease, or irradiation injury. A few instances of vesicovaginal fistula after vesical neck resection in children will occur despite the most careful surgical technique. In 75 patients with vesicovaginal fistulas encountered at the Ochsner Clinic since 1942, repair was accomplished in 60, chiefly by the transvaginal approach. Eleven with malignant fistulas were treated palliatively, and 4 refused additional surgical treatment. Meticulous preoperative preparation should be followed by adequate exposure, watertight closure of the bladder wall, and plication of the pubocervical fascia over the bladder closure. Postoperative care should be designed to accomplish good wound healing with emphasis on estrogen replacement, high protein diet, and supplementation of the ascorbic acid intake. Urinary diversion may be necessary if the musculature of the bladder neck has been destroyed or if contracture of the bladder prevents adequate filling. The vaginal approach offers the best chances for cure.     

Laparoscopic Transvesical Approach for Vesicovaginal Fistula Repair

Study ObjectiveTo access the technical feasibility of performing laparoscopic repair of vesicovaginal fistula.Material and MethodsWe attempted a laparoscopic repair of vesicovaginal fistula in five women with a history of urinary leakage via the vagina after vaginal hysterectomy. Five pelvic ports were used. The surgical procedure was performed using the same principles as for open surgery, i.e., separation of the vaginal wall from the bladder wall, repair of the fistula, and interposition of the omentum.ResultsThere was early recovery of the patients in terms of continence, with less chance of recurrence. Results were comparable to those with the vaginal approach.ConclusionThe use of minimally invasive surgery for vesicovaginal fistula repair helps to ease the suturing deep in the pelvis, and the magnification facilitates good identification of tissues planes and thus better mobilization of the vaginal and bladder walls and decreases postoperative morbidity.     

Transvaginal mobilization and utilization of the anterior bladder wall to repair vesicovaginal fistulas involving the urethra.

Repair of vesicovaginal fistulas resulting from obstetric trauma remains a major challenge to surgeons worldwide. Large defects that result in partial or total urethral loss are especially difficult to repair. Even when closure of such fistulas is accomplished, return of normal urogenital function is often impaired, underscoring the need to improve existing surgical procedures. Transvaginal urethral and bladder neck reconstruction using mobilized anterior bladder wall was helpful in closing 18 of 20 vesicovaginal fistulas with urethral involvement caused by obstetric trauma. This method involves advancement of an anterior bladder wall flap into the vagina, where it is rolled into a neo-urethra or connected to whatever remnant of urethral tissue exists. Complications included stress incontinence requiring further surgery (four), small bladder capacity with detrusor instability (two), urethral stenosis requiring dilatation (two), postoperative hemorrhage (one), and vaginal stenosis (one). Continued modification of this procedure holds promise for many patients considered inoperable in the past.     

Prevention of the development of a vesicovaginal fistula

The cause of vesicovaginal fistulas after hysterectomy is not clearly understood. In an attempt to determine its cause, the records of 12 patients who had vesicovaginal fistula develop (after total abdominal hysterectomy) were compared with 12 consecutive patients who underwent total abdominal hysterectomy without fistula formation. Most of the patients who had vesicovaginal fistulas develop had excessive postoperative abdominal pain, distension or paralytic ileus, or both. Hematuria and symptoms of irritability of the bladder were also noted in the fistula group and prolonged postoperative fever and increased white blood cell count occurred more often. In contrast, the postoperative course was uncomplicated in the nonfistula group. The clinical course observed in many of the patients with vesicovaginal fistulas suggests that the patients had an unrecognized injury to the bladder resulting in urinary extravasation. It is postulated that the fistula develops when the urinoma drains into the vaginal cuff which is dependent and usually not closed. It may be possible to abort the development of many vesicovaginal fistulas by early recognition and treatment of an unsuspected bladder injury. It is suggested that patients with severe abdominal pain, distension, paralytic ileus, hematuria or symptoms of severe irritability of the bladder after abdominal hysterectomy be investigated early for a possible bladder injury.     

Vesicovaginal fistula treated with fibrin glue.

We report here a case of vesicovaginal fistula, following radiation therapy and intensive local chemotherapy for recurrent endometrial cancer of the vaginal stump, which was ameliorated with fibrin glue. The procedure temporarily postponed urinary diversion until the recurrence of irreparable fistula more than 4 years after the development of the first vesicovaginal fistula.     

Formation of vesicovaginal fistulas in laparoscopic hysterectomy with electrosurgically induced cystotomy in female mongrel dogs

OBJECTIVE: The aim of this pilot study was to investigate the relationship between various types of laparoscopic bladder injuries and vesicovaginal fistula formation in an animal model. STUDY DESIGN: Sixteen female mongrel dogs were divided into four groups. All animals underwent a laparoscopic hysterectomy. Those assigned to group 1 sustained a 1-cm bipolar cautery injury to the bladder base without perforation of the bladder mucosa. Animals in group 2 had two sutures of 2-0 polyglactin placed to incorporate the full thickness of the bladder wall and the vaginal cuff. The bladder injury to group 3 was a 1-cm bladder base laceration induced with monopolar cautery, repaired with two interrupted 2-0 polyglactin sutures. Group 4 underwent a bladder base cystotomy similar to those in group 3, with the closure incorporating the anterior vaginal wall. Animals were killed and necropsy was performed at least 28 days after surgery. The bladder and vagina of each animal were harvested en bloc. Evidence of a vesicovaginal fistula was determined by two methods: transurethral injection of indigo carmine solution under direct visualization and air injection during underwater submersion. RESULTS: The four groups were comparable with regard to postoperative weight changes. No mongrels showed signs of infection or sepsis. Inspection of the harvested bladder and vagina revealed no fistulas in groups 1 and 2. One mongrel from group 3 and one from group 4 had evidence of a vesicovaginal fistula. With 95% CIs, the fistula rate would be at least 2% and as high as 38% if a larger study had been undertaken. CONCLUSION: The female mongrel is the first identified animal model of vesicovaginal fistula formation. In this setting, an electrosurgically induced cystotomy and repair of the bladder during the performance of a laparoscopic hysterectomy is associated with the formation of postoperative vesicovaginal fistulas.     

Formation of vesicovaginal fistula: The role of suture placement into the bladder during closure of the vaginal cuff after transabdominal hysterectomy

OBJECTIVE: The objective of this study was to determine whether suture placement through the bladder during closure of the vaginal cuff at the time of transabdominal hysterectomy is associated with formation of postoperative vesicovaginal fistula. STUDY DESIGN: Virgin female New Zealand White rabbits were used to perform this study. The study protocol was approved by the institutional Animal Use and Care Committee. Animals were housed and maintained in the animal facilities at the University of Mississippi Medical Center according to appropriate guidelines. Thirty-two animals were randomized into two groups at a 2:1 ratio. All animals underwent transabdominal hysterectomy. Animals in group 1 (n = 21) had a figure-of-eight suture placed through the anterior vaginal cuff and intentionally into the bladder. Animals in group 2 (n = 11) were treated in an identical manner but care was taken to exclude the bladder when the suture was placed into the anterior vaginal cuff. Animals were put to death, and necropsy was performed 28 days after surgery. The bladder and vagina of each animal were harvested en bloc. Evidence of a fistula between the bladder and vagina was then determined in three distinct ways. Infant formula was infused into the bladder through a urethral catheter, and the vagina was inspected for leakage. Saline solution tinted with methylene blue was used in the same manner. Last, air was injected through the catheter into the bladder with the en bloc vagina and bladder preparation submerged in water. The vagina was observed for air leakage manifest by bubble formation. RESULTS: The two groups were comparable in regard to weight gain, intraoperative complications, and postoperative complications. One animal in each group died. Neither had a surgical complication directly related to the suture placement. During inspection of the vagina and bladder no animal was noted to have a vesicovaginal fistula. CONCLUSIONS: A suture placed through the bladder during closure of the vaginal cuff after transabdominal hysterectomy, as an isolated event, does not appear to be associated with formation of postoperative vesicovaginal fistula.(Am J Obstet Gynecol 1997;177:304)     

Preliminary experience with Mainz type II pouch in gynecologic oncology patients

OBJECTIVE: To evaluate the Mainz low-pressure modification of ureterosigmoidostomy with extramural serous-lined ureterointestinal anastomosis as a method of urinary diversion in gynecologic patients undergoing anterior pelvic exenteration. MATERIALS & METHODS: Between December 1995 and September 1998, Mainz type II pouch was performed in 11 patients aged between 27-70 years (mean 58.5). Four were diagnosed with cervical cancer (2 stage IV A and 2 central recurrences following radical hysterectomy done elsewhere), two with stage III bilharzial bladder cancer, two with urethral cancer (one stage III and one recurrent following surgery done elsewhere), one with stage IV A endometrial cancer, one with stage IV A vaginal cancer complicating long standing incarcerated total procidentia and lastly one patient with refractory obstetric vesicovaginal fistula with almost total loss of the upper urethra, bladder neck and base. All patients were followed closely and particular complications related to the diversion were recorded as acid-base imbalance, renal impairment and incontinence. RESULTS: The pouch construction with anterior exenteration took an average of 242 min (150-330). There were two postoperative deaths due to pulmonary embolism and pneumonia both being related to the precarious condition of the patients and not to the diversionary procedure. The follow-up ranged between 25-60 months, with a mean of 43.5 months for the surviving patients. During that time period, four deaths occurred due to cancer recurrence. Otherwise, all patients remained continent during the day with one patient being incontinent at night. Two patients developed one attack of pyelonephritis and were treated successfully with antibiotics. No hyperchloremic acidosis and no hydronephrotic changes were seen in any patient and renal function remained normal. CONCLUSION: Mainz type II pouch with extramural serous-lined ureterointestinal anastomosis is a safe promising quick and easy method of urinary diversion for patients undergoing anterior pelvic exenteration and having an intact anal sphincter. Longer follow-up and a greater number of patients will be needed to compare it with other forms of urinary diversion.     

Minimally Invasive Management of Concomitant Vesicovaginal and Ureterovaginal Fistulas After Transabdominal Hysterectomy: Laparoscopic Vesicovaginal Fistula Repair With Ureteroneocystostomy Using a Boari Flap

Study Objective

To demonstrate a laparoscopic approach for repair of concomitant vesicovaginal and ureterovaginal fistulas as a troublesome complication of transabdominal hysterectomy (TAH).

Urinary tract fistulas following gynaecological surgery.

Urinary tract fistulas are a relatively uncommon but important complication of gynaecological surgery. Between 1980 and 1995 we identified 17 patients who developed a urinary tract fistula after gynaecological surgery. Seven of the patients had surgery performed for neoplastic disease but none of these patients received adjuvant radiotherapy before the formation of the fistula. There were 12 vesicovaginal fistulas and five ureteric fistulas. Four of the vesicovaginal fistulas were repaired by the vaginal approach and five vesicovaginal fistulas were repaired by the abdominal route. Three vesicovaginal fistulas were treated by catheterisation alone. Two of the 17 patients took medicolegal action. Early recognition and repair of urinary tract fistulas is recommended. Repair of vesicovaginal fistulas by the vaginal approach is advised. The litigious nature of this distressing condition is lessened when early primary closure is successful.     

Rapid Progression of Primary Vaginal Squamous Cell Carcinoma in a Young HIV-Infected Woman

Background. The association of human immunodeficiency virus (HIV) infection with rapid progression of cervical and anal squamous cell carcinoma has been clearly established by several studies. Human papilloma virus (HPV) infection of the anogenital tract is believed to be the causative agent of cervical, anal, vaginal, and vulvar squamous cell carcinoma. While a myriad of reports exist in the literature pertaining to the rapid progression of cervical and anal carcinoma in HIV-infected patients, no association of HIV infection and vaginal carcinoma has been reported. We present an unusual case of a young woman infected with HIV who was diagnosed with advanced vaginal carcinoma and succumbed to her disease shortly thereafter despite aggressive treatment.Case. A 40-year-old woman with a 2-year history of HIV infection presented with Stage IVA squamous cell carcinoma of the vagina and a large vesicovaginal fistula from the tumor eroding through the posterior bladder wall. Computed tomography (CT) of the abdomen and pelvis revealed a large tumor replacing the vagina with mild hydronephrosis and diffuse pelvic and inguinal lymphadenopathy. She underwent urinary diversion with a transverse colon conduit followed by pelvic radiation with weekly cisplatin chemosensitization. A repeat CT scan of the abdomen and pelvis upon completion of her treatment revealed progression of disease with multiple liver metastases and gastrohepatic ligament adenopathy. She subsequently died of advanced metastatic vaginal carcinoma 2 months after completion of treatment.Conclusion. Due to the rarity of primary vaginal carcinoma, the clinical behavior of this neoplasm in the HIV-infected patient is poorly understood. Our case indicates that, although vaginal carcinoma is a disease of the elderly, young women infected with HIV and HPV are predisposed not only to develop cervical or anal carcinoma but also may be at increased risk for vaginal carcinoma with more aggressive and less responsive disease. Furthermore, although vaginal carcinoma is usually a slow-growing neoplasm, this case illustrates the aggressive behavior of such a tumor when associated with HIV infection.     

Robotic Vesicovaginal Fistula Repair

Study ObjectiveTo illustrate a technique of robotic vesicovaginal fistula repair in a patient with a previous history of pelvic radiation therapy and multiple abdominal surgeries.DesignStepwise demonstration of the technique with narrated video footage.SettingThis 59-year-old woman presented with vesicovaginal fistula. She had a history of rectosigmoidectomy followed by pelvic radiotherapy for stage III colon cancer 23 years earlier and subsequent robotic hysterectomy, bilateral salpingo-oophorectomy, and omentectomy with bilateral pelvic and para-aortic lymphadenectomy for stage II mixed cell endometrial carcinoma, which required surgical reintervention because of a pelvic hematoma and complete vaginal cuff dehiscence.InterventionsWe performed a robotic approach to vesicovaginal fistula with several key steps to repair the fistula and maintain the integrity of the abdominopelvic structures: (1) careful bowel adhesiolysis involving multiple segments of the intestine to the abdominal and pelvic peritoneum; (2) cystotomy with vaginal probe guidance; (3) fistulectomy by monopolar scissors after ureteral orifice visualization; (4) dissection of the retropubic space of Retzius, relieving bladder tension; (5) transverse sutures to coapt the raw surfaces on the vaginal side and the bladder in 2 layers with minimal tension; and (6) transurethral instillation of methylene blue into the bladder.ConclusionsTraditionally, patients with vesicovaginal fistula after pelvic radiation therapy and multiple abdominal surgeries are managed by laparotomy. This video demonstrates a feasible robotic approach to vesicovaginal fistula repair, with superior imaging affording 3-dimensional visualization and stabilization of instruments, allowing wrist-like movements.     

Total pelvic exenteration: the Albert Einstein College of Medicine/Montefiore Medical Center Experience (1987 to 2003)

OBJECTIVE: To review the trends, modifications and results of 103 consecutive total pelvic exenterations (TPE) performed at the Montefiore Medical Center and Albert Einstein College of Medicine from 1987 to 2003. METHODS: All patients who underwent TPE from January 1987 to December 2003 were included. The medical record, complications, follow-up, clinical status and demographic information were entered in a database. The procedure performed, the method of urinary diversion, colonic diversion, pelvic floor support and vaginal reconstruction were documented. Surviving patients were surveyed regarding their satisfaction with the urinary diversion, the vaginal reconstruction and their sexual function since the surgery. RESULTS: 103 pts were identified. Indications for TPE were recurrent cancers of the cervix (95), endometrium (2), colon and rectum (5), vulva (1). Overall 5-year survival was 47%. 5-year survival for pts with recurrent cervix cancer was 48%. Six pts (6%) recurred >5 years after the TPE. 14 pts (14%) had ureteral anastomotic leaks (no difference between ileal conduit 9/65 (14%) versus 5/38 (13%) continent conduit (P = 0.92). 34 pts (89%) with continent conduits were "continent." 14 pts (17%) had wound complications. 4 pts (4%) had parastomal hernias. 5/11 (46%) pts who had a low rectal reanastomosis developed recurrence in the pelvis. 21/39 (54%) of pts with continent conduits would choose an ileal conduit if they had the option again. Long-term renal function was similar in pts with ileal and continent conduits. Mesh of any type for pelvic floor reconstruction is associated with infection and bowel/urinary fistulas. VRAM flaps for neovagina fill the pelvic dead space, reduce the risk of fistulas and 20/36 pts (55%) are sexually active. CONCLUSIONS: Our overall 5-year survival is encouraging, and modifications in surgical technique have improved the reconstructive phase. Low rectal anastomoses at TPE adversely affects survival. Many of our pts with continent urinary diversions would not choose this method again. Mesh of any type is associated with sepsis and bowel/urinary fistulas. VRAM for neovagina reduces fistula rate and are functional in >55% of pts. TPE remains a potentially curative option for these pts.     

Tratamiento de las fístulas vesicovaginales no complicadas posthisterectomía

AimTo describe our experience with uncomplicated vesicovaginal fistulasMaterial and methodsWe retrospectively reviewed seven consecutive women who presented with uncomplicated vesicovaginal fistulas after hysterectomy, repaired at our institution between 1995 and 2000. Most of the patients presented with continuous discharge of urine from the vagina. Three patients presented with gross hematuria in the immediate postoperative periodResultsIn all patients conservative management was unsuccessful and vesicovaginal fistula was successfully corrected by surgical treatment. The median postoperative follow-up was 21 months (range: 5–35 months)ConclusionsVesicovaginal fistula after gynecological surgery should be suspected in patients with continuous discharge of urine, hematuria or increased vaginal discharge. Early diagnosis and treatment prevent prolonged stress to the patient an the success rate is high     

Re-innervation pattern of the ‘neovagina’ created from the bladder flap in patients with Mayer-Rokitanski-Kistner-Hauser syndrome: An immunochemical study

Background. Cystovaginoplasty (CVP) is a method of vaginal reconstruction in women with Mayer-Rokitansky-Kistner-Hauser Syndrome (MRKHS). The neo-vagina allows normal sexual intercourses, but after CVP, the sexual life of patients with MRKHS does not differ significantly from normal females. Therefore, we decided to elucidate the pattern of sensory re-innervation of the bladder flap used for the surgery.

Methods. Biopsies were taken from vaginal vestibule and urinary bladder during the CVP and 1 year later in four patients with MRKHS. The following neurotransmitters were studied calcitonin gene-related peptide (CGRP), galanin (GAL), vasoactive intestinal polypeptide (VIP) and pituitary adenylate cyclase-activating peptide (PACAP).

Results. CGRP and PACAP nerve fibres were sparse under the urothelium and in submucosal layer of the neovagina, they were more numerous around blood vessels and in the vicinity of smooth muscles. This was similar to the pattern observed in the urinary bladder. VIP- and GAL-positive nerve fibres were most numerous in the submucosa around blood vessels and in smooth muscle bundles of neovagina. They were distinctly less numerous beneath the epithelium. This innervation pattern mimicked that seen in normal vagina and in vaginal vestibule of patients with MRKHS.

Conclusions. Our findings demonstrate considerable nervous system plasticity in the bladder flap. Distribution of presumably sensory CGRP and PACAP immunoreactive nerve fibers was similar to the pattern observed within the intact bladder wall, and VIP or GAL immunoreactive nerve fibers (vasomotor functions) were distributed in a manner similar to that observed in the intact vaginal wall.     

Bladder mucosal autografts for repair of vesicovaginal fistula

Twenty-two women with primary and secondary (five patients) vesicovaginal fistula attending a tertiary level urological unit in India were treated by repair of the fistula using bladder mucosal autografts. The fistula was approached transabdominally or via a combined abdominal and vaginal approach (for those involving the trigone). After closure of the vaginal layer, bladder mucosa was harvested from the dome of the bladder and laid over the fistula with sutures at each corner to fix it in place. Patients were catheterised for 12-14 days. At follow up after 3 to 12 months, 20 out of 22 patients were continent, with no other symptoms. The two failures had undergone two previous repairs each. This series is the first from India, and demonstrates the efficacy of bladder mucosal autografts for managing large fistulae, those where a previous repair has failed and fistulae adjacent to the ureteric orifice without the need for uretero-neocystostomy.     

Contribution of the Posterior Compartment to the Urinary Continence Mechanism

Objective: To describe the contribution of the posterior pelvic compartment to the urethral closure mechanism.Methods: Urethral profilometry at rest and during stress was performed in 32 continent women before and after inserting a weighted (1 kg) posterior speculum to displace the posterior vaginal wall and levator ani muscles away from the bladder neck and the urethra.Results: Insertion of the speculum decreased the pressure transmission ratios in the proximal quarter of urethra (from 81 to 76; P < .05) and the urethral closure pressure under stress in the proximal two urethral quarters (from 5 to −3 cm H₂O in the first and from 12 to 0 cm H₂O in the second urethral quarter; P < .05) in all 32 women. Before speculum insertion, 20 women had positive urethral closure pressure in the proximal urethra under stress, and 12 had negative urethral closure pressure in the proximal urethra under stress. In the 20 women with positive urethral closure pressures under stress in the proximal urethra without a speculum, the insertion of a posterior speculum decreased the pressure transmission ratios to the proximal urethral quarter (from 87 to 78; P < .05) and decreased the urethral closure pressures under stress in the proximal two urethral quarters (from 13 to −4 cm H₂O in the first urethral quarter and from 24 to 2 cm H₂O in the second urethral quarter; P < .01). In the 12 patients with negative urethral closure pressures under stress in the proximal urethra without a speculum, the profilometry values were unchanged by insertion of a speculum.Conclusion: These observations indicate that the posterior vaginal compartment may contribute to the closure mechanism of the proximal urethra in continent women.     

A modified Mainz II pouch technique for management of refractory vesicovaginal fistulas: patient focused outcomes.

OBJECTIVE: To follow-up the quality of life outcomes in 2 women who underwent a modified Mainz II pouch procedure for refractory vesicovaginal fistulas. METHOD: Two Nigerian patients were located after undergoing a modified Mainz II pouch procedure. They were interviewed 1-2 years postprocedure regarding subsequent sexual function, pregnancy outcomes, and daily life. RESULT: After undergoing the procedure the patients had resumed sexual function, had become pregnant, and had delivered viable neonates. They were also able to provide for their families. CONCLUSION: A urinary diversion procedure for management of refractory vesicovaginal fistula can restore quality of life.     

应用尿道球海绵体肌瓣修补女性复杂尿瘘的探讨

目的:探讨应用尿道球海绵体肌瓣修补女性复杂尿瘘的可行性。方法:经腹经会阴经阴道途径游离膀胱阴道瘘或尿道阴道瘘瘘口,彻底切除瘘口周围疤痕组织,缝合阴道侧瘘口。在大、小阴唇之间作切口,游离尿道球海绵体肌,保护来自后下方的供应血管,离断尿道球海绵体肌的阴蒂端,经小阴唇隧道将该肌置于膀胱(或尿道)侧瘘口及阴道侧瘘口之间,将尿道球海绵体肌蒂端缝合固定于周围器官。结果:应用尿道球绵体肌瓣转移术修补复杂膀胱阴道瘘7例,复杂尿道阴道瘘1例,同时行阴道疤痕切除置模术1例。所有病例术后未再发生阴道漏尿,无尿失禁和尿道狭窄,性生活正常。结论:尿道球绵体肌瓣转移术设计合理、操作简单、是治疗女性复杂尿瘘的理想术式。     

Total abdominal hysterectomy after radiation therapy for cervical cancer: use of omental graft for fistula prevention

Abdominal hysterectomy after treatment of cervical cancer by radiation therapy is associated with a significant rate of postoperative vesicovaginal fistulas. In this series, five patients with invasive cancer of the cervix treated by radiation therapy developed new cervical or uterine neoplasms 1 to 27 years after treatment. All underwent abdominal hysterectomy without postoperative fistula formation. Success is attributed to cautious surgical technique and to the use of the omental pedicle graft to bring new vascularity to the vaginal apex and bladder base. The technique of forming an omental pedicle graft is described.