5.3.2
Vesicovaginal Fistula Repair
René Sotelo Noguera, Roberto Garza Cortés
Introduction
Vesicovaginal fistulae (VVF) may be treated by different surgical techniques, either transvaginal or transabdominal (extra- or transvesical). The selection of the approach is based on the surgeon’s preference. However, there is still controversy over the ideal approach and time of repair [1, 2]. In general, a vaginal approach is associated with lower morbidity, diminished blood loss and postoperative bladder irritability in comparison to the transabdominal approach. Furthermore, this technique may be performed in the outpatient setting. The results are often equal to those achieved with an abdominal approach [3]. The abdominal approach is indicated in case of another intraabdominal condition requiring simultaneous surgical management. The abdominal method is also used when the fistula is lying high and/or on the vaginal vaults. Laparoscopy can be an alternative to the abdominal approach for managing VVF. Nezhat et al. initially reported laparoscopic VVF repair in 1994 [4]. Sotelo et al. reported the largest laparoscopic series. The latter group used a transvesical approach that led expeditiously to the fistulous tract without the need for additional vaginal incisions or further dissection of the vesicovaginal space [5]. Moreover, the laparoscopic approach enables a limited cystotomy, which is associated with less morbidity in comparison to the historical O’Connor procedure. During the latter procedure, the bladder is bivalved to the level of the fistula. In general, the advantages of laparoscopy include magnification of the operative field, efficient haemostasis, decreased hospital stay and shorter convalescence.
Indications " " " " "
!" Inadequate exposure related to a high or retracted fistula in a narrow vagina !" Close proximity of the fistulous tract to the ureter !" Associated pelvic pathology that requires surgery !" Multiple fistulae !" Morbid obesity !" Failure in a previous open surgical approach
Contraindications "
!" Generalised peritonitis !" Uncorrected or uncorrectable coagulopathy !" Severe co-morbidities contra-indicating any surgical management
Preoperative Preparation
!" It is necessary to clearly explain to the patient the type of procedure that will be performed. It is important to address the novelty of the technique and its recent development as a therapeutic option. Risks and complications should be discussed, as well as the possibility of open surgery, owing to anatomical variations or unforeseen complications that might require the open approach !" Most patients are surgically managed after 2 months of unsuccessful conservative management. In case of conservative management failure, a urethral catheter is avoided (if possible) until the day of surgery
Specific Patient Preparation " " "
!" Soft diet, at home !" The evening before the procedure, antegrade bowel preparation !" Fasting from 10:00 p.m. on the day before surgery !" Patient is admitted on the day of the procedure !" Preoperative administration of an intravenous broad-spectrum antibiotic (quinolone or cephalosporin)
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Step 1: Cystoscopy and catheterisation of the ureters and fistula, port placement
a
The patient is placed in dorsal lithotomy position. Cystoscopy is performed and both ureters are cannulated with 5-F ureteric catheters. The latter manoeuvre facilitates the identification of ureteral orifices and the course of the ureters. A ureteral catheter of a different colour is inserted through the bladder, advanced along the fistu-
b
lous tract into the vagina and retrieved at the introitus. For large fistulae, a Foley catheter instead of a ureteral catheter can be used through the bladder. Port placement follows. A standard five-port transperitoneal approach, similar to that employed in laparoscopic prostatectomy, is used.
Step 2: Creation of omental flap, cystotomy
a
A sponge retractor is inserted into the vagina via the introitus to retract the vagina posteriorly. Once in the abdominal cavity, the first step is to dissect any adhesions. A omental flap is created from the site of the right gastroepiploic artery (Step 2a). The first step to repair the fistula is the dissection of the posterior bladder wall. A vertical
b
bladder incision will be performed, creating a small cystotomy that dissects vertically towards the fistula. Step 2b is a schematic of the cystotomy. It is important to remember that the latter transvesical approach leads to the fistulous tract expeditiously.
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Step 3: Identification of the bladder and initiation of cystotomy
a
The identification of the site between the bladder and the vagina is facilitated by the insertion of a cystoscope, which is used to provide endoscopic light guidance to the bladder. Step 3a shows the endoscopic light designating the bladder and the bulging of the uterus to the peritoneal cavity, which could be used as landmarks for
b
the identification of the site where the cystotomy should take place. An incision to the overlying peritoneum is made and the bladder is then opened by a vertical incision. The previously inserted urethral catheter is visible (Step 3b).
Step 4: Cystotomy
a
The incision directed vertically to the posterior bladder wall is extended (Step 4a). The incision is directed towards the bladder neck. The posterior aspect of the urethral catheter balloon and the sponge retractor inserted in the vagina are exposed and the fistulous tract
b
is resected with direction to the vagina (Step 4b). For the performance of cystotomy, ultrasonic shears in combination with laparoscopic graspers are adequate. Nevertheless, the use of J-hook electrocautery or laparoscopic scissors is an alternative.
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Step 5: Exposure of the vesicovaginal communication
a
The resection of the fistulous tract is facilitated when the edges of the bladder incision are retracted laterally to expose the communication of the bladder to the vagina (Step 5a). A suture is placed at each side of the incision. Placement of these sutures can be performed using a Keith needle or a Carter-Thomason port-closure needle
b
device. The two ends of the stitch are retracted and anchored outside of the anterior abdominal wall, resulting in adequate exposure of the fistulous tract. Alternatively, a single stay suture on the superior edge of the cystotomy could be used to retraction. A schematic of the latter method is presented in Step 5b.
Step 6: Excision of the fistulous tract
a
When communication between the vagina and bladder is visualised, the sponge retractor is withdrawn (Step 6a) and a Foley catheter is placed in the vagina. The balloon is inflated with 70 cc of saline to prevent loss of pneumoperitoneum. Dissection is continued until the fistula is completely separated from the vagina. Step 6b shows
b
the excision of the fibrous tissue edges of the fistula with laparoscopic scissors. All fibrotic and necrotic tissue should be excised. It is important to avoid injuring the ureteral orifices or the urethra during the wide excision of the fistulous tract.
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Step 7: Closure of the vagina and bladder
a
The creation of tissue flaps that are adequate for the tension-free closure of the vagina and the bladder requires further dissection of the tissue surrounding the fistulous tract. A combination of laparoscopic scissors and grasper are used for the task. Step 7a shows the site of a vesicovaginal fistula after the excision of the tract.
b
Excessive tissue at the vaginal wall could be used for the closure of the lesion. The latter is closed horizontally with a running 2/0 Monocryl suture on a CT-1 needle (Step 7b). The closure of the bladder defect and the cystotomy never presents a challenge.
Step 8: Tissue interposition
a
Step 8a is a schematic presenting the concept of bladder and vagina reconstruction as well as tissue interposition. Two sutures are placed in the anterior wall of the vagina, distal to the closure line. These sutures are used to anchor the tissue that has been previously prepared for interposition. Step 8b shows the omental flap anchored
b
over the anterior wall of the vagina. The repaired vaginal lesion is fully covered by the omental flap. Recurrence of the fistula is prevented by the interposition of omental tissue. Alternatively, a peritoneal flap obtained superior and lateral to the bladder dome can be used.
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Step 9: Closure of the bladder
a
b
Step 9a shows the omental flap interposition to be completed. The vaginal defect is closed and covered by the flap and the bladder remains open. The posterior bladder wall is closed vertically with a running 2/0 Monocryl on a CT-1 needle suture. The suturing begins at the distal apex and continues proximally (Step 9b). Cystoscopic guidance can be used to facilitate the closure.
Postoperative Management " " " " " " " "
An additional running closure of the bladder serosa is performed with an absorbable suture. The ureteral catheters are removed. A 20-F urethral catheter is then inserted to maintain bladder drainage. The bladder is then filled with saline to confirm a watertight closure. A suprapubic cystostomy tube is not used. A drain is placed in the pelvis.
!" Immediate care !" Two or three more doses of selected intravenous antibiotic !" Prevention of urethral catheter obstruction !" Irrigation of the bladder only if necessary !" Outpatient care !" Drain removal at 2 or 3 days !" Oral antibiotic of choice for 10 days !" Removal of urethral catheter at 10 days, after completion of cystography !" Sexual abstinence for 2 months !" Patients are advised not to use tampons
References 1. Raz S, Bregg K, Nitti V, Sussman E (1993) Transvaginal repair of vesicovaginal fistula using a peritoneal flap. J Urol 150:56–59 2. Blaivas JG, Heritz DM, Romanzi LJ (1995) Early versus late repair of vesicovaginal fistulas: vaginal and abdominal approaches. J Urol 153:1110–1112 3. Raz S (1995) Editorial comment on: Early versus late repair of vesicovaginal fistulas: vaginal and abdominal approaches. J Urol 153:1112–1113 4. Nezhat CH, Nezhat F, Nezhat C, Rottenberg H (1994) Laparoscopic repair of a vesicovaginal fistula: a case report, part 2. Obstet Gynecol 83:899–901 5. Sotelo R, Mariano MB, Garcia-Segui A, Dubois R, Spaliviero M, Keklikian W, Novoa J, Yaime H, Finelli A (2005) Laparoscopic repair of vesicovaginal fistula. J Urol 173:1615–1618