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Formation of vesicovaginal fistula: The role of suture

placement into the bladder during closure of the vaginal


cuff after transabdominal hysterectomy
G. Rodney Meeks, MD, Joseph O. Sams IV, BS, Karen W. Field, BA, Kari S. Fulp, MD,
and M. Thomas Margolis, MD
,Jackson, Mississippi
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;177:1298-304.)

Key words: Vesicovaginal fistula, vesicle suture, transabdominal hysterectomy, vaginal cuff,
rabbits

Most cases of vesicovaginal fistula formation in the


U n i t e d States and o t h e r developed countries are associated with gynecologic surgery, especially a b d o m i n a l hysterectomy.1 T h e incidence of vesicovaginal fistula formation after total a b d o m i n a l hysterectomy is 0.5% to
2.0%. 9, ~ Fistulas in association with simple transabdominal hysterectomy account for some 75% of all fistulas a' 4
and far surpass fistulas caused by transvaginal hysterectomy, cesarean birth, or radical hysterectomy. 4

From the Division of Gynecology, Department q[ Obstetrics and Gynecology, University of Mississippi Medical Center.
Supported in part by the VicksburgHospital Medical Foundation.
Presidential Member Prize Paper, presented at the Twenty-thirdAnnual
Meeting of the Society of GynecologicSurgeons, New Orleans, Louisiana,
February 24-26, 1997.
Reprints not availablefrom the authors.
Copyright 1997 by Mosby-Year Book, Inc.
0002-9378/97 $5.00 + 0 6/6/85858
1298

P r o o f of the exact cause (s) of vesicovaginal fistula has


r e m a i n e d elusive. Theories abound, and c o m m o n l y recognized possibilities include avascular necrosis of the
bladder base, erosion of a suture from the vaginal cuff
into the bladder, p l a c e m e n t of a suture directly into the
bladder, and u n r e c o g n i z e d intraoperative laceration of
the bladder. 5'6 Postoperative cuff abscess may erode
through the bladder. 7 Crush injuries caused by a clamp
or electrocautery injury may result in delayed developm e n t of fistula, s
Recent literature 2'6's'9 seems to have advanced the
premise that ligation of the bladder with suture and
erosion of vaginal cuff sutures into the bladder are
leading factors in the formation of vesicovaginal fistulas.
T h e conclusions of these articles are based on consensus
rather than scientific evidence. The objective of this
study was to d e t e r m i n e w h e t h e r suture p l a c e m e n t into

Volume 177,Number6
AmJ Obstet Gynecoi

Meeks et al.

1299

Ovary
Tube
Uterus
IX

IRa

Urethra

(
'

Fig. 1. Relationship of uterus, bladder, urethra, and vagina in rabbits.


the bladder during closure of the anterior vaginal cuff
after transabdominal hysterectomy is associated with
development of posthysterectomy vesicovaginal fistula.

Material and methods


Virgin female New Zealand White rabbits were the
subjects for this study. Rabbits were selected for the
investigation because of the anatomic relationship of the
uterus, vagina, and bladder (Fig. 1). Unlike humans, in
whom the bladder must be dissected away from the
uterus, cervix, and vagina, no dissection is necessary in
rabbits for the performance of hysterectomy. This allows
the hysterectomy to be performed without disrupting the
bladder at all. Therefore judging the role of a suture in
the bladder is not complicated by other potential problems such as trauma to or devascularization of the
bladder base.

The study (protocol No. 0489, May 18, 1995) was


approved by the institutional Animal Use and Care
Committee of the University of Mississippi Medical Center (UMMC). Animals were housed and maintained in
the animal facilities at UMMC. Care for the animals was
provided according to guidelines approved by the institutional
Animal Care and Use Committee. Thirty-two animals
were randomized into one of two groups with a 2:1 ratio.
Note cards were printed with the words "ligate bladder"
or "do not ligate bladder." Each was sealed in an envelope. The envelopes were throughly mixed. A card was
drawn and opened before each operation to determine
which procedure would be performed.
Rabbits were anesthetized with intramuscular ketamine (50 mg/kg) and intramuscular xylazine (10 m g /
kg). Animals were secured to the operating table in the

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Meeks et al.

Bladde~

Fig. 2. Pressure on bladder with a finger to induce voiding.

supine position with leg straps. The abdomen was shaved


and then prepped with povidone-iodine and alcohol. A
lower midline incision approximately 6 cm long was
made through all layers with an aseptic technique. The
bladder was retracted through the incision, and gentle
pressure was applied until the animal spontaneously
voided (Fig. 2). These maneuvers enhanced visualization
of the uterus, tubes, and ovaries.
M1 animals underwent transabdominal hysterectomy.
A hemostat clamp was placed across the horn of the
uterus and uterine vessels. The tissue was incised and
sutured with 2-0 polyglactin 910 (Vicryl, Ethicon, Some>
ville, NJ.). An identical procedure was performed on
both sides. No effort was directed toward removal of the
tubes or ovaries because in this short-term study no
complications of leaving these organs were anticipated.
The vagina was entered laterallyjust below the cervix and
was incised circumferentially, creating a vaginal cuff.
Pressure was applied to the cuff to obtain hemostasis.
For those rabbits selected for bladder ligation, polyglactin 910, braided, 2-0 caliber suture on an intestinal
needle was used to place a figure-of-eight suture (group
1). The suture was passed through the anterior vaginal
cuff approximately 5 mm from the cut edge and then
into the bladder. The needle was passed entirely through
the bladder wall, with use of the full diameter of the
curved needle (Fig. 3). This provided a uniform-sized
bite of tissue for each rabbit. A second loop was passed
through the anterior cuff and bladder to create a figureof-eight suture. The suture loops were placed approximately 5 mm apart. The suture was then tied with a
2 = 1 = 1 = 1 knot. m Only the anterior vaginal wall was

December 1997
~nJ Obstet Gynecol

sutured in the rabbits randomized to exclude the bladder (Group 2). A figure of eight suture with two suture
loops were placed approximately 5 mm apart.
The midline incision was closed in a r u n n i n g mass
fashion with 4-0 polypropylene (Prolene, Ethicon). The
skin was closed in a subcuticular fashion with 4-0 polypropylene suture. The rabbits were washed to remove povidone-iodine and blood from skin and fur. They were
dried and then placed u n d e r a warming lamp for at least
30 minutes. The rabbits were monitored postoperatively
until they had recuperated from the effects of anesthesia,
Postoperative pain relief was obtained with 0.2 m g / k g
butorphanol (Stadol, Bristol-Myers Squibb Co., Princeton, NJ.) administered intramuscularly every 4 hours for
a m i n i m u m of two doses.
Each rabbit was examined twice daily for the first
postoperative week. The wound was inspected for evidence of infection, wound dehiscence, and autophagia.
The abdomen was also specifically evaluated for evidence
of intraperitoneal sepsis. General appearance, activity
level, eating and drinking, and weight gain were assessed.
Daily examinations were performed until the wound was
healed, then at least weekly inspections of the incision
site were performed. Apple slices and alfalfa cubes were
given to stimulate appetite and to help provide a balanced diet to aid in recovery. Food and water were
allowed at will.
After ketamine sedation the animals were put to death
by carbon dioxide asphyxiation 28 days after surgery, and
necropsy was performed. The abdomen was examined
for evidence of dehiscence or autophagia, as well as
hernia. The previous midline incision was opened, and
the surgical site was identified. Significant abdominal
abnormality, such as adhesions or active infection, was
noted. The bladder and vagina were harvested en bloc by
dissecting the areolar tissue surrounding them, by
transecting the ureters, and by cutting the vagina caudad
to the junction of the urethra near the pubic symphysis.
The vagina was dissected free from the urethra, and a
Foley catheter was inserted through the urethra into the
bladder. The urethra was tied with a suture to prevent
urethral leakage (Fig. 4).
Hemostats were used to hold the cuff of the vagina
open for observation. The bladder and vagina were
submerged into a basin of water to aid in the detection of
any leakage. Evidence of a fistula between the bladder
and vagina was then determined in three distinct ways.
Formula milk was infused into the bladder via the
urethral catheter, and the vagina was inspected for
leakage. Saline solution colored with methylene blue was
used in the same manner. Last, air was injected into the
bladder through the urethral catheter. The vagina was
filled with and submerged in water. The vagina was
observed for leakage manifest by bubble formation. Each
specimen was placed in formalin for future study.

Volume 177, Number 6


am~j Obstet Gynecol

Meeks et al.

/Ureter
~~#~'f
Ureth~~

1301

Suture

Cuff

Fig. 3. Suture through bladder and anterior vaginal cuff.

Urethra
Previous
attachment
of urethra

Fig. 4. Catheter placed in bladder and secured with a ligature.

Anima!s were assessed by weight gain. Intraoperative


complications that were evaluated rupture of the bladder, hemorrhage, difficulty with rectus sheath closure,
and difficulty with skin closure. Postoperative problems
that were monitored included superficial dehiscence,
autophagia, and hernia formation. Intraabdominal abnormality that was assessed included adhesion formation, evidence of active infection, whether the bladder
sutures could be seen, and ultimately whether a vesicovaginal fistula had formed. Statistical analysis included t
test and Fisher's exact test.

FlesuRs
Thirty-two animals were enrolled in the study. Twentyone animals had a figure-of-eight suture placed through the
anterior vaginal wall with each loop of the suture intentionally placed through the bladder (group 1). Eleven animals
had a figure-of-eight suture placed through the anterior
va~nal wall, but care was taken to ensure that the bladder
was not penetrated (group 2). At the time of arrival at tile

animal facilities the rabbits in group 1 weighed 2.40 -+ 0.03


kg (mean _+ SD), and those in group 2, 2.40 -+ 0.05 kg (p
not significant), hnmediately before surgery rabbits in
group 1 weighed 2.81 + 0.23 kg, and those in group 2,
2.93 _+ 0.18 kg (p not significant). At necropsy rabbits in
group l weighed 3.48 _+ 0.31 kg and those in group 2
weighed 3.54 -+ 0.36 kg (p not significant). The mean
weight for both groups increased significantly during the
duration of the study (Table I).
Whereas all animals gained weight between deliver?and surgery, three animals lost weight between surgery
and necropsy. Two of these animals died. One rabbit in
group 1 died 2 days after surgery from unknown causes.
The intraabdominat contents appeared normal, and
there was no evidence to suggest that the death was
caused by complications related to the bladder and cuff
surgery. One rabbit in group 2 was put to death because
of peritonitis caused by a ruptured bladder. Rupture
occurred at a site remote from the cuff. Indeed, the
bladder was not ligated. Rupture was believed to be

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Meeks et al.

December 1997
&n J Obstet Gynecol

Table I. W e i g h t gain during study

Weight gain (kg, mean SD)


Bladder status

Delivery

Ligated (n = 20)*
Nonligated
(n = 10)*

2.40 +- 0.03
2.40 0.05

Surge~
2.81 + 0.23
2.93 0.18

Necropsy
3.48 -+ 0.31
3.54 _+ 0.36

*Analysis of variance, p < 10 -6.


Table II. Complications

Complication
Ruptured bladder
Hemorrhage
Dehiscence
Autophagia
Hernia
Remote adhesions
Site adhesions
Colon adhesions
Small-bowel adhesions

Nonligated
Ligated group group
(n = 20)
(n = 10) Sig~ijfcanee
3
0
1
8
2
8
6
6
5

1
1
0
4
1
1
0
0
0

p
p
p
p
p
p
p
p
p

=
=
=
=
=
=
=
=

0.593
0.333
0.689
0.656
0.749
0.099
0.065
0.065
0.109

F i s h e r ' s e x a c t test.

caused by bladder drainage with a n e e d l e and syringe


because it a p p e a r e d that rupture o c c u r r e d at the n e e d l e
drainage site. In neither case was evidence present to
suggest that rupture was associated with cuff sutures.
Both of these animals were excluded f r o m further analysis. T h e third animal gained weight for 21 days and t h e n
began to lose weight and appear ill. T h e animal was in
the ligated group. Necropsy was p e r f o r m e d on day 26,
and a ligated ureter that had started to leak was identified. No p r o b l e m was n o t e d with the bladder itself. This
animal r e m a i n e d in the analysis because necropsy was
p e r f o r m e d only 2 days early.
Complications are summarized in Table II. During the
course of the study the bladders of four animals were
r u p t u r e d w h e n pressure was applied to induce spontaneous voiding. T h r e e were in the ligated group and one was
in the nonligated group (p n o t significant). The ruptures
o c c u r r e d in the first 7 animals and are likely part of a
learning curve. T h e bladder rents were closed in two
layers. H e m o r r h a g e from the vaginal cuff that was
d e e m e d to be excessive o c c u r r e d in one animal in the
nonligated group. No complications o c c u r r e d with closure of the rectus sheath or skin.
Postoperatively one superficial dehiscence occurred in
the ligated group. Autophagia occurred in 8 rabbits in the
ligated group and 4 in the nonligated group (p not significant). Hernia occurred in 2 rabbits in the ligated group
and in 1 in the nonligated group (p not significant).
Intraabdominal adhesions remote from the surgical site
occurred in 8 rabbiits in the ligated group and in 1 in the
nonligated group (p not significant). Surgical site adhe-

sions occurred in 6 rabbits in tile ligated group and in n o n e


of the nonligated animals (p not significant). Colon adhesions occurred in 6 rabbits in tile ligated group and in n o n e
of the nonligated animals (p not significant). Small-bowel
adhesions developed in 5 rabbits in the ligated group and
in none of the nonligated animals (p not significant). The
suture placed through the anterior vaginal wall could be
identified in 3 rabbits in the ligated group and in 1 of tile
nonligated animals (p not significant).
During inspection of the vagina and bladder, no
animal was n o t e d to have a vesicovaginal fistula by any of
the described techniques. Leaking was identified with
formula milk and saline solution colored with m e t h y l e n e
blue in 1 animal. No air bubbles were seen. However,
close inspection revealed that the leak was c o m i n g from
a transected ureter.

Comment
T h e o c c u r r e n c e of fistulas that are obstetric in origin
has b e e n greatly r e d u c e d in the U n i t e d States because of
i m p r o v e m e n t in intrapartum care and the liberal use of
cesarean section for p r o l o n g e d labor and obstructed
labor. However, no change in the overall incidence of
vesicovaginal fistula formation after gynecologic operations has b e e n d o c u m e n t e d . Prevention has b e c o m e the
watchword. Whereas n u m e r o u s clinical opinions have
b e e n espoused regarding prevention of vesicovaginal
fistulas, no major controlled study has focused on this
issue. This study evaluated p l a c e m e n t of suture into the
bladder as an isolated occurrence.
T h e m e a n weight for each group of animals was similar
at arrival in the U M M C animal facilities, immediately
before surgery, and at necropsy. This confirms that the
groups were comparable. Also, the m e a n weight for each
group increased over the duration of the study. The
steady growth of the rabbits indicates that they were
generally healthy and tolerated the surgery well.
Intraoperative surgical complications, postoperative
complications, and postoperative a b d o m i n a l abnormality.
did n o t differ significantly between the groups. Whereas
no statistically different rate of adhesion f o r m a t i o n was
found, adhesion f o r m a t i o n deserves a special c o m m e n t .
Many m o r e adhesions were n o t e d in the "ligated" group
than in the "nonligated" group. P l a c e m e n t of a suture
t h r o u g h tile bladder may p r o d u c e transient leakage of
urine into the p e r i t o n e u m . If urine leaked even for a
short p e r i o d of time and collected at a r e m o t e site, it
could stinmlate adhesions. Also, it may p r o d u c e a m o r e
intense inflammatory response locally, causing m o r e
adhesions at the surgical site.
Use of sterile milk, m e t h y l e n e blue, a n d air p r o v i d e d
t h r e e alternative m e t h o d s to r e c o g n i z e the p r e s e n c e of
a fistula. By c a t h e t e r i z i n g the b l a d d e r a n d s u b m e r g i n g
it in water, we e n h a n c e d o u r ability to d e t e c t leakage if
present. T h e t e c h n i q u e s for identifying leakage s e e m

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?n'nJ Obstet GD~ecol

to be adequate, because leakage was identified from a


ureter, which was transected at the time of necropsy. No
evidence of vesicovaginal fistula formation was found.
The anatomy of the rabbit appears to be well suited to
e ~ l u a t e the role of suture placement into the bladder at
hysterectomy because no dissection of the bladder is necessary to perform hysterectomy in rabbits. However, three
factors should temper the findings in this study. First, the
anatomy of the rabbit and h u m a n differs slightly. H u m a n
subjects require m n c h m o r e dissection of the bladder to
separate it from the uterus before performance of the
h}~terectomy is possible. As well, the peritoneum of the
rabbit creates a double layer of tissue between the vagina
and the bladder, which may serve to protect against fistula
formation. Second, this study evaluated only one type of
suture. Sutures that are larger, m o r e reactive, or slower to
resorb may result in a significantly greater chance of fistula.
Third, this stud), had a limited n u m b e r of subjects. However, we predicted that at least 5% of procedures would be
associated with one or m o r e fistulas.
These findings would seem to seriously challenge the
premise that suture p l a c e m e n t into the bladder d u r i n g
transabdominal hysterectomy, as an isolated event, resuhs in vesicovaginal fistula. We fnrther postulate that
vesicovaginal fistula d e v e l o p m e n t is a c o m p l e x event.
Additional studies will be necessary to elucidate the
causes of vesicovaginal fistula formation.
T h e illustrations of Michael P. S c h e n k greatly enh a n c e d this manuscript.
REFERENCES
i. Lee RA, Symmonds RE, Williams TJ. Current status of
genitourinary fistula. Obstet Gynecol 1988;72:313-9.
2. Montella JM. Vesicovaginal fistula. Am Urogynecol Soc Q
Rep 1993;11:1-3.
3. Fichmer J, Voges G, Steinbach F, Hohenfellner R.
Uterovesicovaginal fistulas. Surg GynecoI Obstet 1993;176:
571-4.
4. Tancer ML. Observations on prevention and management
of vesicovaginal fistula after total hysterectomy. Surg Gynecol Obstet 1992;175:501-5.
5. Latzko W. Postoperative vesicovaginal fistulas: genesis and
therapy. AmJ Surg 1942;58:211-'28.
6. Kursh ED, Reid MM, Resnick MI, Persky L. Prevention of
the development of a vesicovaginal fistuIa. Surg Gynecol
Obstet 1988;166:409-12.
7. Symmonds RE. Prevention and management of genitourinary fistula. J Cont Educ Obstet Gynecol 1979;21:13-24.
8. Margolis MT, Mercer LJ. Vesicovaginal fistula. Obstet Gynecol Surv 1994;49:840-7.
9. Lee RA. Atlas of gynecologic surgery. Philadelphia: WB
Saunders; 1992. p. 280-90.
10. Tera H, Aberg C. Tensile strength of 12 types of knots
employed in surgery using different suture materials. Acta
Chit Scand 1976;14`2:1-7.
Discussion
DR. GEORGE T. SCHNEIDER,N e w Orleans, Louisiana. It
is a pleasure to discuss this prize paper of Meeks and
colleagues on the possibility that a vesicovaginal fistula

Meeks et ai.

1303

will develop after an inadvertent suture p l a c e m e n t into


the b l a d d e r contiguous with the vaginal cuff closure after
an a b d o m i n a l hysterectomy.
A b d o m i n a l hysterectomy is still one of the major
surgical procedures associated with a vesicovaginal fistula. Unfortunately, hysterectomy for b e n i g n disease
accounts for about 80% of its incidence. I believe all of us
agree, however, that the m o r e ditlqcult procedures, such
as those associated >dth severe endometriosis and pelvic
inflammatory disease, with or without a b n o r m a l bleeding, have an increased risk of bladder damage.
Incidentally, probably 20% to 25% of fistulas in one
series followed surgery by general surgeons outside the
realm of gynecology and obstetrics.
What causes this? Injury to the bladder d u r i n g the
surgery with avascular necrosis and devitalization of
tissue is, of course, the m a j o r cause. U n d e r this h e a d i n g
falls the inadvertent p l a c e m e n t of a suture into the
bladder w h e n the vaginal cuff is closed.
With this in mind, as you have just heard, Dr. Meeks
and associates devised a very nice animal e x p e r i m e n t
using rabbits to test the suture hypothesis. They are to be
congratulated on the excellence of their work, which
d e m o n s t r a t e d no fistula d e v e l o p m e n t in the rabbit after
the inadvertent suture p l a c e m e n t c o n n e c t e d to the vaginal cuff.
Unfortunately, as they emphasized, the rabbit anatomy
is somewhat different f r o m that of women, and in d o i n g
a hysterectomy on a rabbit o n e does not n e e d to dissect
the bladder downward off the lower uterine s e g m e n t or
celwix, as one does in women. This is where disturbance
of vascularity occurs with subsequent tissue devitalization, h e m a t o m a formation, and infection. Moreover, I
am certain that the u p p e r female vagina is exposed to
many m o r e infectious bacteria than is the u p p e r vagina
of the virginal rabbits that were used in this experiment.
This is especially so nowadays, even t h o u g h all of us
routinely attempt to cleanse the vagina preoperatively
and sometimes use preoperative antibiotics.
Using nonreactive 2-0 polyglycolic 9-10 suture, as the
authors described, also reduces the possibility of tissue
reaction in comparison with a larger, m o r e reactive
suture, such as catgut, or a n o n a b s o r b a b l e suture.
T h e only time urologists or urogynecologists worry
about an inadvertent suture into the b l a d d e r cavity would
be d u r i n g a n e e d l e bladder neck suspension p r o c e d u r e ,
such as a modified Pereyra p r o c e d u r e , w h e n p e r m a n e n t
sutures are used. O f course, this is why the cystoscope is
used routinely to check the interior of the b l a d d e r
postoperatively. It is not d e e m e d necessary with absorbable suture or delayed absorbable suture that is used
d u r i n g a Burch or Marshall-Marchetti-Krantz procedure,
when no outside contact of the suture occurs.
I feel certain, w h e n there is no bladder dissection,
bladder damage, a b n o r m a l bleeding, or infection, that
placing an inadvertent, nonreactive suture into the bladder will n o t result in a fistula, as the authors d e m o n strated. However, all of the a b o v e - m e n t i o n e d situations
m i g h t be h a r d to r e p r o d u c e in the rabbit model.

1304

Meeks et al,

I certainly hope Dr. Meeks and his associates will


continue their experiments in this field.
Da. M~E~ (Closing). First, to Dr. Schneider, what to
do if you know a suture is in the bladder? At this point in
time, I would take the suture out if I knew it was through
the bladder. The scenario you presented may be indicative of the complex etiology of fistula formation. We
selected the figure-of-eight suture and took relatively
large bites of both the anterior cuff and the bladder. A
full thickness of the bladder wall was sutured in hopes
that the figure-of-eight suture would indeed lead to
devascularity of this area and necrosis of the bladder wall.
I do not use a r u n n i n g suture to close the cuff at
hysterectomy. I use interrupted sutures. I cannot answer
the question regarding wha-t causes these fistulas. On the
basis of this model, placement of a single suture
probably does not cause the fistula formation. The

December 1997
,'MnJ Obstet G)aaecol

incidence of infection in these animals is relatively low.


However, infection is probably a significant problem.
On the basis of my review of the literature, a model for
evaluating infection does not appear to be available.
Also, the bladder is a durable organ, and we have
probably b e e n fortunate in that it is forgiving. I used
large clamps because I could get these clamps from
disposable circumcision sets free of charge. This was
the most expeditious way for us to get this project
accomplished. No ureteral fistulas were recognized.
We did ligate one ureter. It was not recognized immediately. The animal became sick on postoperative day
26, a n d it was put to death because it had become so
ill. We included this animal in the study because it was
just 2 days short of the defined time. We have not
performed histologic studies at this time, but we have
preserved the samples for future use.