Vesicovaginal Fistula

VESICOVAGINAL FISTULA REASON FOR VISIT: • The uncontrolled leakage of urine into the vagina • Urinary incontinence • An increase in vaginal discharge • Increased postoperative abdominal, pelvic, or flank pain • Prolonged ileus • Fever • Recurrent cystitis • Recurrent pyelonephritis • Abnormal urinary stream • Hematuria RISK ASSESSMENT • Old age • Hypertension • Diabetes • Bleeding disorders • Allergies to medication/anesthesia • Heart diseases • Advance stage of cancer ANESTHESIA: • General anesthesia • Spinal anesthesia PREPARATION OF THE PATIENT: • Blood tests • Urine analysis • Chest X-ray • ECG • Biopsy

• Intravenous urogram (IVU) • Retrograde ureteropyelography • Cystoscopy • Tratner catheter • Cystourethroscopy • Combined vaginoscopy-cystoscopy • Color Doppler ultrasonography • CT scan • MRI • The patient was given prophylactic antibiotic in the preoperative holding area • Blood thinning medication was stopped • Do not eat and drink any thing ____hrs prior to the procedure POSITION OF THE PATIENT: • Lawson position • Jackknife position • Dorsal lithotomy position THE PROCEDURE TECHNIQUES OF REPAIR • The vaginal approach • The abdominal approach VAGINAL APPROACH Exposure • The labial folds were sutured to the ipsilateral thigh • deep vaginoperineal incision was given/ parasacral incision was given Latzko technique: • Vaginal mucosa was sharply denuded in a circular fashion at a distance of 1.5 cm from the fistula opening.

• The fistula at the bladder mucosa was not disturbed. • A double row of sagittally oriented sutures was placed in the raw surfaces on either side of the fistula, with the second row imbricating the first. • Suturing of the vaginal wall was then performed, providing a third layer of closure. Flap-splitting techniques • The vaginal wall was incised circumferentially around the fistula, leaving a rim of intact vaginal wall encircling the fistula tract. • At the lateral sides of the fistula incision, the skin incisions were extended toward the vaginal apex in a parallel fashion. • One incision was carried further than the other, thereby incising a J shape in the vaginal wall. • The anterior and posterior flaps were widely dissected from the underlying endopelvic fascia. • The fistula tract was closed with 3-0 chromic or Dexon suture in a continuous fashion. • A second layer of closure in the endopelvic fascia was performed with 3-0 Dexon suture; it was placed perpendicular to the prior suture line. • The distal vaginal flap was trimmed. • The proximal flap was advanced beyond the fistula repair site, reaching the trimmed distal margin, and reapproximated in a running fashion. Vaginal cuff excision • The patient was placed in dorsal lithotomy position. • Cystoscopy was performed. • Traction on the fistula site was obtained by placing a Foley catheter into the fistula tract from a vaginal approach, • The balloon was inflated • Traction sutures were placed at 1-cm distances from the fistula. • The vaginal mucosa was denuded circumferentially for a radius of 3-5 mm from the vaginal cuff, including the fistula. • This incision was extended obliquely to the bladder wall

• The fistula tract and vaginal cuff scar was resected in a funnel-shaped specimen. • The defect was closed in 4 layers. • First, the bladder was closed with interrupted 4-0 sutures • The subvaginal pubocervicovaginal fascia was closed in 2 layers with interrupted 3-0 sutures. • This was followed by a vaginal wall closure with polyglycolic acid suture material. • A suprapubic catheter was placed for bladder drainage and is maintained for 3 weeks postoperatively. ABDOMINAL APPROACH Position Supine with trendelenburg orientation Transvesical extraperitoneal technique • With the patient placed in a steep Trendelenburg position, a transvesical incision was performed to visualize the fistula. • The bladder mucosa adjacent to the fistula was circumscribed and removed. • The bladder was dissected off the vagina and • The bladder and vaginal defects are sutured separately. O'Conor and Sokol technique • Abdomen was opened with an infraumbilical incision • The peritoneal cavity was entered. • The posterior wall of the bladder was dissected free as much as possible. • The bladder was bivalved at the dome. • This incision was extended posteriorly to the level of the fistula. • Stay sutures were placed sequentially along the incisional margins every few centimeters to permit traction and elevation of the bladder wall in order to aid in exposure and dissection. • Ureteral orifices and the location of fistula(s) were identified, • ureteral catheters were placed • The fistula tract and scarred and necrotic tissue were resected.

• Dissection of the posterior wall of the bladder from the underlying endopelvic fascia and vagina was completed. • The bladder and vagina were closed in separate layers. • The bladder was closed with a 2-0 chromic suture in continuous running fashion beginning at the apex and extending through the full muscle layers and imbricated with a second layer with interrupted 1-0 chromic sutures. • Peritoneal /interposition grafts were added. • A suprapubic catheter was brought out laterally to the sagittal closure. • A transurethral catheter placed • Abdomen was sutured in layers Vesical autoplasty • The bladder was entered through a transverse incision at the dome. • Catheterization of the ureters was performed. • The fistula tract was completely excised with the assistance of stay sutures secured around the fistula tract. • The bladder wall was carefully mobilized off the endopelvic fascia and vaginal wall. • The vaginal defect was closed with a single-layer closure. • A bladder flap was constructed to close the bladder defect. • Incisions were made at the superolateral angles of the bladder defect and extended cephalad toward the dome. • The anterior margin of the flap was drawn down over the bladder defect to meet the caudal margin of the bladder defect. • It was sutured in place with 3-0 catgut through the submucosal and muscular layers in interrupted fashion • The ureteral catheters were removed • The anterior cystotomy was closed in a single extramucosal layer. Bladder mucosal autologous grafts • A Pfannenstiel /infraumbilical low vertical midline incision was given • Entered the peritoneal cavity with • An extraperitoneal cystotomy was performed at the anterior bladder wall. • Ureteral catheters were placed.

• Bladder mucosa was denuded circumferentially at the fistula site at a distance of 1 cm. • The fistula tract and vaginal wall were left undisturbed. • A free bladder mucosal graft was sharply dissected from its underlying muscularis layer at the edge of the anterior cystotomy margin. • This graft of mucosa was then secured over the fistulous tract with interrupted 4-0 chromic catgut sutures that are placed into the superficial muscularis at a distance of 2-3 cm. • The anterior cystotomy was closed in 2 layers. • A transurethral catheter was placed • A suprapubic Malecot drain was placed • Abdominal incision was closed with sutures FINDINGS: Fistula was present at _____ AFTER PROCEDURE: • Continuous catheter drainage was placed • Patient was shifted to intensive care unit • Pulse rate, blood pressure, oxygenation was monitored DURATION _____hrs POSTOPERATIVE CARE • Take Vitamin C at 500 mg orally 3 times per day/methenamine mandelate at 550 mg plus sodium acid phosphate at 500 mg 1-4 times • Take estrogen replacement therapy • Take Urised as prescribed • Take antibiotics as prescribed • Take stool softeners and a high-fiber diet • Avoid pelvic and speculum vaginal examinations during the first 4-6 weeks postoperatively • Prohibit coitus and tampon use for a minimum of 4-6 weeks.

COMPLICATIONS • Infection • Hemorrhage • Injury to the ureters • Surgical failure of fistula repair • Possible new fistula formation • Thromboembolism • Sexual dysfunction • Sexual dissatisfaction • Incontinence • Abdominal and pelvic adhesions • Dyspareunia • Tenderness at the site of the donor Martius graft • Diminished vaginal length and caliber