Anatomic and functional results of transperitoneal-transvesical vesicovaginal fistula repair

Surgical outcomes of vesicovaginal fistulae in patients with previous pelvic radiotherapy

INTRODUCTION AND HYPOTHESIS

Vesicovaginal fistulae (VVF) repair success rates for simple surgical fistulae are high, but constitute a significantly greater challenge when occurring in a radiotherapy field. We aim to evaluate the causes, assessment, closure rates and functional outcomes of VVF surgery in patients with previous radiotherapy.

METHODS

Data on all VVF repairs were collected prospectively. A retrospective review of outcomes in those with VVF performed between 2009 and 2018 was carried out. Details including time from radiotherapy, pre-operative assessments, approach to surgery and functional outcome were analysed.

RESULTS

Twenty women with VVFs were identified. The mean age was 59 (range 25-88) years. Primary malignancy was cervical in 16 women, with the remaining 4 women having ovarian, urethral, endometrial and rectal cancer respectively. All women had external beam radiotherapy with 6 (30%) undergoing boosted brachytherapy. Mean interval between radiotherapy and fistula repair was 19 (range 0-40) years. Fistulae arose spontaneously in 14 patients, whereas 6 occurred following a further surgical intervention.Closure was attempted vaginally in 7 women and abdominally in 1, whereas 12 had a primary diversion owing to significant bladder contracture and ureteric involvement. The closure rate in those attempted was 62.5%, 40% in those with spontaneous fistulae compared with 100% for post-surgical fistulae, but only 20% for the total cohort.

CONCLUSIONS

Closure of VVF is a significant challenge, with an initial success rate of 20% and an overall success rate of only 25%. Seventy percent required primary or secondary urinary diversion. Vaginal surgery was utilised in the majority to try to avoid a hostile pelvis, but the surgical approach should be tailored to individual circumstances.

Urinary bladder organ hypertrophy is partially regulated by Akt1-mediated protein synthesis pathway

AIMS

The present study aims to investigate the role of Akt in the regulation of urinary bladder organ hypertrophy caused by partial bladder outlet obstruction (pBOO).

MAIN METHODS

Male rats were surgically induced for pBOO. Real-time PCR and western blot were used to examine the levels of mRNA and protein. A phosphoinositide 3-kinase (PI3K) inhibitor LY294002 was used to inhibit the activity of endogenous Akt.

KEY FINDINGS

The urinary bladder developed hypertrophy at 2 weeks of pBOO. The protein but not mRNA levels of type I collagen and α-smooth muscle actin (αSMA) were increased in pBOO bladder when compared to sham control. The phosphorylation (activation) levels of Akt1 (p-Ser⁴⁷³), mammalian target of rapamycin (mTOR), p70S6 kinase (p70S6K), and 4E-BP1 were also increased in pBOO bladder. LY294002 treatment reduced the phosphorylation levels of Akt1 and 4E-BP1, and the protein levels of type I collagen and αSMA in pBOO bladder. The mRNA and protein levels of proliferating cell nuclear antigen (PCNA) were increased in pBOO bladder, and PCNA up-regulation occurred in urothelial not muscular layer. LY294002 treatment had no effect on the mRNA and protein levels of PCNA in pBOO bladder. LY294002 treatment partially reduced the bladder weight caused by pBOO.

SIGNIFICANCE

pBOO-induced urinary bladder hypertrophy is attributable to fibrosis, smooth muscle cellular hypertrophy, and urothelium cell hyper-proliferation. Akt1-mediated protein synthesis in pBOO bladder contributes to type I collagen and αSMA but not PCNA up-regulation. Target of Akt1 is necessary but not sufficient in treatment of urinary bladder hypertrophy following pBOO.

The Aetiology, Treatment, and Outcome of Urogenital Fistulae Managed in Well- and Low-resourced Countries: A Systematic Review

CONTEXT

Urogenital fistula is a global healthcare problem, predominantly associated with obstetric complications in low-resourced countries and iatrogenic injury in well-resourced countries. Currently, the published evidence is of relatively low quality, mainly consisting retrospective case series.

OBJECTIVE

We evaluated the available evidence for aetiology, intervention, and outcomes of urogenital fistulae worldwide.

EVIDENCE ACQUISITION

We performed a systematic review of the PubMed and Scopus databases, classifying the evidence for fistula aetiology, repair techniques, and outcomes of surgery. Comparisons were made between fistulae treated in well-resourced countries and those in low-resourced countries.

EVIDENCE SYNTHESIS

Over a 35-yr period, 49 articles were identified using our search criteria, which were included in the qualitative analysis. In well-resourced countries, 1710/2055 (83.2%) of fistulae occurred following surgery, whereas in low-resourced countries, 9902/10398 (95.2%) were associated with childbirth. Spontaneous closure can occur in up to 15% of cases using catheter drainage and conservative approaches are more likely to be successful for nonradiotherapy fistulae. Of patients undergoing repairs in well-resourced countries, the median overall closure rate was 94.6%, while in low-resourced countries, this was 87.0%. Closure was significantly more likely to be achieved using a transvaginal approach then a transabdominal technique (90.8% success vs 83.9%, Fisher's exact test; p=0.0176).

CONCLUSIONS

It is difficult to conclude whether any specific route of surgery has advantage over any other, given the selection of patients to a particular procedure is based upon individual fistula characteristics. However, surgical repair should be carried out by experienced fistula surgeons, well versed in all techniques as the primary attempt at repair is likely to be the most successful.

PATIENT SUMMARY

Urogenital fistulae are a common problem worldwide; however, the available evidence on fistula management is poor in quality. We searched the current literature and identified that 95% of fistulae occur following childbirth in low-resourced countries, whereas 80% of fistulae are associated with surgery in well-resourced countries, where successful repair is also more likely to be achieved. The first attempt at repair is often the most successful and therefore fistula surgery should be centralised to hospitals with the most experience.

[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.

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.

Laparoscopic transabdominal transvesical repair of supratrigonal vesicovaginal fistula

INTRODUCTION AND HYPOTHESIS

We investigated the clinical efficacy of early laparoscopic repair of supratrigonal vesicovaginal fistula.

METHODS

Laparoscopic repair of vesicovaginal fistula was performed and retrospectively studied in 18 consecutive patients who had clear indications for iatrogenic supratrigonal vesicovaginal fistula following hysterectomy or obstetric trauma during delivery. All patients underwent laparoscopic surgery via the transabdominal transvesical route. Wide mobilization of the bladder and vaginal wall, complete excision of devitalized tissue, tension-free closure, omental interposition, and efficient postoperative bladder drainage provides dependable support for definitive closure of the path. Success was defined as the disappearance of the fistula.

RESULTS

Average patient age was 36.7 years; none required open conversion. Mean operative time was 135 (range 75-175) min. Mean duration of bladder catheterization was 15 (range 14-16) days. All patients were cured at the first attempt, with no surgical reintervention or recurrence at a mean follow-up of 22.7 (range 3-45) months.

CONCLUSIONS

We believe that laparoscopic repair of supratrigonal vesicovaginal fistula is an excellent alternative to the traditional abdominal approach and provides excellent results.

Large-conductance calcium-activated potassium channel activity, as determined by whole-cell patch clamp recording, is decreased in urinary bladder smooth muscle cells from male rats with partial urethral obstruction

OBJECTIVES

To examine the effect of partial urethral obstruction (PUO) on bladder smooth muscle outward potassium current and the contribution of the large-conductance calcium-activated potassium (Maxi-K, BKCa) channel to this activity in smooth muscle cells isolated from bladders of sham-operated and PUO male rats using whole-cell patch clamp recording techniques. To determine the effect of PUO on the expression of the Maxi-K channel α and β1 subunits and in vitro detrusor contractility.

MATERIALS AND METHODS

Twenty adult male Sprague-Dawley rats were divided equally into two groups and subjected to surgical ligation of the urethra (PUO) or sham surgery (SHAM). After 2 weeks, the detrusors from PUO and SHAM rats were used for molecular analyses (mRNA and protein quantification of Maxi-K subunits) or organ bath contractility studies, or myocytes were isolated for conventional whole-cell patch clamp analyses.

RESULTS

PUO increased bladder mass 2.5-fold and detrusor strips exhibited a more tonic-type contraction and increased contractility compared with controls (SHAM). Iberiotoxin (300 nM) sensitive Maxi-K channel current comprised about 40% of the outward whole-cell current in SHAM bladders but only about 8% in PUO bladders. Expression of the α subunit of the Maxi-K channel was significantly decreased ~40% while the expression of the β1 subunit was increased ~2-fold at the mRNA level. The increase in β1 expression was confirmed by Western blotting.

CONCLUSIONS

Our findings show that obstruction of the rat bladder is associated with decreased Maxi-K channel activity of bladder smooth muscle cells, determined via direct current measurement. Increased expression of the β1 subunit points to a compensatory reaction to decreased Maxi-K channel activity. Maxi-K channel openers or gene therapy may therefore provide therapeutic benefit for the overactive bladder.

Repair of vesicovaginal fistula: Single-centre experience and analysis of outcome predictors

Objectives

Data from 80 patients with a vesicovaginal fistula (VVF) were collected and analysed, to define the probable factors affecting the outcome of surgery.

Patients and methods

In a retrospective study, the records of 80 women with a mean (SD) age of 35.8 (9) year were assessed; 40% of the VVF occurred after abdominal hysterectomy, 30% after Caesarean section, 15% after difficult vaginal delivery and 11.25% after forceps vaginal delivery. Fifteen women (18%) had a previous failed repair. The median duration of the VVF was 11.5 months.

Results

Of the 80 VVF, 41 were high, 30 were low, four combined high and low and five were at the bladder neck. Nine cases had multiple openings on pan-endoscopy. An abdominal approach was used in 54 patients, vaginal in 20 and a combined approach in six. The median (SD) catheter duration was 14 (3.9) days. Ureteric stents were left in 59 patients. At a mean (SD) follow-up of 33.02 (65.7) months, the VVF was cured in 65 (81%) patients. Univariate analysis of variables possibly affecting the success of surgery showed that the duration of VVF, surgical approach, previous repair and position of the VVF were significant factors. Only previous intervention and surgical approach maintained significance in multivariate analysis.

Conclusion

An abdominal approach seems to give superior results. Previous failed repair had a significant negative effect on success. An earlier repair (<6 months) is associated with higher success rates.

Rho-kinase, a common final path of various contractile bladder and ureter stimuli

Normal urinary bladder function is based on the proper contraction and relaxation of smooth muscle (SM), which constitutes the majority of the bladder wall. The contraction and relaxation of all SM involves a phosphorylation-dephosphorylation pathway involving the enzymes smooth muscle myosin light chain kinase (SMMLCK) and smooth muscle myosin light chain phosphatase (SMMLCP), respectively. Although originally thought to function just as a passive opposition to SMMLCK-driven SM contraction, it is now clear that SMMLCP activity is under an extremely complex molecular regulation via which SMMLCP inhibition can induce "calcium sensitization." This review provides a thorough summary of the literature regarding the molecular regulation of the SMMLCP with a focus on one of its major inhibitory pathways that is RhoA/Rho-kinase (ROK) including its activation pathways, effector molecules, and its roles in various pathological conditions associated with bladder dysfunction. Newly emerging roles of ROK outside of SM contractility are also discussed. It is concluded that the RhoA/ROK pathway is critical for the maintenance of basal SM tone of the urinary bladder and serves as a common final pathway of various contractile stimuli in rabbits, rats, mice, and pigs as well as humans. In addition, this pathway is upregulated in response to a number of pathological conditions associated with bladder SM dysfunction. Similarly, RhoA/Rho-kinase signaling is essential for normal ureteral function and development and is upregulated in response to ureteral outlet obstruction. In addition to its critical role in bladder SM function, a role of ROK in the urothelium is also beginning to emerge as well as roles for ROK in bladder infection and invasion and metastasis of bladder cancer.

Experience of our surgery in iatrogenic vesicovaginal fistulas

OBJECTIVE

In this study, transvesical and transvaginal approaches used in our clinic for the treatment of gynecologic iatrogenic vesicovaginal fistulas are discussed.

MATERIAL AND METHODS

11 patients with vesicovaginal fistula admitted to the Department of Urogynecology, Zeynep Kamil Teaching- Research Hospital between 2005-2009 were enrolled in our study. Transvesical and transvaginal fistula repair were performed on all patients. All patients were treated by surgical repair, 4 cases by a classic transabdominal approach, 5 cases by an omental flap interposition and 2 cases by a martius flap interposition.

RESULTS

The most common cause of iatrogenic vesicovaginal fistula in our patients was total abdominal hysterectomy for benign conditions (n=10/11). The mean patient age was 43 years (34-53) and the mean time from the causative surgery to the operation was 7.5 months (3-12). The surgical techniques were successful in all patients. There were no intraoperative complications and no postoperative recurrences.

CONCLUSION

The mouth of the fistula should be determined clearly on preoperative evaluation and surgery procedure should be planned according to the fistula aperture. The point to be careful of is excision of all diseased tissue in the bladder and vagina, complete separation of the bladder from the vagina with a margin of healthy tissue, and watertight closure of both bladder and vagina without tension. The aim of the vascularized tissue interposition between the closed bladder and the vagina is to provide the improvement of vascularity. We believe that in the treatment of supratrigonal and large fistulas, the transvesical approach with use of omental flap interposition is more effective, while, in the treatment of small and trigonal fistula, the transvaginal approach with use of martius flap interposition is an effective tecnique.

Limited anterior cystotomy: a useful alternative to the vaginal approach for vesicovaginal fistula repair

In developed nations, vesicovaginal fistulas are most commonly encountered as a complication after gynecologic surgery. Most fistulas are corrected using a transvaginal approach; however, complicated cases often require intraabdominal repair. A novel abdominal approach is described, using a small anterior cystotomy and omental pedicle interposition.

A decade's experience with vesicovaginal fistula in India

A retrospective analysis of 252 cases of vesicovaginal fistulae was done to analyse its etio-pathology and management in an Indian population. After a thorough evaluation, different techniques of fistula closure were used for repair and the results were listed. The main outcome measures were the etiology of the fistula, need for tissue interposition and cure rate per repair as well as the overall cure rate. We compared our results with literature and concluded that simple and small fistulae should be repaired with layered closure. All complicated fistulae should be repaired with tissue interposition or tissue graft. This is the first study from India compiling 10 years of experience on vesicovaginal fistula.

Supratrigonal VVF Repair by Modified O’Connor’s Technique: An Experience of 26 Cases

OBJECTIVE

To report the technical modifications of O'Connor's procedure and their outcome in 26 supratrigonal vesico vaginal fistulae.

MATERIALS AND METHODS

Twenty-six cases of supratrigonal VVF (17 primary, 9 recurrent) were operated using the described modifications. It consisted of approaching the bladder transperitoneally, without dissecting the retropubic space, making a short sagittal or parasagittal cystotomy in between stay sutures, liberal use of bladder rotation flaps instead of midline closure, using single layer, continuous, closely placed, interlocking stitches for bladder as well as vaginal approximation and universal use of vascularised tissue interposition.

RESULTS

Mean fistula size was 2.8 cm (range 1.0 to 3.7). Mean operative time was 104 minutes, and blood loss was insignificant. Three patients required ureteroneocystostomy. All patients were dry after 2-3 weeks of suprapubic and per urethral catheter drainage. One patient persisted with stress urinary incontinence. No patient on follow up complained of features suggestive of prolonged ileus, peritonitis or adhesive intestinal obstruction.

CONCLUSION

Modified O'Connor's repair is safe and achieves excellent functional results. It requires a shorter cystotomy instead of bi-valving of the bladder, thus minimizes tissue trauma, intraoperative blood loss and operating time. It also gives option of tailoring the cystotomy in sagittal or parasagittal line, according to the site and size of the fistula, and thus permits closure of fistula by rotation of bladder flap into the defect without any lateral traction on the bladder edges. Retropubic dissection and drainage of the retropubic space is also not required.

Vesicovaginal fistula repair: transurethral suture cystorrhaphy as a minimally invasive alternative

Further experience and success in the transurethral repair of vesicovaginal fistula (VVF) prompted a review of our current technique and results. Patient selection criteria, instrumentation, technique, and potential pitfalls are discussed.