Vesicovaginal fistula is an anomalous communication between the bladder and vagina, resulting in continuous urine leakage through the vagina. This condition occurs most commonly after obstetrical and gynecological injury. In the developed world, the most common cause of vesicovaginal fistula is gynecological surgery. In North America, bladder injury during a hysterectomy is the most common cause.[rx][rx]
In developing countries, obstructed labor with resulting pressure necrosis is the most common cause of vesicovaginal fistulas. The diagnostic workup should be comprehensive as the majority of vesicovaginal fistula require definitive surgical management. Timing, approach, graft usage, postoperative management, and surgical expertise must be optimized when exercised for successful management. The primary complication of vesicovaginal fistula surgery is recurrent fistula formation.[rx]
Types of Vesicovaginal Fistula
VVF, mainly obstetric, is often classified by two systems, namely the Goh and the Waaldijk classification systems. The Waaldijk Classification takes into account the
- (1) involvement of the closure mechanism,
- (2) involvement of the external urethral meatus, and
- (3) the extent of the defect.
The Goh Classification considers the
- (1) distance between the distal edge of the fistula to the external urethral meatus,
- (2) the extent of fibrosis of the fistula site, and
- (3) size of the fistula tract. Capes et al. have demonstrated that the prediction of successful fistula repair was significantly better with the Goh Classification than with the Waaldijk Classification.[rx]
VVF can also be classified as either simple or complex. Any fistula which is solitary and is ≤0.5 cm in size in a nonirradiated and nonmalignant situation is termed as a simple fistula. Fistulas that are large in size (≥2.5 cm), multiple, have a history of failed previous fistula repair, are associated with chronic infection and disease, are post-radiation-induced, or are associated with malignancy are termed as complex fistulas.[rx]
Clinically, VVF can be classified as follows:[rx,rx]
- Based on the site of the fistula on cystoscopy – Supratrigonal, trigonal, and infratrigonal (bladder neck)
- Based on the etiology of fistula – Congenital and acquired. Acquired VVF could be of the following types: Benign, malignant, traumatic, inflammatory or infective, and miscellaneous types
- Based on the involvement of continent mechanism – (i) Type 1 – not involving the closing mechanism; (ii) Type 2 – involving the closing mechanism: (a) not involving total urethra (b) Involving total urethra; and (iii) Type 3 – miscellaneous, for example, ureteric fistula
- Based on the size of VVF – small <2 cm, medium 2–3 cm, large 4–5 cm, and extensive >6 cm and
- Based on the clinical examination – vesicocervical, juxtacervical, mid-vaginal vesicovaginal, suburethral vesicovaginal, and urethro-vaginal.[rx]
The various classification methods help in management decision-making, adjunct treatment, and follow-up methods. However, they do not predict overall success rates and other outcomes.[rx]
Causes of Vesicovaginal Fistula
The etiology for this condition varies and can be categorized into congenital or acquired. Acquired vesicovaginal fistula can be further divided into obstetric surgical, malignant, radiation, and miscellaneous categories. Congenital vesicovaginal fistula is very rare and typically associated with other urogenital malformations. Vesicovaginal fistula occurs most commonly after obstetrical and gynecological injury. In the developed world, the most common cause of vesicovaginal fistula is gynecological surgery. In North America, bladder injury during a hysterectomy is the most common cause. In developing countries, obstructed labor and the resulting pressure necrosis is the most common cause of vesicovaginal fistulas. Poor socioeconomic status, malnourishment, low literacy rate, early marriage and childbearing, and inadequate obstetrical care are important risk factors for developing a vesicovaginal fistula in the developing world.[rx]
Miscellaneous acquired causes of this condition include retroperitoneal, vascular or pelvic surgery, urologic or gynecologic instrumentation, infectious and inflammatory diseases, sexual trauma, vaginal laser procedures, external violence, and vaginal foreign bodies.[rx]
Etiology of vesicovaginal fistula
| •Traumatic |
| •Postsurgical |
| •Abdominal hysterectomy |
| •Vaginal hysterectomy |
| • anti-incontinence surgery |
| • Anterior vaginal wall prolapse surgery (e.g., colporrhaphy) |
| • Vaginal biopsy |
| • Bladder biopsy/endoscopic resection/laser |
| • Other pelvic surgery (e.g., vascular, rectal) |
| • External trauma (e.g., penetrating, pelvic fracture, sexual) |
| • Radiation therapy |
| • Advanced pelvic malignancy |
| •Infectious/inflammatory |
| •Foreign body |
| •Obstetric |
| • Obstructed labor |
| •Forceps laceration |
| •Uterine rupture |
| •Caesarean section injury to the bladder |
| •Congenital |
Vaginal Fistula Symptoms
A vaginal fistula doesn’t usually hurt, but it can cause some problems that need medical care. If you have a vesicovaginal fistula (an opening between your vagina and bladder), urine will constantly leak from your bladder into your vagina. This can make you unable to control your urination (incontinent).
Also, your genital area may get infected or sore, and you can have pain during intercourse.
Other symptoms of vaginal fistulas include:
- Fever
- Belly pain
- Diarrhea
- Weight loss
- Nausea
- Vomiting
Diagnosis of Vesicovaginal Fistula
The classic clinical presentation of a patient with a vesicovaginal fistula is continuous urinary incontinence after recent pelvic surgery. The severity of symptomology and timing of presentation is variable.
Postoperative patients with a vesicovaginal fistula are usually easily diagnosed by the complaint of urine leaking through the vagina 7 to 12 days after gynecological or pelvic surgery. The timing of symptomology is likely related to tissue necrosis following obstructed prolonged labor or tissue strangulation by sutures placed during pelvic surgery.
- Tampon dye test – This test involves inserting a regular tampon or gauze in the vagina, then back-filling the bladder with dilute methylene blue and having the patient ambulate – this can be performed shortly after filling the bladder, and a prolonged period of ambulation is not required as long as the bladder was sufficiently full with 200-300 mL of fluid. It is preferable to place the gauze or tampon prior to back-filling the bladder to avoid contaminating the gauze with dye during insertion. The tampon or gauze is then removed and inspected; if there is blue dye noted on the gauze near the apex, a vesicovaginal fistula is confirmed. If the dye is only noted on the distal tampon, this may represent spillage of the dye during filling or other forms of urinary incontinence.[rx]
- Office cystoscopy – and contrast studies, such as computed tomography (CT) urogram, are generally used to aid in the diagnosis of additional injuries (such as a concomitant urethral injury or fistula) and for surgical planning.
- Methylene blue dye test – a “double-dye” test is also generally performed. This is accomplished by having the patient take oral phenazopyridine just prior to coming into the office.[rx] A tampon or gauze is inserted into the vagina. Once the bladder is sufficiently full (indicated by an urge to urinate), the tampon is removed and inspected for orange-staining, and, if present, a genitourinary tract fistula is diagnosed. This could encompass a ureterovaginal or vesicovaginal fistula. The bladder is then back-filled with dilute methylene blue, as described above. If there are only orange-staining and no blue-staining of the tampon, a ureterovaginal fistula is most likely. If there is both orange and blue staining on the gauze then, a vesicovaginal fistula is likely but a concomitant uterovaginal fistula cannot be entirely excluded. This can be further confirmed with imaging. Transvaginal ultrasonography, cystoscopy, and contrast studies may be utilized.
- Transvaginal ultrasonography – may clearly visualize the exact size, site, and course of the fistula. Transvaginal sonographic evaluation is well-tolerated with a low side-effect profile and more instructive than some other conventional investigations.[rx] However, sonographic findings are dependent on operator skill and experience and are infrequently used in the evaluation of fistulas.
- Cystoscopy – is of particular help and can be used to identify the exact location of the fistula tract in the bladder. A small ureteric catheter or pediatric foley catheter can be passed through a suspected fistula tract to determine if and where it enters the vagina. Vaginoscopy can be performed in the office using the cystoscope and may aid in the localization of the fistula opening on the vaginal side. It is easily performed in the office and is well tolerated by most patients.[rx]
- Multiphasic CT urogram – is recommended before proceeding with surgical repair to identify concomitant ureteral fistulas or abnormalities. More invasive and advanced techniques are generally not required but may include endoanal ultrasound or subtraction magnetic resonance epistolography.[rx] Simple vesicovaginal fistulas are singular, small in size (<0.5 cm), and found in non-radiated patients with no evidence of malignancy involvement. A vesicovaginal fistula is considered intermediate in size if measured at 0.5-2.5 cm. Complex vesicovaginal fistulas are large in size (>2.5 cm), associated with chronic disease, post-radiation, or failed previous fistula repair.[rx]
Treatment of Vesicovaginal Fistula
For small, early-detected, and non-malignant vesicovaginal fistulas, conservative management can be pursued to help in the spontaneous closure of the defect. Conservative management includes transurethral foley catheter placement for 2 to 8 weeks along with anticholinergic medication if needed for symptom control. If a simple vesicovaginal fistula is diagnosed later in pathogenesis, electrocoagulation of the mucosal layer followed by transurethral catheter placement for 2 to 4 weeks could help in the closure of the defect.[rx] Fulguration can be performed either cystoscopically or vaginally. Fibrin glue has also been described with varying results.[rx]
If conservative management fails, surgical intervention should be considered. A successful surgical intervention requires an accurate diagnosis, appropriate timing, and properly executed basic surgical principles. The surgeon’s training and expertise, as well as the type and location of the fistula, will determine the method of repair.[rx]
The best chance of a successful vesicovaginal repair is at the first surgical attempt. Definitive surgical repair can be complex, requiring interposition grafts from abdominal or vaginal repair approaches. If feasible, the vaginal approach is preferred and has high success rates. Complex vesicovaginal fistulas (related to pelvic irradiation) or recurrent fistulas may require the interposition of highly-vascularized tissue for a chance at successful repair.
Postoperatively, the bladder should be continuously drained via a transurethral Foley catheter. When the vesicovaginal fistula involves the bladder neck, the catheter should be sutured in place and the balloon left deflated. Alternatively, a suprapubic catheter can be placed to avoid pressure from the inflated catheter balloon on the repair. The catheter should remain in place for two to three weeks following surgical repair. Cystography is often performed before catheter removal to determine the integrity of the repair. However, if this is not available, back-filling to the bladder to evaluate for vaginal leakage or an office cystoscopy are alternative options. Again, anticholinergics may be administered to manage catheter-associated irritative bladder symptoms. Prophylactic antibiotic coverage is not required while the indwelling catheter is in place. Pelvic rest for 6-8 weeks postoperatively is recommended.[rx]
Conservative methods – Newer trends
Conservative management of VVF has been followed for years. Various methods have been detailed that allow for a fistula to heal.
Continuous bladder drainage (CBD), catheterization with fulguration of the fistula tract, glue injection, injection of platelet-rich plasma (PRP), and administration of anticholinergics have been practiced with varied success rates. In intractable and recurrent VVF cases, methods such as percutaneous nephrostomy (PCN), PCN with bilateral ureteric occlusion, isobutyl-2-cyanoacrylate injection, balloons (detachable or nondetachable), nylon plugs, coils, gelatin sponges, and fulguration have been used. CBD is advised immediately after documenting leakage of urine from vagina either as a result of an obstetric complication or following surgical intervention.
Conservative management with CBD is useful if:
- (1) the urine leakage decreases with indwelling catheter CBD,
- (2) the fistula onset is <3 weeks,
- (3) the fistula tract is long and narrow, and
- (4) the size of the fistula <1 cm.[rx] Similarly, conservative management should not be advocated in complicated VVF when (1) the size of the fistula is >3 cm, (2) the fistula is secondary to radiation-induced damage to the urogenital tract, (3) there is extensive scarring around the fistula, and (4) the onset of the fistula >6 weeks.[rx,rx] The overall success rate of CBD alone ranges between 3%–32%.[rx] If the size of the fistula is <5 mm and the patient became dry after catheter placement, the chance of healing with CBD is high.[rx]
Fulguration of the fistula tract
Fulguration is performed when the fistula is small in size, recent in onset, has a long and narrow track, and fibrosis is absent. The lining epithelial layer of the fistula tract is fulgurated with electrocautery, with an intention to facilitate fibrosis. Stotsky et al. have reported a success rate of 73% with electrofulguration along with 2 weeks of CBD in patients with small fistulas (≤3.5 mm size).[rx]
Fibrin glue injection
Fibrin glue is used as an adjunct to VVF repair. The glue is injected transvaginally under cystoscopic guidance after electrofulguration of the fistulous tract. CBD is followed for about 1–4 weeks duration, and the fibrin glue helps to promote fibrosis.[rx] Fibrin glue could also be used as an interposition agent. It can act as a substitute to the more invasive method of harvesting a local flap.[rx] Morita and Tokue have reported endoscopic closure of radiation-induced VVF using the fibrin glue.[rx] Fibrin glue is also used as an adjunct during the robotic VVF repair.[rx]
Injection of platelet-rich plasma
PRP is injected around the fistula creating a mound,-similar to that created by injecting reflux in cases of vesicoureteral reflux, which occludes the fistula mechanically, meanwhile, the growth factors derived from platelets stimulate fibrosis and neovascularization. Shirvan et al. have successfully treated 11 of the 12 patients (92%) of iatrogenic VVF with perifistulous injection of PRP along with abrasion and fibrin glue injection in the fistula tract.[rx]
Bilateral percutaneous nephrostomies and ureteric occlusion
Percutaneous nephrostomies are often performed as a palliative procedure in patients with malignant VVF, poor performance status, and limited life span due to the advanced stage of the disease.[rx] Permanent nature of the PCNs should be explained and the patient’s willingness to remain on nephrostomy tubes in situ should be taken into account. Smaller fistulas may heal with PCNs. For larger fistulae, PCNs alone are insufficient to make the patient dry, and percutaneous ureteric occlusion is required as an adjunct. Isobutyl-2-cyanoacrylate, balloons (detachable or nondetachable), nylon plugs, coils, vascular plugs, and gelatin sponges are used for bilateral ureteral occlusion along with PCNs.[rx] Percutaneous ureterostomy and ureteral clipping are rarely performed and isolated success of these procedures has not been assessed in any of the reported series.
Certain basic principles of VVF repair have to be followed to get successful outcomes. These principles apply to all the methods of repair performed by any route.[rx] They are summarized.
Timing of Surgery – Early or late?
The timing of VVF repair is influenced by multiple factors. Most surgeons would prefer to repair the VVF when there is no active inflammation, infection, and necrosis. Whereas, others advocated to intervene as soon as the VVF is diagnosed and have achieved similar results.[rx] Usually, the repair is performed at 12 weeks duration after the diagnosis. Timing of the repair is influenced by factors such as:
- (1) nature of injury leading to fistula,
- (2) nutritional status of the patient,
- (3) presence of infection and foreign bodies, and
- (4) immunocompromised status.[rx] The first attempt is the best attempt and has the highest probability of achieving a successful outcome after VVF repair. Hence, choosing the ideal time for repair is of paramount importance. Women with VVF, while waiting for surgical repair, would go through an anxious depressive state. thus emotional and psychological support from the treating physician and the family is much needed.
For post-obstetric fistula
Delaying the repair of an obstetric fistula ensures that the necrotic tissue would slough out and the inflammation would subside. If the fistula is simple and has no evidence of infection, an early repair can be performed. However, contemplating the repair in the settings of unresolved necrosis, and infection is very challenging.[rx]
For postsurgical vesicovaginal fistula
The twelve weeks rule holds good for postsurgical VVFs too.[rx] This time frame allows for inflammatory changes to subside and the necrotic tissues to get delineated. Exceptions to this rule are: (1) VVF confirmed within few days of primary causative surgery, (2) associated concomitant ureteric injury requiring intervention, and (3) patient’s desire or compulsion on the surgeon.
For radiation-induced vesicovaginal fistula
Early surgery should be avoided if the acute post-radiation tissue response is progressing. Radiation-induced reaction heals in about a year. Delayed repair after 6 months is often followed.[rx]
Surgical approach-transabdominal versus transvaginal
The choice of surgical approach depends on the familiarity of the approach by the surgeon, location of the fistula, available space in the vaginal cavity, need for ancillary procedures such as ureteric reimplantation, and the feasibility of obtaining necessary interposition flaps. Hillary et al. showed that the success rate was much higher for the transvaginal repair (90.8%) when compared to the transabdominal repair (83.9%).[rx] Kapoor et al. in their series, have preferred the transvaginal route for simple fistulae and the transabdominal route for complex fistulae and achieved successful outcomes in most of the VVFs repaired transvaginally.[rx,rx] There are certain situations where a specific surgical approach may be preferred.
The vaginal route has certain specific advantages[rx]:
- (1) avoids abdominal and bladder incisions,
- (2) lesser blood loss,
- (3) options of interposition flaps are plenty,
- (4) shorter operative time, and
- (5) shorter hospital stay and rapid recovery.
This approach is often used when the abdominal wall is scarred by previous surgeries. Vaginal route is contraindicated if there is:
- (1) narrow-scarred vagina,
- (2) postradiation fistula, and
- (3) concomitant rectovaginal fistula.
The abdominal route is preferred when the vaginal route is contraindicated. It is also often advocated if:
- (1) concomitant procedures such as ureteric reimplantation and augmentation cystoplasty are required,
- (2) presence of vesical stones, and
- (3) highly placed fistula with a narrow vagina.[rx,rx]
Augmentation cystoplasty is required in patients with complicated VVF when radiation, obstructed labor, or chronic infection lead to decreased bladder volume, significant loss of anterior vaginal wall and vaginal stenosis. Ureteric reimplantation and vaginal reconstruction with the bowel may also be required concomitantly.[rx]
Positioning during vesicovaginal fistula repair
The size and the location of VVF, the amount of exposure required for the repair, and the experience of the operating surgeon would dictate the position for repair. The Lawson and Jackknife positions are ideal for proximal urethral and bladder neck fistulas. The addition of the reverse Trendelenburg position to these further improves the visualization of VVF and eases the repair.[rx] However, both positions may require general anesthesia to avoid patient discomfort in the prone position.
The dorsal high lithotomy position with steep Trendelenburg positioning gives an excellent view for the repair of a high VVF and is also used during laparoscopic and robotic VVF repairs. Traditional Sims position for VVF repair is no longer used.
Almost all the cases of obstetric VVF can be performed in lithotomy position with Trendelenberg position as evident by the surgeons performing complicated obstetric fistula repair in centers with limited resources.[rx]
Role of colpocleisis in vesicovaginal fistula repair – today’s scenario
Partial colpocleisis may be performed as a part of VVF repair. Two techniques of colpocleisis in VVF repair are (1) Simon colpocleisis (transverse closure) and (2) Latzko colpocleisis (sagittal closure).[rx] Simon colpocleisis is complicated and leads to the pseudodiverticular formation and is not practiced. Latzko technique has prerequisites,[rx] namely (1) post hysterectomy status, (2) adequate preoperative vaginal vault length, and (3) close proximity of the fistula to the vaginal vault. Currently, colpocleisis is performed in women with small proximal postsurgical VVFs and in postradiation-induced VVFs. Colpocleisis leads to a significant shortening of the vaginal space and can cause sexual dysfunction. Advantages of the Latzko procedure include simplicity of the technique, high success rate, low morbidity, no impairment in bladder capacity, and no compromise of the ureteral orifices, even in fistulae that lie close to the orifices. The success rate in patients with simple post-hysterectomy VVFs varies between 93% and 100%.[rx]
Technical modifications in transabdominal vesicovaginal fistula repair: Vertical cystotomy versus horizontal cystotomy versus transvesical repair
Classically, bivalve the bladder to repair the fistula as described by O’Connor and Sokol was the standard practice for abdominal VVF repair.[rx] This classical approach has been questioned by newer and recent techniques that report similar outcomes. These include limited vertical cystotomy,[rx] horizontal cystotomy,[rx], and intravesical repair[rx] of VVF. These approaches have been proposed to (1) decrease the operating time (2) improve the ease of laparoscopic suturing leading to better luminal delineation, (3) decrease the incidence of overactive bladder, and (4) help in early anterior dissection which reduces the tension on the suture line.[rx] Limiting the dissection while following the principles of VVF repair is claimed to provide better post-operative recovery, however, long-term results of these techniques need evaluation.
Role of the interposition of tissue between the layers of repair
Grafts and flaps are interposed between the bladder and the vagina to improve healing and to reduce the chances of recurrence.[rx] A number of flaps have been described for both transabdominal and transvaginal VVF repair. Labial fibrofatty tissue (Martius flap), peritoneum, omentum, gluteus muscle, rectus abdominis muscle, gracilis muscle, small intestinal submucosa, human dura grafts, sigmoid epiploicae, and urachus are some of the issues described for interposition.[rx]
Radiation-induced vesicovaginal fistula
Pelvic radiation is the primary cause of delayed VVF.[rx] The majority of the fistulae form 1.5–2 years after the completion of radiotherapy. Recurrence of malignant disease at the edges of the fistula must be excluded by multiple focal biopsies.[rx]
Radiation-induced recurrent VVFs have the lowest success rates and require the most demanding treatment. Due to radiation-induced fibrosis, it is necessary to completely excise the scar till the fresh tissue margin, and consequently, because of the large size, primary closure of the defect may become difficult. The radiation-induced fibrosis also causes tissue hypoxia, which makes tissue repair difficult.[rx] The approach, abdominal or vaginal, is decided by the location of the fistula and surgeon’s experience and should be tailored to the individual case. Laztko technique (colpocleisis) is preferred in patients with small radiation-induced VVF, as it avoids injuries to the ureters and the trigone. However, colpocleisis leads to shortening or near obliteration of the vaginal space, thereby causing permanent sexual dysfunction. It is worth attempting when the tissues around the fistula are healthy and the reported success rate is about 89%–100%.[rx,rx]
Tissue interposition should be considered whenever the closure lines or the vaginal tissues are of questionable quality.[rx] Adjacent muscle flaps have a better success rate than bulbocavernosus flap, as the vascularity of bulbocavernosus muscle may be compromised by the previous radiation.[rx] Fibrin glue has also been used in patients with previously failed repairs and who underwent have radiation therapy and chemotherapy with good success rates.[rx]
Pushkar et al. analyzed the outcomes of the vaginal approach for radiation-induced VVF among 210 patients and found that the success rate of the primary repair was 48.1%, which increased cumulatively to 80.4% after three surgeries. They found that subsequent repairs did not reduce the chances of cure and reported a high cumulative cure rate. They emphasized that the failure of the repair could be attributed to the continuing tissue reaction caused by radiation and hence the authors suggest considering the re-do surgery of a failed fistula repair as the primary surgery.[rx] Also, the approach, either the vaginal or abdominal does not affect the success rates which usually range from 40% to 100%.[rx]
Trauma-induced vesicovaginal fistula
VVF, as a result of pelvic fracture, is rare and only a few anecdotal reports have been published [rx] The site of injury is at the bladder neck and is often associated with urethral injury. Female urethral injury secondary to pelvic fracture is reported in 6% of the cases.[rx]
Female urethral injury can be classified as complete (avulsion) and partial (longitudinal). Immediate repair of the pelvic fracture with the urethral and vaginal injuries is advised as mere suprapubic drainage often leads to obliterative stricture of the urethra along with urethrovaginal fistula. Affected patients would often be hemodynamically unstable and may need intervention for associated injuries which may preclude immediate repair of the lower urinary tract. Primary endoscopic realignment of the separated urethral ends over a catheter may be an alternative method. Even though the injury will heal, the resultant bladder neck or urethral stricture will require delayed reconstruction with vaginal or bladder wall flaps depending on the length of the stricture and degree of scarring.[rx]
Urinary diversion in inoperable vesicovaginal fistula
Although the literature regarding the role of urinary diversion in patients with inoperable VVFs is scarce, they are being opted for by a few patients as the last resort. Urinary incontinence despite successful fistula closure may result from small bladder capacity due to the loss of tissues at the time of injury, impaired urethral function, or complete absence of the urethra. Also, extensive tissue destruction may render a fistula inoperable. These patients with total urinary incontinence continue to experience social isolation and discrimination.
Mainz II pouch and ureterosigmoidostomy can be performed at VVF centers with minimal resources.[rx] The long-term dangers of urinary diversion should be clearly explained to the patients and a plan for early detection and management of complications should be made. Until, the safety, efficacy, practicality, and ethical acceptability of these operations can be ascertained, they should be offered with great restraint and with a maximum of effort to explain our limitations to the patients.
Management of overactive bladder in vesicovaginal fistula
Overactive bladder, an acute spasmodic pain arising from the bladder, is an important problem that needs to be tackled during the postoperative period after VVF repair.[rx] However, the literature evaluating bladder spasm following surgical urogenital fistula repair is scarce. Spasms can occur despite postoperative analgesia and require multiple medications. Ekwedigwe et al. evaluated the incidence of bladder spasms amongst patients who underwent urogenital fistula repair by a vaginal or an abdominal approach and have noted a higher prevalence in the abdominal approach. The highest incidence of bladder spasms was observed among patients with vault fistula, followed by those with vesicouterine fistula.[rx] Abdominal approach essentially requires bladder splitting and results in a higher incidence of bladder spasm however, this increase may not be significant. A reduction in the tension at the suture line may prevent/reduce the postoperative bladder spasms.[rx] Patients with bladder spasm after ureteric reimplantation could benefit from ketorolac.[rx] Besides, all patients post VVF repair will have continuous catheter drainage for a few weeks, which is one of the nonmodifiable factors causing bladder spasm.[rx] Anticholinergics, along with adequate analgesics in the 1st postoperative week, may reduce patient discomfort and avoid unnecessary tension at the suture line.
Biopsy/excision of the fistulous tract – Is it necessary?
Tuberculosis, actinomycosis, schistosomiasis, and endometriosis[rx,rx,rx] have been reported in the biopsy specimens of the fistulous tract. However, these reports are anecdotal and routine biopsy is not recommended and an individually tailored approach would be helpful to avoid undue complications secondary to the biopsy.[rx] A biopsy is recommended when: (1) there is a previous history of genitourinary malignancies and (2) staging information is required for locally advanced malignancies involving the urinary bladder as the entire management plan would be dependent on local staging.[rx] Excising the fistula tract may compromise the vaginal space when a transvaginal repair is being performed. Also, preserving the fistula tract (1) avoids injury to ureteric orifices, (2) retains fibrosis and allows for suturing, and (3) minimizes the blood loss and fistula size.
Stress urinary incontinence (SUI) after vesicovaginal fistula repair
An ischemic or iatrogenic injury to the supports of the urethra, either from the inciting or from the surgical trauma, may result in SUI post VVF repair. Repair of the fistula near the bladder neck or in the proximal urethra usually results in SUI.[16] The placement of a mid-urethral sling during the primary repair of VVF is controversial. The artificial suburethral sling should be avoided in the primary settings as the chances of erosion and failure of repair are high.[rx] Rectus fascial sling, pubococcygeal sling, plication of pubocervical fascia, and avoiding tight closure of the vagina with judicious use of skin grafts and Martius flaps are measures recommended to prevent SUI.[rx]
Vesicovaginal fistula repair and sexual outcomes
Sexual outcomes following VVF repair have been analyzed in recent studies.[rx,rx] Mohr et al. evaluated 91 patients undergoing VVF repair and reported a post-surgery continence rate of 82% (transvaginal) and 90% (transabdominal) at 6 months of follow-up. Also, the sexual function in the 64 sexually active patients has significantly improved post-surgery, but neither approach was superior to the other.[rx] Pope et al. studied sexual function among 115 patients with 12 months of follow-up. They found that the vaginal length decreased on an average by 5 mm following surgery. Also, larger-sized fistulas (>3 cm diameter) and reduced vaginal caliber were associated with a higher risk of postoperative sexual dysfunction.[rx] They also found that 30% of patients were waiting for the doctor’s permission to resume intercourse even after 6 months of surgery.[rx] Although some patients avoid sexual intercourse and pregnancy due to fear of recurrence, others have a strained relationship because of prolonged abstinence.[rx] Although the literature on the ideal time to resume sexual activity after VVF repair is scarce, intercourse is usually prohibited for a period 3–6 months following VVF repair. However, recent studies have shown that sexual activities can be resumed as early as 6 weeks.[rx] Adequate foreplay, avoiding rough sex, and intercourse during menstruation are the general postoperative advice given to these patients.
Open versus laparoscopic versus robotic repair
Traditionally, the VVFs are repaired via the transabdominal or the transvaginal approach. Laparoscopic repair of VVF requires a high level of surgical skill especially during dissection and intracorporeal suturing. The advent of surgical robots has made these demanding tasks easy. A rapid rise in the utilization of these minimally invasive techniques has hastened post-operative recovery and has reduced the hospital stay. Two approaches have been described for robotic VVF repair– (1) transperitoneal transvesical and (2) transperitoneal extravesical. Both the laparoscopic and robotic VVF repairs have been shown to have similar outcomes with minimal complication rates.[rx] Robotic repair of VVF certainly has advantages over conventional laparoscopy such as a magnified three-dimensional vision, enhanced 7° degrees of freedom of movement, easy suturing, precise dissection, and lesser blood loss. Although robotic surgery has revolutionized the outlook of minimally invasive surgery in the 20th century, the debate, whether robotic VVF repair is feasible on a large scale in developing nations where the disease burden is high and the economic conditions are unfavorable, still exists. The cost of robotic urological procedures is high even in the developed nations.[rx] In fact, most of the VVFs in developing nations are still repaired transvaginally like in African nations. It pronounces that advanced surgical tools like robotics may not be mandatory to guarantee success as long as the essential principles of VVF repair are followed well. No randomized studies are available to compare the outcomes of open, laparoscopic, and robotic methods of VVF repair. With improvements in minimally invasive surgery, open transabdominal surgical repair of VVF may become obsolete. But still, transvaginal repair should be the gold standard wherever feasible.
Suturing in vesicovaginal fistula repair
Traditionally, VVF is repaired with absorbable sutures such as polyglactin (Vicryl) or similar ones. With the advent of laparoscopic and robotic techniques, rapid and precise suturing has become important. Barbed sutures such as the V-Loc and STRATAFIX are being frequently used to improve the suturing maneuvers and reduce the operating time.[rx] Long-term outcomes of these repairs are yet to be published.
Is filling cystogram required prior to catheter removal after vesicovaginal fistula repair
Cystograms are often performed after reconstructive surgery of the lower urinary tract to assess the integrity of the repair and to decide on the time of catheter removal. The time of catheter removal following VVF repair also varies from 2 to 4 weeks.[rx,rx,rx,rx] There is no recommendation on when to perform a cystogram after VVF repair. As most of the surgeons prefer catheter removal after confirming the absence of leak on filling cystograms, we suggest cystograms should be performed under dynamic fluoroscopy to avoid inadvertent complications.
Surgery
Surgical treatment is the primary method for repairing VVFs. Whether the approach is vaginal or abdominal, the outcome of surgical reconstruction is good and exceeds 90%. The surgeon must be aware that the outcome may be suboptimal in certain types of VVFs, e.g. RT-induced, longstanding (bladder is defunctionalized for a long time), and recurrent. Absolute indications for an abdominal approach include ureteric involvement, the need for concomitant bladder augmentation, severe vaginal stenosis, and an inability to tolerate the dorsal lithotomy position (e.g. due to muscular spasticity). When the VVF is close to the bladder neck, preoperative documentation of stress UI (SUI) is required. Synthetic slings should be avoided and autologous slings can be used.
Typically it is recommended to wait at least 3 months to allow the inflammatory response to subside before definitive surgery. Early VVF repair can be performed in the absence of infection and in patients who have not received pelvic RT. Contraindications to early repair include RT-induced VVF and associated enteric injury [rx]. The advantage of early repair includes avoidance of prolonged urine leakage, which has a negative effect on the patient’s quality of life. During the waiting period, risk factors for poor healing (malnutrition, RT, immunosuppression, or vaginal atrophy) should be assessed and corrected when possible [rx].
Vaginal approach
Most VVF’s are accessible via a transvaginal approach. The vaginal approach is associated with less morbidity, less blood loss, less burdensome for patients, and lesser hospital stay than the abdominal approach. Through the anterior vaginal wall, the vagina is dissected off of the bladder followed by a multilayer closure. Before we start the procedure we insert a ureteric catheter. To ensure bladder drainage, we place both a urethral and suprapubic catheter. We usually use only a wide-bore urethral catheter in cases of straightforward obstetric VVFs [rx]. An alternative approach is a Latzko technique. The Latzko technique may be typically indicated for proximal post-hysterectomy VVF. The technique consists of a circumferential ellipsoid incision around the VVF, with wide mobilization of the vaginal epithelium in all directions. The vaginal epithelium around the VVF site is excised and the fistulous tract is closed. The repair is reinforced by a layer derived from the perivesical tissue. A modified colpocleisis is performed, with several layers of absorbable sutures from the anterior to posterior vaginal wall obliterating the upper vagina. The Latzko partial colpocleisis procedure is an alternative technique to traditional vaginal repair. Shortening of the vaginal canal can occur but rarely affects sexual function. However, caution should be exercised when considering it in sexually active females [rx].
Abdominal approach
Traditionally, the abdominal approach has been indicated in patients who have VVF, or those who require additional intra-abdominal procedures, or simultaneous urological procedures, such as ureteric re-implantation or augmentation cystoplasty. The suprapubic approach described by O’Connor et al. [rx] involves bivalve the bladder from the dome to fistulous opening separating the bladder from the vagina for a distance of 2–3 cm beyond the VVF, which is the key step for a successful repair. In the transversal approach, the bladder is opened but not bivalved and the VVF is accessed from inside the bladder, allowing excision of the VVF, dissection between the bladder and vagina, and closure of vagina and bladder. A posterior wall bladder flap may be used to close a large gap or to avoid overlapping of suture lines. A combined transabdominal and transvaginal approach may be used for large, complex, or recurrent cases.
Laparoscopic approach
Nezhat et al. [rx], in 1994, were the first to describe a laparoscopic approach to VVF repair, whilst Melamud et al. [rx] reported on the first robot-assisted repair of a VVF in 2005. The laparoscopic approach has the advantages that the pneumoperitoneum facilitates dissection of tissue planes, the magnification offered by the video camera can improve visualization of the tissue, and that patient morbidity and hospital stay are decreased as compared to open surgery [rx].
Graft interposition
Graft interposition is not indicated in all cases of VVF repair [rx]. No high-quality evidence supports the routine use of graft interposition. The use of grafting in obstetric VVF has significantly declined [rx]. Relying on watertight, tension-free, uninfected multilayer closure is often sufficient. Graft interposition is indicated in cases of recurrent, RT-induced, and long-standing VVFs [rx]. A variety of grafts have been used in abdominal repairs including omentum and peritoneum covering the bladder dome [rx]. When operating transvaginally, the peritoneal reflection of the cul-de-sac or the more popular Martius bulbocavernosus muscle/fat graft may be interposed between the bladder and vagina to help prevent re-fistulization [rx]. The Martius flap is derived from the labial fat pad and can be based on either the anterior or posterior circulation (pudendal or epigastric) depending upon the location of the lesion to be covered. The flap can be tunneled under the labia minora to the site of fistula reconstruction. A 0.64 cm (0.25 inch) Penrose drain at the end of the procedure is essential to avoid hematoma collection. Women should be counseled that the donor labial site will appear to be somewhat deformed after harvest but that within 6 months new adipose tissue will correct any cosmetic abnormality. The chromic suture is best for skin closure to avoid prolonged vaginal discharge. The labial fat-pad graft can be used in all areas of the vagina; however, very proximal apical lesions may be difficult to reach with this particular graft and in this case, the peritoneal flap would be useful. The peritoneal flap was first described by Raz et al. [rx] and involves dissecting the posterior vaginal wall flap posteriorly toward the cul-de-sac. The pre-peritoneal fat and peritoneum are sharply mobilized caudally. The peritoneal flap can then be advanced over the repair and secured with interrupted 3–0 polyglactin 910 (Vicryl®; Ethicon Inc., Somerville, NJ, USA). One study mentioned a higher success rate in a small series of RT-induced VVFs when interposition grafts were used (100%) vs 67% when no grafts were used, although these differences were not statistically significantly different [rx].
References
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