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Vesicovaginal Fistula
Craig V. Comiter, MD, Sandip P. Vasavada, MD, and Shlomo Raz, MD
Ten percent of small iatrogenic VVFs will close spontaneously with continuous
bladder drainage and antibiotics. If the fistula has not closed after 3 weeks of
catheter drainage, it is unlikely that the fistula will close without surgical intervention. When the fistula is extremely small (1 mm), coagulation of the fistulous tract
may occasionally be successful. Immediate surgical repair is indicated when the
fistula is large enough that most of the urine passes per vagina in spite of continuous bladder drainage. Estrogen replacement is begun at the time of diagnosis in
hypoestrogenic women, and continued until the time of surgery. With an otherwise
healthy patient, success rates have not been shown to differ with early versus
delayed W F repair.
CONTRAINDICATIONS TO SURGERY
ATLAS OF THE UROLOGIC CLINICS OF NORTH AMERICA Volume 8 Number 1 April 2000
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COMITER et al
DIAGNOSIS
Patients typically present with continuous daytime and nighttime leakage per
vagina, with a recent history of gynecologic surgery. Depending on the size of the
fistula, and thereby the ability to store urine in the bladder, the amount of urine
voided versus the amount lost per vagina will vary. Most causes of W F resulting
from surgical trauma are clinically apparent within 10 days of surgery. On the other
hand, radiation-induced VVF may not present until 20 years after radiotherapy.
Pelvic examination often identifies the fistulous opening in the vagina. If the
examination is unrevealing, and the suspicion remains high, the bladder may be
catheterized and filled with a colored solution. The vagina may then be inspected
for leakage. Additionally, the vagina may be packed with a tampon, and the vagina
re-examined after ambulation. If suspicion still remains high, intravenous indigo
carmine or oral phenazopyridine may help to diagnose a uretero-vaginal fistula.
In any patient with a suspected or confirmed fistula, voiding cystourethrography, cystoscopy, and upper tract evaluation are indicated. Voiding cystourethrography may demonstrate the fistula and any concomitant prolapse. Cystoscopy is
necessary to evaluate bladder capacity, the size and location of the fistula, and its
relation to the ureteral orifices. Biopsy is recommended if there is a history of
genitourinary malignancy. Upper tract evaluation is useful to rule out ureterovaginal fistula or ureteral obstruction.
The patient should be in the dorsal lithotomy position. A rectal pack helps the
surgeon to identify the rectum, especially if a peritoneal flap is incorporated into the
repair (See Figs. 1 to 5).
Figure 1. The fistula is dilated with sounds and an 8F Foley catheter is inserted through the tract. The catheter balloon is filled with 1
to 2 mL of water, and the catheter is used for traction. The vaginal
wall is filled with saline to aid the subsequent dissection. The fistula
is circumscribed and the incision is extended as an inverted J, with
the long arm of the J ending at the vaginal apex. (From Raz S:
Atlas of Transvaginal Surgery. Philadelphia, WB Saunders, 1992, p
147.)
VESICOVAGINAL FISTULA
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COMITER et al
VESICOVAGINAL FISTULA
POSTOPERATIVE CARE
The vagina is packed with antibiotic-impregnated gauze, which may be removed after several hours. The suprapubic and urethral catheters are joined to a Yconnector, and left in place for 10 days. An oral cephalosporin or fluoroquinolone is
continued until the catheters are discontinued, and cholinolytics are given to minimize bladder spasms. Before catheter removal, a voiding cystogram is performed to
evaluate the integrity of the repair. Sexual relations may resume after 12 weeks.
EARLY COMPLICATIONS
LATE COMPLICATIONS
HIGH-RISK FISTULAE
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COMITER et al
MARTIUS GRAFT
See Figure 6.
VESICOVAGINAL FISTULA
PERITONEAL FLAP
See Figure 7
Figure 7. Peritoneal flap. Unlike the Martius graft, constructing a peritoneal flap does not require extra-vaginal
harvesting. After raising the vaginal wall flaps, the posterior flap is further dissected to the cul-de-sac. The preperitoneal fat and peritoneum are sharply mobilized in a caudal direction. After closing the initial two layers of the
fistula, the peritoneal flap is advanced over the suture line
and sewn in place with interrupted SAS. Finally the vaginal flap is placed over the peritoneal flap, and closed with
running-locking 2-0 SAS. Over the past several years the
authors have been using a peritoneal flap in all vesicovaginal fistula repairs, owing to the simplicity of the technique.
RESULTS
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