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VAGINAL RECONSTRUCTIVE SURGERY

Vesicovaginal Fistula
Craig V. Comiter, MD, Sandip P. Vasavada, MD, and Shlomo Raz, MD

In developing countries, ischemic injury secondary to obstructed labor is the


leading cause of vesicovaginal fisutla (VVF). In the United States, most VVFs result
from iatrogenic injury. Trauma during gynecologic surgery is responsible for 90% of
WFs, with transabdominal hysterectomy accounting for most cases. Other less
common causes include radiation-induced injury and locally advanced neoplasms
( e g , cervical, endometrial, and vaginal carcinomas).

INDICATIONS FOR SURGERY

Ten percent of small iatrogenic VVFs will close spontaneously with continuous
bladder drainage and antibiotics. If the fistula has not closed after 3 weeks of
catheter drainage, it is unlikely that the fistula will close without surgical intervention. When the fistula is extremely small (1 mm), coagulation of the fistulous tract
may occasionally be successful. Immediate surgical repair is indicated when the
fistula is large enough that most of the urine passes per vagina in spite of continuous bladder drainage. Estrogen replacement is begun at the time of diagnosis in
hypoestrogenic women, and continued until the time of surgery. With an otherwise
healthy patient, success rates have not been shown to differ with early versus
delayed W F repair.

CONTRAINDICATIONS TO SURGERY

Early repair is not recommended in patients with untreated vaginal cuff or


pelvic infection. In such instances, prolonged antibiotic therapy is necessary prior to
repair and reconstruction. Furthermore, operative repair in ill patients is delayed
until the health status improves enough to tolerate surgery. Additionally, surgery
should not be performed in cases of ischemic fistula until the area of necrosis
stabilizes. The transvaginal route is contraindicated in patients who cannot tolerate
the lithotomy position, or in those with severe vaginal stenosis. In cases of a small
capacity bladder (secondary to radiation) in which a concomitant augmentation
cystoplasty is planned, a transabdominal repair of the fistula is indicated.
From the Department of Urology, University of Arizona, Tucson, Arizona (CVC), the Department of
Urology, Thomas Jefferson University, Philadelphia, Pennsylvania (SP), and the Department of Urology, University of California, Los Angeles, California (RS)

ATLAS OF THE UROLOGIC CLINICS OF NORTH AMERICA Volume 8 Number 1 April 2000

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DIAGNOSIS

Patients typically present with continuous daytime and nighttime leakage per
vagina, with a recent history of gynecologic surgery. Depending on the size of the
fistula, and thereby the ability to store urine in the bladder, the amount of urine
voided versus the amount lost per vagina will vary. Most causes of W F resulting
from surgical trauma are clinically apparent within 10 days of surgery. On the other
hand, radiation-induced VVF may not present until 20 years after radiotherapy.
Pelvic examination often identifies the fistulous opening in the vagina. If the
examination is unrevealing, and the suspicion remains high, the bladder may be
catheterized and filled with a colored solution. The vagina may then be inspected
for leakage. Additionally, the vagina may be packed with a tampon, and the vagina
re-examined after ambulation. If suspicion still remains high, intravenous indigo
carmine or oral phenazopyridine may help to diagnose a uretero-vaginal fistula.
In any patient with a suspected or confirmed fistula, voiding cystourethrography, cystoscopy, and upper tract evaluation are indicated. Voiding cystourethrography may demonstrate the fistula and any concomitant prolapse. Cystoscopy is
necessary to evaluate bladder capacity, the size and location of the fistula, and its
relation to the ureteral orifices. Biopsy is recommended if there is a history of
genitourinary malignancy. Upper tract evaluation is useful to rule out ureterovaginal fistula or ureteral obstruction.

VAGINAL REPAIR OF SIMPLE VVF

The patient should be in the dorsal lithotomy position. A rectal pack helps the
surgeon to identify the rectum, especially if a peritoneal flap is incorporated into the
repair (See Figs. 1 to 5).

Figure 1. The fistula is dilated with sounds and an 8F Foley catheter is inserted through the tract. The catheter balloon is filled with 1
to 2 mL of water, and the catheter is used for traction. The vaginal
wall is filled with saline to aid the subsequent dissection. The fistula
is circumscribed and the incision is extended as an inverted J, with
the long arm of the J ending at the vaginal apex. (From Raz S:
Atlas of Transvaginal Surgery. Philadelphia, WB Saunders, 1992, p
147.)

VESICOVAGINAL FISTULA

Figure 2. Vaginal wall flaps are created by dissecting the


vaginal wall for 2 to 4 cm away from the incision proximally, distally, and laterally. The perivesical fascia is exposed, and the circumscribed fistula opening is left intact.
Excision of the tract risks enlarging the communication
between the bladder and vagina, as well as bleeding from
the edges of the fistula. By leaving the fistula in situ, the
vaginal flaps are created in healthy tissue, minimizing
bleeding and permitting a tension-free closure of the defect.

Figure 3. After removing the intrafistula catheter, the fistula


tract is closed transversely with interrupted 2-0 SAS. Sutures
are placed 2 to 3 mm from the edge of the fistula (in healthy
tissue), and incorporate the bladder wall and the epithelialized
tract.

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Figure 4. The second layer is closed in an imbricating fashion


with 2-0 SAS. This second layer lies perpendicular to the first
layer, thereby minimizing suture overlap. The sutures should enter the perivesical fascia and detrusor muscle 5 rnm from the
previous line of closure. This second layer inverts the prior line
of closure. The bladder should be filled with methylene blue or
indigo carmine solution to evaluate the integrity of the repair. In
cases of a high vesicovaginal fistula, we will harvest a peritoneal
flap to be placed over the first two layers of repair (described
below, see Fig. 7).

Figure 5. The distal vaginal flap is excised and the


proximal flap is advanced anteriorly 3 cm beyond the
fistula repair. This third layer is closed with runninglocking 2-0 SAS, covering the site with healthy vaginal
tissue, while avoiding suture line overlap.

VESICOVAGINAL FISTULA

POSTOPERATIVE CARE

The vagina is packed with antibiotic-impregnated gauze, which may be removed after several hours. The suprapubic and urethral catheters are joined to a Yconnector, and left in place for 10 days. An oral cephalosporin or fluoroquinolone is
continued until the catheters are discontinued, and cholinolytics are given to minimize bladder spasms. Before catheter removal, a voiding cystogram is performed to
evaluate the integrity of the repair. Sexual relations may resume after 12 weeks.

EARLY COMPLICATIONS

Early complications include vaginal bleeding, bladder spasms, and urinary or


vaginal infection. Intraoperative bleeding should be controlled with suture ligation,
minimizing electrocautery. Postoperative bleeding is usually controlled by vaginal
packing and bed rest. Bladder spasms can be treated with cholinolytics. Vaginal or
urinary infection should be treated with oral antibiotics.

LATE COMPLICATIONS

Late complications include vaginal stenosis and foreshortening, unrecognized


ureteral injury, and fistula recurrence. Vaginal shortening or stenosis usually results
from overaggressive resection of vaginal tissue during construction of the vaginal
wall flaps. Delayed recognition of a ureteral injury is best managed by percutaneous
drainage, with definitive surgical repair only after several months, so as not to
jeopardize the fistula repair. Recurrent fistula mandates reoperation. The second
repair is most efficacious when delayed for several months, until the inflammation
associated with the original surgery has completely subsided. Martius flap or peritoneal flap interposition is recommended for repair of recurrent vesicovaginal fistula.

HIGH-RISK FISTULAE

In cases of recurrent fistulae, radiation-induced fistulae, or ischemic (obstetric)


fistulae, and when the fistula is high in the vaginal vault or associated with poor
tissue quality (hypoestrogenic states), the interposition of another source of healthy
tissue is recommended. The most commonly interposed tissues are the Martius
fibrofatty labial graft and the peritoneal flap.

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MARTIUS GRAFT

See Figure 6.

Figure 6. Martius graft. A vertical incision is made in the labia


majora. Borders of dissection include the labiocrural fold laterally,
Colles fascia covering the urogenital diaphragm posteriorly, and
the bulbocavernosus muscle and labia minora medially. The
blood supply may be based inferiorly on the inferior labial artery,
or superiorly on the external pudendal artery. During mobilization
of the graft, the lateral blood supply (via the obturator artery) is
sacrificed, and either the superior or inferior blood supply must
be severed. A tunnel is created between the perivaginal tissue
and the vaginal wall at the site of the fistula repair, and the
fibrofatty flap is transferred to cover the fistula. The graft is then
secured in place with interrupted 2-0 SAS. The vaginal wall flap
is advanced over the Martius graft, and closed with runninglocking 2-0 SAS as described above. When the vagina is deep,
a Martius flap may not easily reach the area of repair without a
difficult and extensive dissection. The authors reserve the labial
fibrofatty flap for distal fistulae (trigone, bladder neck, or urethra).

VESICOVAGINAL FISTULA

PERITONEAL FLAP

See Figure 7

Figure 7. Peritoneal flap. Unlike the Martius graft, constructing a peritoneal flap does not require extra-vaginal
harvesting. After raising the vaginal wall flaps, the posterior flap is further dissected to the cul-de-sac. The preperitoneal fat and peritoneum are sharply mobilized in a caudal direction. After closing the initial two layers of the
fistula, the peritoneal flap is advanced over the suture line
and sewn in place with interrupted SAS. Finally the vaginal flap is placed over the peritoneal flap, and closed with
running-locking 2-0 SAS. Over the past several years the
authors have been using a peritoneal flap in all vesicovaginal fistula repairs, owing to the simplicity of the technique.

RESULTS

Using the aforementioned technique, with a median follow-up of 5 years (range


6 months-12 years), cure rate was 93% at our institution. Of note, 60% of the
women had failed a previous W F repair.
Address reprint requests to
Shlomo Raz, MD
Professor of Urology
924 Westwood Blvd
Suite 520
Los Angeles, CA 90024
e-mail:sraz@ucla.edu

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