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0022-5347/05/1735-1615/0 THE JOURNAL OF UROLOGY® Copyright © 2005 by AMERICAN UROLOGICAL ASSOCIATION

Vol. 173, 1615–1618, May 2005 Printed in U.S.A.

DOI: 10.1097/01.ju.0000154701.97539.ef

LAPAROSCOPIC REPAIR OF VESICOVAGINAL FISTULA ´ SOTELO, MIRANDOLINO B. MARIANO, ALEJANDRO GARCI´A-SEGUI, RINCI DUBOIS, RENE MAXIMILIANO SPALIVIERO, WARTAN KEKLIKIAN, JOHN NOVOA, HENRY YAIME AND ANTONIO FINELLI From the Section of Laparoscopic and Minimally Invasive Surgery, Department of Urology, “La Floresta” Medical Institute, Caracas, Venezuela, and Hospital Ma˜e de Deus (MBM), Porto Alegre, Brazil

ABSTRACT

Purpose: Vesicovaginal fistula may be a complication of urogynecologic surgery. We describe the technique of laparoscopic repair of vesicovaginal fistula as performed at our 2 institutions. Materials and Methods: Since August 1998 laparoscopic repair of vesicovaginal fistula was performed in 15 select patients who had clear indications to undergo surgical treatment through an abdominal approach. Hysterectomy had previously been performed in 14 patients (93%). Conservative treatment was initially attempted for more than 2 months in all cases. Four patients had undergone a previous surgical fistula closure attempt with unsuccessful results. Our technique involved cystoscopy, catheterization of the vesicovaginal fistula, laparoscopic cystotomy, opening and excision of the fistulous tract, dissection of the bladder from the vagina, cystotomy closure and colpotomy with interposition of a flap of healthy tissue. Demographic as well as perioperative and outcome data were recorded. Results: Average patient age was 38 years. None of the cases required open conversion. Mean operative time was 170 minutes (range 140 to 240). Mean hospital stay was 3 days (range 2 to 5). The mean duration of bladder catheterization was 10.4 days (range 9 to 15) At a mean followup of 26.2 months (range 3 to 60) 14 patients (93%) were cured. Conclusions: We believe that laparoscopic repair of vesicovaginal fistula is a feasible and efficacious minimally invasive approach for the management of this entity. KEY WORDS: bladder, vagina, fistula, vesicovaginal fistula, laparoscopy.

Abdominal hysterectomy remains as the most common cause of vesicovaginal fistulae (VVF) in developed countries, occurring in 1/1,800 hysterectomies.1 When a fistula is diagnosed, a trial of conservative therapy should be initiated. Conservative measures include proper and undisturbed bladder drainage for several weeks, treatment with antibiotics when indicated and in some cases an attempt can be made to fulgurate a small fistulous tract, albeit with a low probability of success (7% to 12.5%).2, 3 When the fistula is large or when it does not respond to these conservative measures, corrective surgery is indicated.3⫺5 VVF that results from operative injury can be repaired with a success rate of 75% to 97%. With recurrent fistulas a failure rate of 10% has been reported.6, 7 We believe that the first attempt to repair the fistulous tract offers the patient the best opportunity to achieve a successful outcome. VVF may be treated with various surgical techniques depending on the etiology, location and surgeon experience.1 Most VVFs result from difficult hysterectomy and initial repair is usually attempted via a vaginal approach, most often by gynecologic surgeons. This approach is satisfactory in most cases. However, when the fistula is high lying on the posterior bladder wall and the vagina is severely scarred, vaginal exposure may be difficult.5 Lee et al recommended an abdominal approach for certain indications, namely 1) inadequate exposure related to a high or retracted fistula in a narrow vagina, 2) close proximity of the fistulous tract to the ureter, 3) associated pelvic pathology and 4) multiple fistulas. In complicated cases a combined transabdominal and transvaginal approach has been reported.8 There have also been reports of laparoscopic repairs of vesicovaginal fistulas.3, 6, 9 We describe our laparoscopic technique to repair VVF and our results. Submitted for publication July 30, 2004.

METHODS

A total of 15 patients with clear surgical indications for VVF repair through an abdominal approach were diagnosed with a vesicovaginal fistula at 2 institutions in Venezuela and Brazil between August 1998 and March 2004. In all patients conservative treatment had failed. We proposed a transperitoneal laparoscopic approach following the same principles as those of laparotomy. During the informed consent process patients were advised that other surgical alternatives were available and conversion to laparotomy might be required. Statistical analysis was performed using bivariate analysis with central trend and dispersion. Office evaluation supported the diagnosis of VVF. Cystoscopy, retrograde cystourethrography and excretory urography confirmed VVF and ruled out ureteral injury. Surgical treatment was done a minimum of 2 months after the initial diagnosis. Two urological surgeons performed the procedures in Caracas, Venezuela (RSN) and in Porto Alegre, Brazil (MBM), respectively. After general anesthesia is administered, the patient is placed in low lithotomy in stirrups. Initially cystoscopy is performed and the 2 ureters are catheterized. This facilitates ureteral identification and protection during excision and closure of the fistula. A ureteral catheter of a color different than those used for the ureters is then pulled through the fistula into the vagina and retrieved outside through the vaginal introitus to facilitate identification during excision. When a large fistula tract is identified, a Foley catheter is placed rather than a ureteral catheter. A sponge retractor is inserted into the vagina up to the vaginal apex. The cystoscope is reinserted into the bladder. The patient is placed in the Trendelenburg position. After pneumoperitoneum is established a 5 port transperitoneal approach is used, similar to that for laparoscopic radical

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prostatectomy.10 After the vagina is retracted posterior with a sponge retractor the light from the cystoscope becomes clearly visible through the bladder in the vicinity of the vesicovaginal fistula. The posterior bladder wall is incised vertically with a harmonic scalpel in the proximity of the vesicovaginal fistula (fig. 1). The ureteral or Foley catheter that runs along the fistulous tract is identified and the incision is carried vertically downward (fig. 1). This is continued in the direction of the catheter that defines the fistula, sectioning the posterior wall of the tract until the posterior aspect of the catheter as well as the vaginal sponge retractor is exposed (fig. 2). After communication between the bladder and vagina becomes evident the sponge retractor is withdrawn and a vaginal tamponade is prepared and applied to prevent pneumoperitoneum loss. The remaining borders of the fistulous tract are excised, creating a lateral margin of viable tissue wide enough to allow subsequent closure. After generous excision of the tract meticulous dissection is performed to separate the bladder from the vagina using laparoscopic scissors and gentle countertraction (fig. 3). All nonviable or necrotic tissue is excised. Bladder closure is then initiated at the apex of the incision. Starting with the initial knot on the outer bladder surface 2-zero polyglactin on a CT-1 needle is used to close the cystotomy in 1 layer in a running, continuous fashion. This suture is run in a superior direction under cystoscopic guidance. The serosal layer is reinforced using a continuous 1-zero chromic catgut suture. Vaginal closure is subsequently performed with viable tissue in 1 layer using a continuous 2-zero polyglactin suture. This suture is run in the transverse direction. An anchoring suture is then placed at the anterior vaginal wall, distal to the vaginal closure. This suture is then used to anchor part of the omental flap, which can be harvested from the nearest anatomical location. Alternatively an epiploic appendix can be mobilized from the sigmoid colon. The bladder is filled with saline to assess how watertight a closure was achieved. Bladder drainage is usually accomplished by an indwelling urethral catheter. A suprapubic cystostomy tube is not used. A closed system drain is placed in the area of the vaginal closure. We believe that an important aspect of the postoperative course is to maintain urethral catheter patency by preventing clot obstruction and retention. Irrigation of these tubes is done only if there is a suspicion of catheter obstruction. Ambulation is encouraged and appropriate prophylactic antibiotics are generally given. The closed drainage system is usually removed on postoperative day 2 or 3. The urethral

FIG. 2. Incision is carried downward until posterior aspect of catheter and sponge stick are exposed, creating communication between bladder and vagina.

FIG. 3. Retraction facilitates dissection of bladder from vagina

catheter is generally removed 10 days postoperatively. A retrograde cystogram may be performed before catheter removal to ensure fistula closure. Patients are advised to avoid the use of tampons and refrain from sexual activity for 2 months after the procedure. RESULTS

FIG. 1. Posterior bladder wall is incised vertically with harmonic scalpel in proximity of VVF.

A total of 15 patients were treated with this transperitoneal laparoscopic approach. Average age was 38.8 years (range 19 to 59). Of the patients 14 (93.3%) had a history of abdominal hysterectomy and the remaining patient had experienced significant obstetric trauma during the delivery of twins. A total of 11 patients (73.3%) had not undergone previous surgical attempts to repair the VVF. Four patients underwent unsuccessful surgery, including an open abdominal approach in 3 and a vaginal approach in 1. One of these patients underwent 3 previous attempts and another underwent 2 failed procedures. All vesicovaginal fistulas were diagnosed with the methylene blue test. In most cases the location of the fistula was supratrigonal (93.3%) and in 1 it was intratrigonal (6.7%). Of the patients 13 underwent only laparoscopic repair of VVF. One of the other 2 patients underwent concomitant laparoscopic vesicoureteral reimplantation and the other un-


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LAPAROSCOPIC REPAIR OF VESICOVAGINAL FISTULA Publications on laparoscopic repair of VVF References

No. Pts

Mean Operative Time (mins)

Nezhat et al9 Phipps11 von Theobald et al6 Miklos et al14 Nabi and Hemal15 Ou et al4

1 2 1 1 1 2

85 160 70 Data not available 190 Data not available

derwent laparoscopic nephroureterectomy for long-standing renal obstruction that was likely secondary to remote hysterectomy. Mean operative time was 170 minutes (range 140 to 240). Average length of stay was 3 days (range 2 to 5). The urethral catheter remained indwelling an average of 10.4 days (range 9 to 15). Complications occurred in 2 patients. Enterotomy was recognized and repaired laparoscopically at VVF surgery. In this patient the postoperative course was complicated by an enterocutaneous fistula, which resolved with conservative therapy. This patient had a history of 3 previous surgeries with significant intraperitoneal adhesions. Another patient experienced epigastric artery injury at trocar insertion. This was not recognized during the procedure and, thus, it necessitated laparoscopic reexploration within 24 hours. The point of arterial bleeding was identified and ligated with a Carter-Thomason device. Thereafter the postoperative course in this patient was uneventful. At a mean followup of 26.2 months (range 3 to 60) laparoscopic VVF repair failed in only 1 case. DISCUSSION

Various surgical techniques for VVF repair have been described. Fistulas may be successfully repaired with an abdominal, vaginal or combined approach. The choice of approach usually depends on surgeon preference and experience.11⫺13 However, recently proponents of the vaginal approach noted advantages in terms of lower patient morbidity, blood loss and postoperative bladder irritability. The procedure may be done in an outpatient setting, postoperative pain is minimal and successful results equaling those of the abdominal approach are achieved.5 Proponents of the abdominal approach argue that it has enjoyed reproducible and durable success, and the advent of limited anterior cystotomy has improved the historically more morbid O’Connor procedure, in which the bladder is bivalved to the level of the fistula. Additionally, some believe that high lying fistulas or inaccessible vaginal vaults preclude the vaginal approach.5 However, others use the abdominal approach only in rare cases when an intra-abdominal pathological condition requires simultaneous care.1, 4 Laparoscopy is an alternative to laparotomy for many urogynecologic procedures. The advantages of a minimally invasive procedure are well known, including magnification during the procedure, hemostasis, decreased abdominal pain and a shorter hospital stay with more rapid recovery and earlier return to work. Laparoscopy respects the basic principles of successful surgical repair by the abdominal approach, namely 1) wide exposure of the fistula and surrounding tissues, 2) excision of all fibrous tissue, 3) tension-free closure of well vascularized flaps, 4) use of suitable suture material, 5) interposition of various tissues, such as omentum, peritoneum, a bladder flap taken from a site away from the fistula or an epiploic appendix taken from the sigmoid colon and 6) efficient postoperative bladder drainage.9 In 1994 Nezhat et al initially reported laparoscopic VVF repair9 and several other reports followed (see table). We believe that an advantage of our technique is the incision, which leads us to the fistulous tract expeditiously. Upon

Mean Blood Loss (cc)

Mean Hospital Stay (days)

Mean Foley Duration (days)

100 Data not available 100 Data not available Data not available Data not available

1 1 8 1 4 2–12

10 10 7 21 21 14–20

completing the opening of the posterior tract wall we reach a precise and ideal location in the vagina without the need for additional vaginal incision or further dissection of the vesicovaginal space. The remaining borders of the fistulous tract are resected and then the vesicovaginal space is dissected sharply, separating the bladder from the vagina. The exposure and magnification afforded by video laparoscopy facilitate efficient and direct access to the fistula, meticulous dissection and fistula resection. Video cystoscopic guidance enhances access, eliminating the need for bladder dome incision to improve exposure. We believe that the laparoscopic VVF repair is a feasible and efficacious approach with a successful outcome in the majority of our patients. Laparoscopic freehand intracorporeal suturing can be challenging, although with growing experience with laparoscopic radical prostatectomy skill transfer should improve the learning curve. In our series we have only 1 patient in whom laparoscopic fistula repair failed. In this case we were unable to interpose healthy tissue between the suture lines. Significant intraperitoneal adhesions precluded access to suitable tissue. If this scenario is noted in the future, we intend to use a Martius flap via an additional vaginal incision. CONCLUSIONS

The laparoscopic approach to VVF repair is an excellent alternative to the traditional abdominal approach but it requires laparoscopic experience, particularly pelvic surgery with intracorporeal suturing. We believe that laparoscopic VVF repair is a feasible and efficacious minimally invasive approach for the management of this entity. Dr. Inderbir Gill provided assistance and guidance during our early laparoscopy experience, and Drs. Larissa V. Rodriguez and Ariel Kaufman provided for comments and suggestions. REFERENCES

1. Miller, E. A. and Webster, G. D.: Current management of vesicovaginal fistulae. Curr Opin Urol, 11: 417, 2001 2. Hilton, P.: Vesico-vaginal fistula: new perspectives. Curr Opin Obstet Gynecol, 13: 513, 2001 3. O’Conor, V. J., Jr.: Review of experience with vesicovaginal fistula repair. J Urol, 123: 367, 1980 4. Ou, C. S., Huang, U. C., Tsuang, M. and Rowbotham, R.: Laparoscopic repair of vesicovaginal fistula. J Laparoendosc Adv Surg Tech A, 14: 17, 2004 5. Shlomo, R.: Editorial comment: early versus late repair of vesicovaginal fistulas: vaginal and abdominal approaches. J Urol, 153: 1112, 1995 6. von Theobald, P., Hamel, P. and Febbraro, W.: Laparoscopic repair of a vesicovaginal fistula using an omental J flap. Br J Obstet Gynecol, 105: 1216, 1998 7. Eilber, K. S., Kavaler, E., Rodrı´guez, L. V., Rosenblum, N. and Shlomo, R.: Ten-year experience with transvaginal vesicovaginal fistula repair using tissue interposition. J Urol, 169: 1033, 2003 8. Lee, R. A., Symmonds, R. E. and Williams, T. J.: Current status of genitourinary fistula. Obstet Gynecol, 72: 313, 1998 9. Nezhat, C. H., Nezhat, F., Nezhat, C. and Rottenberg, H.: Lapa-


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roscopic repair of a vesicovaginal fistula: a case report. Obstet Gynecol, part 2, 83: 899, 1994 10. Gill, I. S. and Zippe, C. D.: Laparoscopic radical prostatectomy: technique. Urol, Clin North Am, 28: 423, 2001 11. Phipps, J.: Laparoscopic repair of posthysterectomy vesicovaginal fistula. Two case reports. Gynecol Endosc, 5: 123, 1996 12. Raz, S., Bregg, K., Nitti, V. and Sussman, E.: Transvaginal repair of vesicovaginal fistula using a peritoneal flap. J Urol, 150: 56, 1992

13. Blaivas, J. G., Heritz, D. M. and Romanzi, L. J.: Early versus late repair of vesicovaginal fistulas: vaginal and abdominal approaches. J Urol, 153: 1110, 1995 14. Miklos, J. R., Sobolewski, C. and Lucente, V.: Laparoscopic management of recurrent vesicovaginal fistula. Intern Urogynecol J, 10: 116, 1999 15. Nabi, G. and Hemal, A. K.: Laparoscopic repair of vesicovaginal fistula and right nephrectomy for nonfunctioning kidney in a single session. J Endourol, 15: 801, 2001


LAPAROSCOPIC REPAIR OF VESICOVAGINAL FISTULA. Journal of Urology 2005