Guidelines of how to manage vesicovaginal fistula

Repair of complex vesicovaginal fistulas by combining a rotational bladder flap and full thick vascular peritoneal interposition

PURPOSE

To present the experience of repairing iatrogenic vesicovaginal fistulas (VVFs) using a rotational bladder flap and peritoneal interposition technique.

METHODS

Between January 2009 and June 2014, a total of 18 patients (mean age, 44.0 years; age range, 29-51 years) with VVFs were treated using a transperitoneal approach. All VVFs were complications of gynecologic procedures. Twelve patients experienced recurrent VVFs and one patient had a concomitant rectovaginal fistula after radiotherapy. The fistula was approached transabdominally. The peritoneum covering the bladder was isolated to expose the bladder and prepare for the interposition. The bladder was opened along the sagittal plane to the fistula and a bladder flap was rotated downward to fill the fistula defect. The vaginal defect was closed, then a flap using the isolated peritoneum was interposed and fixed between the vagina and bladder. A ureteral re-implantation was performed in one patient. All VVF procedures were performed by one urologist (SW). Repair of the rectovaginal fistula was performed by a general surgeon at the same time.

RESULTS

Seventeen patients (success rate = 94% [100% for primary cases and 92% for recurrent cases]) had no evidence of recurrent VVF at a mean follow-up of 20 months (range, 6-36 months). The only patient who had previously undergone a repair procedure failed.

CONCLUSIONS

A transperitoneal approach with the use of a rotational bladder flap and peritoneal interposition might be a feasible and reliable procedure for surgical management of iatrogenic VVFs, especially in complicated cases. Neurourol. Urodynam. 35:934-938, 2016. © 2015 Wiley Periodicals, Inc.

Surgical technique of a recurrent post-radiation vesicovaginal fistula with a small intestine graft

Vesicovaginal fistulas are devastating conditions for the affected women. The combination of a hysterectomy and radiation increases the fistula risk 5-10 times. Radiation-induced recurrent vesicovaginal fistulas have the lowest success rate and require the most demanding treatment. We present the case of a recurrent post-radiation vesicovaginal fistula treated with a small intestine graft after unsuccessful conservative and failed previous operative treatments. The surgical management with a small intestine graft led to a permanently closed fistula. We describe the surgical abdominal procedure step-wise and review the rather scarce, post-radiation fistula literature. The closure of a vesicovaginal fistula with a small intestine graft is a complex surgical treatment with a long-term, successful result.

[Repair of post-hysterectomy vesicovaginal fistulae: the state of the art]

In western countries, vesicovaginal fistulae (VVF) are mostly iatrogenic and in the majority of cases are secondary to hysterectomy. The golden standard for the treatment of VVF has remained largely unchanged since 1953 (Couvelaire): good visualization, good dissection, good approximation of the margins, and good urine drainage. However, several aspects are still being debated, including whether or not to pursue conservative repair, the timing for surgical repair, whether to perform excision of the fistula tract, the best type of surgical access, and whether or not to use tissue interposition. We decided to review the state of the art in the treatment of VVF, which are exclusively of a traumatic nature and non-radiated, by performing a bibliography search carried on Pubmed using keywords such as "vesicovaginal fistula". The search focused on recent articles and was largely restricted to the past 10 years.

Treatment of ureterovaginal fistula using a Memokath stent

Ureterovaginal fistula (UVF) is a challenging problem for patients and doctors, especially in patients who have been treated by radiation for malignancy. UVF may occur in conjunction with surgeries involving the uterus. A success rate of 70-100% has been reported for fistula repair with the best results in non-radiated patients. Meanwhile, conservative treatment using ureteral stents in selected patients has resulted in reported success rates of 71%. We present the case of a 24-year-old woman with UVF due to surgery and radiotherapy for cervix cancer. The patient has been successfully treated with the insertion of a Memokath 051 stent (PNN Medical A/S, Denmark), which is a thermoexpandable, nickel-titanium alloy stent. The patient has been totally continent during a follow-up period of 3 years. The Memokath stent has been changed twice within this period due to dysfunction.

Surgical Approach for Repair of Rectovaginal Fistula by Modified Martius Flap

Rectovaginal fistulas (RVF) are rare but represent a challenge for both patients and surgeons. The most common cause of RVF is obstetric trauma, and treatment is based on fistula classification and localization of the fistula in relation to the vagina and rectum. Conventional therapy frequently fails, making surgery the most viable approach for fistula repair. One surgical procedure which offers adequate repair of lower and middle rectovaginal fistulas consists of interposition of a bulbocavernosus fat flap also called modified Martius flap. First described by Heinrich Martius in 1928, this approach has been continuously modified and adjusted over time and is used in the repair of various pelvic floor disorders. Overall success rates reported in the literature of the interposition of a Martius flap as an adjunct procedure in the surgical management of RVF are 65-100 %. We present a detailed description of the operation technique together with a discussion of the use of a dorsal-flapped modified Martius flap in the treatment of RVF.

Sexual function after vaginal and abdominal fistula repair

OBJECTIVE

The purpose of this study was to compare clinical outcomes and sexual function between transvaginal and transabdominal repairs of vesicovaginal fistulae (VVF).

STUDY DESIGN

Participants (99 women with VVF at a tertiary referral center) were treated with urinary catheterization for 12 weeks and, if the procedure was unsuccessful, underwent repair using either the transvaginal (Latzko) or transabdominal technique. Objective clinical parameters were analyzed; subjective outcomes were recorded prospectively before surgery and at the 6-month follow-up examination with the use of the female sexual function index to evaluate sexual function and the visual analog scale to measure general disturbance by the fistula.

RESULTS

After bladder drainage for 12 weeks, 8 patients had spontaneous fistula closure. Demographic variables were similar in the transvaginal (n = 60) and transabdominal (n = 31) repair groups. The transvaginal procedure showed significantly shorter operation times, less blood loss, and shorter hospital stay. Continence rates 6 months after surgery were 82% (transvaginal) and 90% (transabdominal). Sexual function in the 64 sexually active patients was significantly improved, and overall disturbance by the fistula was reduced with both operative techniques. Neither surgical intervention was superior to the other regarding sexual function or visual analog scale.

CONCLUSION

Fistula repair improves sexual function and quality of life with no difference attributable to surgical route. Given this and that operating time, blood loss and length of stay are less with the transvaginal approach, the transvaginal approach is preferred in VVF repair if fistula and patient characteristics are suitable.

Robotic-assisted laparoscopic repair of a vesicovaginal fistula: a time-consuming novelty or an effective tool?

Vesicovaginal fistulas are a rare complication of hysterectomy. When conservative therapy fails, vaginal or abdominal repair is necessary. A robotic-assisted laparoscopic approach can be a useful tool to repair complex fistulas. A 50-year-old woman with a vesicovaginal fistula located at the top of the vagina, was treated with robotic-assisted laparoscopic repair. The fistula tissue was removed from the vaginal wall and bladder, and epiploic of the sigmoid was interposed in between. The total operation time was 104 min. The hospital stay was 3 days; no complications occurred. Cystography 6 weeks and 6 months postoperative confirmed a successful repair. A review of current literature is presented regarding the application of robotic assistance during this procedure. The presented case shows that robotic-assisted laparoscopic repair of a vesicovaginal fistula seems to be a feasible technique with promising results.

Impact of post-radiation biopsies on development of fistulae in patients with cervical cancer

OBJECTIVE

In the post-radiation patient, late vascular sequelae and fibrosis predispose women to poor tissue healing, such that small tissue injuries could theoretically evolve into much larger ones such as fistulae. We sought to determine if a correlation exists between invasive procedures such as post-treatment biopsies and the subsequent development of gynecologic fistulae.

METHODS

A retrospective review was performed evaluating all patients treated for cervical cancer at our institution between 1997 and 2010. Biopsies or pelvic surgeries were included if performed within the radiated field, and evaluated in a multivariate predictive model for development of gynecologic fistulae.

RESULTS

Out of 325 total patients, 27 patients with fistulae were identified (8.2%). 14 fistulae (51.9%) were considered toxicity-related, 6 (22.2%) resulted from primary disease, and 7 (25.9%) were attributable to recurrent disease. Eighty-nine patients underwent an invasive procedure (55 biopsies and 34 pelvic surgeries). Recurrent and/or residual cancer was found in 28 (31.5%) specimens, and of the 61 patients who underwent an invasive procedure and were not found to have evidence of recurrent disease, 9 (14.8%) subsequently developed a fistula at a median 3.08 months. An elevated dose of radiation to the rectum (OR 1.001 for dose >72 Gy, p=0.0005), advancing tumor stage (OR 5.38 for stage III, OR 10.47 for stage IV, p=0.0288), and a post-radiation biopsy (OR 5.27, p=0.013) were significantly associated with fistula development.

CONCLUSIONS

Performing a biopsy in an irradiated field is associated with a relatively low yield and significantly contributes to the risk for fistula development.

The outcomes of surgical repairs of vesicovaginal fistula in 16 patients

We retrospectively analysed 16 patients who underwent surgical repair for vesicovaginal fistula (VVF) in our department from 1995 to 2012. A total of 14 patients (88%) were cured after the primary repair and two patients were cured by reoperation. We compared the characteristics of the patients whose VVF occurred early and late after surgery. In univariate analysis, the estimated area of the fistula was significantly greater in the late-onset group (p = 0.011). There was a tendency for the maximum diameter of the fistula to be larger (p = 0.08) and a surgical energy device was used more frequently during surgery (p = 0.12) in the late-onset group than in the early-onset group. In conclusion, the outcomes of surgical VVF repair were acceptable. The characteristics of VVF that developed late postoperatively were different from those that developed early postoperatively.

Vesicovaginal fistula: diagnosis and management

Vesicovaginal fistula (VVF) is still a major cause for concern in many developing countries. It represents a significant morbidity in female urology. Continual wetness, odor, and discomfort cause serious social problems. The diagnosis of the condition has traditionally been based on clinical methods and dye testing. A successful repair of such fistulas requires an accurate diagnostic evaluation and timely repair using procedures that exploit basic surgical principles and the application of interposition flaps. The method of closure depends on the surgeon's training and experience. The main complication of VVF surgery is recurrent fistula formation.

Outcome of repeat supratrigonal obstetric vesicovaginal fistula repair after previous failed repair

INTRODUCTION

Currently, surgical repair for vesicovaginal fistula (VVF) provides excellent results, but the recurrent VVF is difficult to treat as compared to primary.

PATIENTS AND METHODS

Sixty-eight patients (44 primipara and 24 multipara) with recurrent VVF repair from January 2002 to December 2007 were included in present study. The mean size of fistula was 2.8 cm (1.0-6.5). The previous surgical repair was through the abdominal route in 50 patients (73.53%) and through the vaginal route in the remaining 18 patients (26.47%).

RESULTS

The procedure was successful in 62 of 68 patients (91.17%). The mean duration of surgery was 146.6 min (100-210). Mean blood loss was 160 ml (110-400) and mean hospital stay was 5.6 days (4-10). Eight patients developed complications.

CONCLUSION

Recurrent VVF is difficult to treat, but excellent results can still be achieved by strictly sticking to the principals of surgical repair for VVF.

[Treatment of urogenital fistula in women]

INTRODUCTION AND OBJECTIVES

We aimed to assess the results of the genitourinary fistula cases intervened in our center in a ten year period.

PATIENTS AND METHODS

We evaluated the clinical data regarding genitourinary fistula from the medical records of 42 female patients who underwent surgery for this condition between May 2001 and June 2010. Age, previous medical history, diagnostic tools used, operative data and clinical outcomes of the patients were evaluated retrospectively.

RESULTS

The mean age of patients was 51 years. Of 42 patients, 28 had vesicovaginal, 11 had ureterovaginal, and 3 had vesicouterine fistulas. Etiology of vesicovaginal fistula was surgical trauma in 71,5% and obstetric trauma in 28,5% of the patients. O'Connor technique was performed as a single procedure in 12 vesicovaginal fistula cases, and ureteroneocystostomy was added in 3. Transvesical repair was performed in 9, and transvaginal repair in 3 of the patients. All of 11 patients with ureterovaginal fistula were of iatrogenic origin; ureteroneocystostomy was performed in 6, and Boari flap was performed in 5 of these patients. Three vesicouterine fistulas were repaired primarily. Success rates in vesicovaginal, ureterovaginal and vesicouterine fistulas were 96, 100 and 100 percent, respectively.

CONCLUSION

In experienced hands and according with the related basic surgical principles, operative treatment in genitourinary fistula represents an effective modality with high success rate.

A modified surgical technique for treatment of radiation-induced vesicovaginal fistulas

OBJECTIVE

To present a modified surgical technique in the management of radiation-induced vesicovaginal fistulas. Radiation-induced vesicovaginal fistulas pose a great challenge to the treating surgeon owing to the fibrotic, poorly vascularized tissue in the area. Various techniques have been used to promote healing and prevent fistula recurrence, but most centers still recommend urinary diversion or more individualized management.

MATERIALS AND METHODS

We used the left rectus abdominis muscle based on the deep inferior epigastric vessels as an interposition flap in 3 patients presenting with vesicovaginal fistulas 19, 28, and 34 years after radiotherapy for cervical cancer. The fistulas were isolated using an abdominal approach, and the distal half of the left rectus abdominis muscle was mobilized. Without closure of the 2 defects, the muscle was then interposed between the bladder and vagina, where it was fixed using single sutures around the edges of the 2 defects. The operations were performed by a team that included both a urologist and a plastic surgeon.

RESULTS

All 3 patients underwent successful treatment. With a follow-up of 5-8 years, there has been no recurrence of symptoms.

CONCLUSION

This modified surgical technique offers well-vascularized, nonirradiated tissue to be used as an interposition flap based on the inferior epigastric vessels in the management of radiation-induced vesicovaginal fistulas. The technique allows obstruction of the fistula without the need for closure of the mucosal defects in the bladder and vagina.

Vaginal repair of supratrigonal vesicovaginal fistulae--a 10-year review

INTRODUCTION AND HYPOTHESIS

A 10-year retrospective study was done to determine the outcome of vaginal repair for supratrigonal vesicovaginal fistulae (VVF).

METHODS

One hundred thirty-two urinary fistulae were managed from 2001 to 2011 which include 34 ureterovaginal and 98 lower urinary tract fistulae. Fifty-three out of 98 were supratrigonal VVF, 49 were of benign etiology and 4 were malignancy induced. Further analysis of 49 supratrigonal VVF of benign etiology revealed that 38 (77.5%) were of gynecological origin and 11 (22.5%) obstetric. Forty-three were primary and six were recurrent VVF. Thirty (61.2%) supratrigonal VVF were repaired vaginally and 19 (38.8 %) abdominally. Mean follow-up period was 51.7 months.

RESULTS

The successful outcome for vaginal and abdominal repair was 86.7% and 100%, respectively (p value = 0.26). Overall, 91.8% supratrigonal VVF were cured at our first attempt.

CONCLUSIONS

Majority of supratrigonal VVF can be approached vaginally with success rate comparable to abdominal approach.

Retroperitoneoscopic ureterocutaneostomy as a method of urinary diversion in case of complicated urinary fistula after radiotherapy

The case of 71-year-old woman with massive vesicovaginal and recto-vaginal fistula after radiotherapy treated with bilateral laparoscopic ureterocutaneostomy is presented. A retroperitoneoscopic access was applied. The technical aspects of the procedure are described. The interdisciplinary character of this not so rare problem is underlined. In our opinion this kind of procedure may be considered as a valuable alternative for commonly used methods of urine deviation.

Urogenital fistulae: A prospective study of 50 cases at a tertiary care hospital

Introduction:

The misfortunate incident of formation of a urogenital fistula remains a major challenge for surgical urologists worldwide. Such fistulae may not be a life-threatening problem, but surely the women face demoralization, social boycott and even divorce and separation. The fistula may be vaginal, recto-vaginal or a combination of the two. The World Health Organization (WHO) has estimated that in the developing nations, nearly 5 million women annually suffer severe morbidity with obstetric fistulae being the foremost on the list. The objective of our study was to enunciate the patient demography, patient profile, incidence, type of surgery, as well as the long-term outcomes encountered in the management of all types of genital fistulae at a tertiary care centre.

Materials and Methods:

50 consecutive patients, attending the outpatient department with urogenital fistulae, were studied during the period of 5 years from July 2005 to July 2009. All female patients with complaints of urinary incontinence and fecal incontinence and dribbling, patients having a history of obstructed labor, radiotherapy, instrumental delivery, foreign body or trauma and with a history of hysterectomy (abdominal/ vaginal) and lower segment caesarean section (LSCS) were included. A thorough urological examination included a dye study using methylene blue, Renal function tests, X-ray KUB and intravenous urography (IVU). Cystoscopy along with examination under anaesthesia (EUA) were done to assess the actual extent of injury. All patients were subjected to appropriate surgical interventions via the same combination of surgeons . Post operatively, prophylactic antibiotics were administered to all patients and patients were managed till discharge and followed thereafter via regular outpatient visits for a period of 3 years.

Results:

Age of patients ranged from 21 to 40 years. 64% patients hailed from rural areas, 76% were from the lower socio-economic strata, 40% illiterate and 69% were short Statured. Vesico vaginal fistulae (VVF) was seen in 64% cases of which 50% were due to obstructed labor, 19% cases post LSCS and 31% cases post total abdominal hysterectomy (TAH). 68% of urogenital fistulae were between 1 to 3 cms. We obtained a 75% cure rate in UVF, 87.5% cure rate in RVF while a 93.75% cure rate was observed in patients with VVF. 76% of all patients were cured while 8% had a recurrence, probably due to the large size of fistula.

Conclusion:

Genital fistula is preventable, yet it remains a significant cause of morbidity among females of reproductive age group. Despite facilities available, certain conditions like physical, social, economic, illiteracy, and a very casual attitude towards maternal health and children birth practices limit utilization of services for women. It is important that the modern health care providers should be aware of these aspects, so that they can recognize services that are appropriate and acceptable to the people. Thus, one must agree that in cases of urogenital fistulae, "prevention is better than cure".

Treatment of malignant enterovesical fistula with octreotide

Surgical treatment for internal fistula is rarely indicated for terminally ill patients with cancer because of their poor prognoses. Reports of surgical or pharmacologic treatment of vesicoenteric fistula in terminally ill patients with cancer are rare. A 73-year-old woman with rectal cancer that had directly invaded the bladder and metastasized to the liver was admitted to our hospital with high fever and severe perineal pain. Retrograde urography indicated an enterovesical fistula. Although the urinary tract infection was treatable with antibiotics, frequent episodic pain, due to urethritis secondary to the fistula, was not alleviated with opioid and topical treatment. Three days after starting octreotide 0.3 mg/d, the severe pain was alleviated, and follow-up retrograde urography revealed closure of the fistula. This suggests that treatment with octreotide may have enabled closure of the fistula. Thus, octreotide should be considered a viable therapeutic option in terminally ill patients with inoperable internal fistula.

Comparative analysis of outcome between open and robotic surgical repair of recurrent supra-trigonal vesico-vaginal fistula

INTRODUCTION

Recurrence of fistula is one of the very common complications of fistula repair. The disease has immense psychosomatic effect on the patients due to continuous leakage of urine. Management of recurrent vesico-vaginal fistula (VVF) repair poses a challenge to surgeons.

MATERIALS AND METHODS

Group I-12 patients with recurrent VVF, having robotic repair from August 2006 to June 2008, were included in the present study. Group II-20 patients matched in all possible parameters with recurrent VVF having open surgical repair in the past were taken as controls. Patients in both the groups were evaluated by assessing relevant clinical details; performing urine routine examination and culture, renal function test, three swab test, ultrasonogram-kidney, ureter, and bladder radiograph, intravenous urogram (to look for upper tract and rule out uretero-vaginal fistula), and urethro-cystoscopy. The details were retrospectively recorded from the case sheets.

RESULTS

In group I, 100% were successfully managed as compared with 90% in group II, but it was not statistically significant (p > 0.05). Mean blood loss was significantly less (p < 0.05) in group I compared with group II (mean 88 vs. 170 mL). The mean hospital stay also was significantly less (p < 0.05) in group I in comparison with group II (mean 3.1 vs. 5.6 days). None of the patients had complications in group I compared with group II, but it was not significant.

CONCLUSION

The present study suggests that robotic VVF repair is a better option for recurrent fistulas in view of its reduced morbidity, without compromising the results.

Vesico-vaginal fistula post cold cup bladder biopsy: mini review

Introduction

We report a case of a vesico-vaginal fistula (VVF) post cold cup biopsy; to our knowledge this is the only reported case. We present the clinical history/presentation, investigation and the outcome of the treatment. VVFs are among the most distressing complications of gynecologic and obstetric procedures. The risk of developing a VVF is more than 1% after radical surgery and radiotherapy for malignancies. Management of these fistulas has been better defined and standardized over the last decade.

Methods and results

A case of low grade superficial bladder cancer was treated with multiple resections of bladder tumor and a single installation of mitomycin post initial resection which successfully cleared her bladder cancer, but nevertheless led to a small size and scarred bladder. In addition there was a long history of smoking with its effects on tissue integrity and healing. VVFs are very rare and are an unpleasant outcome post a cold cup biopsy, adding to the psychological and social effects of the surgical treatment.

Conclusion

Although cold cup biopsy is a normal day procedure performed by both residents and consultants, consensus should exist on how to treat a patient who has a bladder with defective integrity and small capacity. The rate of successful fistula repair reported in the literature varies between 70% and 100% in nonradiated patients, with similar results when a vaginal or abdominal approach is performed, the mean success rates being 91% and 97%, respectively.

Fistulas in malignant gynecologic disease: etiology, imaging, and management

A fistula that occurs in association with a malignancy of the female reproductive tract may be caused by a primary or recurrent tumor or may be a complication of surgery or radiation therapy. Identification of the cause, complexity, and location of a fistula is essential for optimal management planning. Radiologic imaging, particularly with computed tomography and magnetic resonance techniques, is invaluable for the assessment of gynecologic fistulas and may help direct the clinician toward the most appropriate management pathway. The modality and technique selected for the initial imaging evaluation depend largely on the clinical history and manifestations. However, imaging with a combination of techniques often is required for accurate diagnosis and effective treatment planning. Radiologists should be familiar with suggestive clinical signs and symptoms as well as with the characteristic appearances of rectovaginal, vesicovaginal, ureterovaginal, enterovesical, enterocutaneous, and other pelvic fistulas at multimodality imaging.

Obstetric fistulas: A clinical review

A high proportion of genitourinary fistulas have an obstetric origin. Obstetric fistulas are caused by prolonged obstructed labor coupled with a lack of medical attention. While successful management with prolonged bladder drainage has occasionally been reported, mature fistulas require formal operative repair, and it is crucial that the first repair is done properly. The literature reports 3 approaches to fistula repair: vaginal, abdominal, and combined vaginal and abdominal. Many authors report high success rates for the surgical closure of obstetric fistulas at the time of hospital discharge, without further evaluation of the repair's effect on urinary continence or subsequent quality of life. Data on obstetric fistulas are scarce, and thus many questions regarding fistula management remain unanswered. A standardized terminology and classification, as well as a data reporting system on the surgical management of obstetric fistulas and its outcomes, are critical steps that need to be taken immediately.

Complex obstetric fistulas

Obstetric fistulas are rarely simple. Most patients in sub-Saharan Africa and parts of Asia are carriers of complex fistulas or complicated fistulas requiring expert skills for evaluation and management. A fistula is predictably complex when it is greater than 4 cm and involves the continence mechanism (the urethra is partially absent, the bladder capacity is reduced, or both); is associated with moderately severe scarring of the trigone and urethrovesical junction; and/or has multiple openings. A fistula is even more complicated when it is more than 6 cm in its largest dimension, particularly when it is associated with severe scarring and the absence of the urethra, and/or when it is combined with a recto-vaginal fistula. The present article reviews the evaluation methods and main surgical techniques used in the management of complex fistulas. The severity of the neurovascular alterations associated with these lesions, as well as inescapable limitations in staff, health facilities, and supplies, make their optimal management very challenging.

Juxtacervical vesicovaginal fistulae: outcome by route of repair

Vesicovaginal fistula is a major public health problem in Nigeria with diverse medical, psychological and social consequences for the patient. This study compared the outcome of vaginal vs abdominal repair of juxtacervical vesicovaginal fistulae. It was a retrospective review undertaken at the University of Nigeria Teaching Hospital, Aghaeze Hospital and Mbanefo Hospital, all in Enugu, Nigeria, from 1 January 1992 to 31 December 2004. The outcome measures were primary repair success rate, blood transfusion, postoperative urinary tract infection rate and duration of hospital stay. Abdominal repair of juxtacervical vesicovaginal fistula was associated with a significantly higher need for blood transfusion when compared with vaginal repair. Both routes of repair had similar primary repair success rates, postoperative urinary tract infection rates and duration of hospital stay. It was concluded that the route of repair of juxtacervical vesicovaginal fistula should be determined by accessibility of the fistula and whenever possible, the vaginal route should be preferred.

Delineating the anatomy of oncologic postradiation vesicovaginal fistulae with reconstructed computed tomography

The key diagnosis and treating of vesicovaginal fistulae is accurate imaging. We illustrate the latest use of enhanced computed tomography for such cases.

Spontaneous closure of vesicovaginal fistulas after bladder drainage alone: review of the evidence

A vesicovaginal fistula may occur as a surgical complication, the result of obstructed labor, or a late manifestation of radiotherapy. Surgical treatment includes many routes and techniques, with a success rate reaching 100%. The spontaneous closure of vesicovaginal fistulae following [corrected] bladder drainage alone for varying periods has been reported by many. The factors favoring the success of this conservative method have not been well examined [corrected] In this investigation [corrected] all articles referring [corrected] to this modality were reviewed [corrected] The parameters studied included etiology, size, interval from [corrected] causative insult to drainage, and duration of drainage. The incidence of spontaneous closure of fistulae [corrected] after bladder drainage alone ranged between [corrected] 0 and 100%. Among all assessed criteria, the interval to drainage seems to have the best correlation with success. This finding [corrected] is most likely explained on the basis of the epithelialization of the fistulous tract with time, preventing spontaneous healing. In the view of the retrospective nature of the reviewed articles, the absence of a detailed classification system, and the heterogeneity of the treatment in question, no solid conclusion regarding management recommendations can be drawn.

Bulbocavernosus muscle flap in the repair of complicated vesicovaginal fistula

AIM

To investigate the transposition of the bulbocavernosus muscle flap for repairing complicated vesicovaginal fistulas.

METHODS

Vesicovaginal fistulas were repaired via combined abdominal and perineal approaches. Through an abdominal approach, the fistula and surrounding scar tissue were excised thoroughly. A perineal incision was made between the orifices of the urethra and the vagina, dissecting until the fistula. The vaginal defect was closed through either the abdominal or the perineal approach depending upon its position. Through the abdominal approach, the bladder defect was closed in two layers with the suture lines vertical to each other. The bulbocavernosus muscle was freed through an incision between the labium majus pudendi and the labium minus pudenda, without damaging the pudendal vascular supply. The bulbocavernosus muscle flap was tunneled beneath the labium minus pudendi, and was sutured in place on the bladder wall over the fistula repair site.

RESULTS

Nine patients with complicated vesicovaginal fistulas were treated using this technique. After surgery, no symptoms of vagina leakage, urinary incontinence, or urethral stricture were reported by any of the patients, and they reported normal sexual function.

CONCLUSIONS

Transposition of the bulbocavernosus muscle flap is an excellent technique with low morbidity and high success rate for repairing complicated vesicovaginal fistulas.