Timing of the repair has been the subject of controversy and can pose a dilemma to physician and patient alike. Traditionally, an interval of 3 months was recommended between the index surgery and fistula repair, with a delay of up to 1 year when the fistula was radiation-induced. However, little data support these recommendations.
Today most experts recommend an individualized approach, delaying the surgery until inflammation and infection of the surrounding tissue have resolved. The use of estrogen, antibiotics, or steroids to facilitate healing during this period also has been recommended.7 Comparable success rates have been reported for early and late repair of surgery-induced fistulae based on these principles.8-10
Vaginal approach. Most vesicovaginal fistulae can be surgically corrected using a vaginal approach. Traditionally, a Latzko partial colpocleisis or fistulectomy with flap-splitting closure has been advocated.
Debate continues about whether resection of the fistulous tract is necessary. Some experts believe that wide resection increases the size of the fistula and, therefore, the risk of recurrence. They also maintain that the fibrous tissue surrounding the fistula helps to reinforce the surgical repair. Proponents of fistulectomy counter that resection of the fistula and exposure of healthy tissue optimizes wound healing and improves surgical success rates. Comparable success has been reported for both techniques.11,12
We prefer an individualized approach, with minimal resection of the fistulous tract to simplify the procedure and minimize associated complications, including recurrence.
- Latzko partial colpocleisis. This technique, first reported in 1942, remains a common procedure, with success rates of 90% to 100%.13 Advantages include a short operative time, low intraoperative and postoperative morbidity, and low risk of ureteral injury.
- Fistulectomy technique. Alternatively, to perform fistulectomy with a flap-splitting closure, begin by resecting the fistulous tract to expose healthy tissue at the wound margins. Then close the defect in a multilayer fashion, beginning with the bladder mucosa, bladder serosa, pubocervical fascia, and vaginal mucosa. Be careful to avoid tension on suture lines. In addition, create a fascial flap to prevent opposition of the incision planes and reduce the risk of recurrence.
- Grafts. In cases with a high risk of recurrence, such as complex or large fistulae, a Martius fat-pad graft should be interposed between the closure layers to promote vascularization and reduce the risk of recurrence.14 Placement of a cadaveric biomaterial graft also has been reported, reducing the need for complicated flap procedures.15
Abdominal approach. Although most vesicovaginal fistulae can be surgically corrected via the vaginal approach, the abdominal route may be preferred when the fistula is high and inaccessible, large and complex, multiple in number, or when there is concurrent uterine or bowel involvement or a need for ureteral reimplantation. The abdominal approach may be facilitated by cystoscopically guided placement of a catheter through the fistulous tract to assist in subsequent identification and dissection.
To begin, make a vertical skin incision to optimize visualization and allow mobilization of an omental flap, if necessary. Expose the bladder and perform a high extraperitoneal cystotomy to visualize the fistulous tract. Place ureteral stents if the fistula is in close proximity to the ureteral orifice.
Extend the bladder incision to the fistulous tract and completely excise it following mobilization of the vagina. Then close the vagina and bladder with interrupted, delayed absorbable suture in a double layer.
Transpose an omental flap between the vaginal and bladder incisions to promote vascularization, minimize opposition of suture lines, and reduce the risk of recurrence (FIGURE 2).
Laparoscopic approach. A similar laparoscopic repair has been reported with comparable results, but requires advanced skills with endoscopic suturing and knot tying (FIGURE 3).16
FIGURE 2 Abdominal repair
Abdominal repair of vesicovaginal fistula, with closure of bladder defect and posterior cystotomy and separate closure of vaginal defect. Note the omental flap pictured in the insert.
FIGURE 3 Laparoscopic repair
Laparoscopic repair of vesicovaginal fistula.The authors report no financial relationship with any companies whose products are mentioned in this article.