SCIENTIFIC PAPER Immediate Laparoscopic Nontransvesical Repair without Omental Interposition for Vesicovaginal Developing after Total Abdominal Jung Hun Lee, MD, Joong Sub Choi, MD, Kyo Won Lee, MD, Jong Sul Han, MD, Pil Cho Choi, MD, Jeong-Kyu Hoh, MD

ABSTRACT Results: The median age and body mass index of the patients were 47 years and 22.3 kg/m2, respectively. Op- Background and Objective: We conducted this study to erating time, hemoglobin change, and hospital stay were evaluate the feasibility and efficacy of immediate laparo- 95 minutes, 1.1 g/dL, and 5 days, respectively. There were scopic nontransvesical repair without omental interposi- no complications or laparoconversions. During follow-up tion for vesicovaginal fistula (VVF) developing after total (median 56.1 weeks; range 26.6 to 74.0), there was no abdominal hysterectomy (TAH), which causes not only evidence of recurrence. social and economic misery for the patient but also con- siderable stress to the physicians who perform the sur- Conclusions: Immediate laparoscopic nontransvesical gery. repair without omental interposition might be an effective, feasible alternative to the traditional methods in select Methods: We performed a retrospective review of 5 patients with small sized (Ͻ1 cm) VVF developing after women who underwent immediate laparoscopic non- TAH. transvesical repair without omental interposition for VVFs, developing after TAH from October 2007 to March 2009. Key Words: Complication, Hysterectomy, Laparoscopy, In terms of laparoscopic procedure, cystoscopy was per- Vesicovaginal fistula. formed to confirm the location of fistula and ureteral openings, initially. Without opening the bladder, the fis- tula tract was identified, and the bladder was dissected from the . The bladder defect was closed by using intracorporeal, continuous, and double-layer suturing, INTRODUCTION laparoscopically. The vaginal defect was closed using in- In developing countries, vesicovaginal usually re- terrupted and single-layer suturing, vaginally. A Foley sult from obstetrical causes. In developed countries, ob- catheter was inserted for 2 weeks and removed after stetrical vesicovaginal fistulas (VVFs) are uncommon, and bladder integrity was confirmed with a retrograde cysto- most VVFs are related to radiation therapy, malignant gram. disease, and surgical injury. The most common surgical procedure associated with subsequent formation of VVF is hysterectomy, and VVF occurs in 0.08% of the patients Department of and Gynecology, Kangbuk Samsung Hospital, 1–4 Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (Drs JH who undergo total abdominal hysterectomy (TAH). Lee, JS Choi, KW Lee, JS Han). The development of VVF after gynecologic surgery not Department of Emergency Medicine, Kangbuk Samsung Hospital, Sungkyunkwan only causes social and economic misery for the patient but University School of Medicine, Seoul, Republic of Korea (Dr PC Choi). Department also causes considerable stress to the physicians who of Obstetrics and Gynecology College of Medicine, Hanyang University (Dr. J-K Hoh). perform the surgery. This article was not supported by any financial funds and not affiliated with the instrumental company referred to in the text. The authors declare that there are no Traditionally, most VVFs are treated surgically. However, conflicts of interest. there is no consensus on several matters: the time of Address correspondence to: Prof. Joong Sub Choi, MD, PhD, Director of Division operation (when is surgical management performed after of Gynecologic Oncology and Gynecologic Minimally Invasive Surgery, Kangbuk the development of VVF?) and surgical methods (should Samsung Hospital, Sungkyunkwan University School of Medicine, 108 Pyung-dong Jongno-gu, Seoul 110-746, Republic of Korea. Telephone: 82-2-2001-2499; (401) the transabdominal approach or the transvaginal ap- 626-0022 (USA), Fax: 82-2-2001-2187, E-mail: [email protected] proach be used?). Recently, the laparoscopic and the ro- DOI: 10.4293/108680810X12785289143918 botic repair of VVF have been reported, and they make 5–11 © 2010 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by the choice of surgical procedure more difficult. Addi- the Society of Laparoendoscopic Surgeons, Inc. tionally, in all of these studies omental interposition was

JSLS (2010)14:187–191 187 Immediate Laparoscopic Nontransvesical Repair without Omental Interposition for Vesicovaginal Fistula Developing after Total Abdominal Hysterectomy, Lee JH et al.

performed. By contrast, Goyal et al12 reported a high nal article.13 Intravenous preoperative antibiotics, 2 g success rate (97.5%) with the layered closure technique cefminox and 1.5 g metronidazole, were administered, without omental interposition for (1 cm) VVFs performed and preoperative bowel preparation with Fleet Phospho- using either the abdominal or vaginal approach. soda was done in all cases. After the port placement system was established, the inspection of the abdominal Therefore, the authors conducted this study to evaluate and pelvic cavity was performed, and any adhesions were the feasibility and efficacy of immediate laparoscopic non- sufficiently dissected using a bipolar coagulator, a dissect- transvesical repair without omental interposition for small ing Metzenbaum, and endoscissors. For identifying the VVF developing after TAH. border between the bladder and vagina, 250 mL normal saline was infused into the bladder through a Foley cath- METHODS eter. The peritoneum covering the border between the bladder and vagina was incised with endoscissors, and the In this retrospective study, we evaluated 5 patients who bladder was carefully dissected away from the vagina until were referred for VVF developing after TAH. Each under- the VVF was exposed. The bladder surrounding the con- went laparoscopic nontransvesical surgery not accompa- firmed VVF was sufficiently desquamated. In 3 cases, the nying the omental interposition at Kangbuk Samsung suture material used for TAH was located and removed. In Hospital from October 2007 to March 2009. The VVF was this process, the blunt portion of a rubber suction bulb confirmatively diagnosed by using the indigo carmine test. was inserted to expand the upper vagina, which helped The initial preoperative evaluations included a medical with dissection of the vesicovaginal layer. The bladder history, physical examination, pelvic examination, hema- defect was closed in an intracorporeal, continuous, and tological tests, intravenous pyelogram for identifying VVF double layer with Vicryl 3–0 without debridement; the and eliminating a possibility of ureteral injury, and diag- vaginal defect was closed in an interrupted single layer nostic cystoscopy for identifying the locations of VVF and with Vicryl 1–0, vaginally (Figure 1). To confirm the both ureteral openings. After being informed of the lapa- urine leakage through the closed bladder defect laparo- roscopic nontransvesical surgery not accompanying omental scopically, 250 mL normal saline was infused into the interposition, the relevant complications, the failure rate, bladder through a Foley catheter repeatedly. A diagnostic and the possibility of laparoconversion, each patient gave cystoscopy was conducted to verify the repair and the informed consent. ureteral opening. Following the completion of all surgical We analyzed the patients’ age, body mass index, the procedures, a drainage tube was inserted after both ure- history of previous abdominal surgery, the size and loca- teral peristalsis and the absence of any bleeding foci in the tion of VVF, the period from the previous TAH to the abdominal cavity were confirmed. The omental interposi- surgical treatment for VVF, operating time, hemoglobin tion and the catheterization of the ureter during the sur- change, the return of bowel activity, hospital stay, and any gery were not performed. A Foley catheter was kept in operative complications. The hemoglobin change was place for 2 weeks and then removed after it was con- measured as the difference between the value before firmed that there was no urine leakage on the retrograde surgery and that on the first day after surgery. However, cytogram. hemoglobin change is limited in that it might not reflect actual blood loss due to postoperative hemodilution and RESULTS so forth. The operating time was defined as the time elapsed from the insertion of the first trocar to the closure From October 2007 to March 2009, 5 patients were re- of all trocar sites. The return of bowel activity was defined ferred for VVF developing after TAH. Each one underwent as the period from the end of general anesthesia to the laparoscopic nontransvesical surgery not accompanying first occurrence of bowel gas passage. Postoperatively, all omental interposition in our hospital. In these patients, the patients were reevaluated by history taking, physical ex- transvaginal approach was not preferred due to a high amination, and pelvic examination every 1 month to 6 retracted fistula in a narrow vagina, and laparoscopic months until this article was finished. repair for VVF was performed, immediately.

The detailed clinical characteristics and operative results Operative Techniques are presented in Table 1. Indications of TAH were symp- Preoperative patient preparation and the laparoscopic tomatic myoma in 4 women and in 1 technique were the same as described in a previous jour- woman. The median interval between TAH and fistula

188 JSLS (2010)14:187–191 Figure 1. An actual image of laparoscopic nontransvesical repair for vesicovaginal fistual. A: A view of pelvic cavity after adhesiolysis. B: The suture material used for TAH was noted between bladder and vaginal vault. C: The bladder defect was closed in an intracorporeal, continuous, and double layer with Vicryl 3–0. D: An image after laparoscopic nontransvesical repair for vesicovaginal fistula.

Table 1. without management for it before Clinical Characteristics and Operative Results being transferred to our hospital. Intravenous pyelograms showed that there was no evidence of ureteral injuries in Clinical Characteristic Median (Range) any of the patients. There were no intraoperative and Age (years) 47 (40–51) postoperative complications or laparoconversions. During Parity 2 (1–2) a median follow-up of 56.1 weeks (range, 26.6 to 74.0), there were no urologic sequelae associated with VVF or Body mass index (kg/m2) 22.3 (20.4–27.2) laparoscopic surgery for VVF, nor did any patient exhibit Number of previous abdominal surgery 1 (1–3) signs of recurrence through the last follow-up. Size of vesicovaginal fistula (cm) 0.6 (0.5–0.9) Location of vesicovaginal fistula Supratrigonal Interval between primary surgery 24 (14–289) DISCUSSION and fistula repair (days) Since Nezhat et al14 initially reported the laparoscopic Operative Results repair of VVF in 1994, several reports have advocated the feasibility and advantages of the laparoscopic approach 5–11 Operating time (minutes) 95 (85–115) compared with abdominal or transvaginal approaches. Table 2 summarizes the following data from previous Hemoglobin change (g/dL) 1.1 (0.4–2.3) studies: whether bladder dome incision was performed, Return of bowel activity (hours) 29.3 (19.8–40.4) whether omental interposition was performed, closure Hospital stay (days) 5 (5–17) methods of bladder or vaginal defects, and failure rate. Complications 0 Period of follow-up (weeks) 56.1 (26.6–74.0) The surgical technique performed in our hospital has several characteristics that differentiate it from the other reports. First, we performed the laparoscopic repair im- symptom onset was 24 days (range, 14 to 30). In an mediately when the patient was transferred for VVF, re- unusual case, one woman was transferred 289 days after gardless of the time of the previous surgery. The usual TAH, because she had regarded the symptoms of VVF as strategy delays the surgical repair for 3 to 6 months after

JSLS (2010)14:187–191 189 Immediate Laparoscopic Nontransvesical Repair without Omental Interposition for Vesicovaginal Fistula Developing after Total Abdominal Hysterectomy, Lee JH et al.

Table 2. Comparison of Surgical Techniques for Laparoscopic Repair of Vesicovaginal Fistula on Pevious Studies Study No. of Bladder Incision Closure Method of Closure Method of Omental Failure Patients Bladder Defect Vaginal Defect Interpositioning Rate (%)

Ou et al. 2 Non-transvesical Interrupted, Continuous, Single Performed 0 (2004)2 Double layer layer Sotelo et al. 15 Transvesical Continuous, Continuous, Single Performed 7 (2005)3 Double layer layer Modi et al. 1 Transvesical Continuous, Single Interrupted, Not performed 0 (2005)4 layer Double layer Tiong et al. 1 Non-transvesical Continuous, Single Interrupted, Single Performed 0 (2007)5 layer layer Mahapatra et 12 Transvesical Interrupted, Single Not sutured Performed 8.3 al. (2007)6 layer Nagraj et al. 13 Transvesical Continuous, Single Single layer Performed 7.3 (2007)7 layer Current study 5 Non-transvesical Continuous Interrupted Single Not performed 0 Double layer layer

the injury, expecting the spontaneous closure of VVF and patients after the surgical treatment of VVF.18,19 In these the control of inflammation. However, according to sev- symptoms, those related to detrusor instability seemed to eral recent reports, there are no benefits in delaying sur- be related to the severity of the bladder injury. During the gical repair once acute inflammation subsides, and early traditional transvesical approach, there is the possibility of surgical repair can achieve success rates equal to those of injury from the incision of the bladder performed to ex- the previously mentioned strategy.7,15,16 Because the size pose the fistula tract and correct it along with the damage of fistula is small and the inflammatory reaction is not from the VVF. Accordingly, the incidence of the symptoms severe in most VVF developing after TAH, compared with related to detrusor instability should be high, a prediction VVFs that result from obstetrical complication or radiation that is supported by the relatively low incidence of these therapy, the success rate of the early surgical repair symptoms with the transvaginal approach.18 For these seemed to be relatively high. Furthermore, considering reasons, the nontransvesical approach is expected to have that VVF developing after TAH have such negative effects good results for the functional aspect of the bladder with on the patients, the early surgical repair is thought to have abdominal or laparoscopic surgical repair of VVF. In ad- value more than the shortening of the treatment period or dition, the small-sized VVF developing at the supratrigo- the saving of medical expenses. Accordingly, the authors nal area is thought to be able to be treated laparoscopi- believe that consideration of early surgical repair in VVF cally by gynecologic laparoscopists familiar with the developing after TAH is meaningful. Of course, there may interface of the bladder and the vagina, and better results be the negative insistence against the early surgical repair can be anticipated for the functional aspect of the bladder. in a small-sized VVF as that observed in this study, be- Lastly, the omental interposition was not performed in this cause VVF Ͻ1 cm has been reported to have the high series. In the study by Evans et al,20 the success rate was possibility of spontaneous closure.17 Nonetheless, the au- 100% in cases when the interposition was performed for thors recommend considering early surgical repair to limit the abdominal surgery of VVFs. But in cases when the negative effects of fistula in patients’ lives. Second, the interposition was not performed, a success rate of 63.2% nontransvesical approach was used instead of the trans- of cases of VVF resulting from benign disease and 66.7% vesical approach for fistula exposure in laparoscopic re- of cases of VVF resulting from malignant disease were pair. The traditional surgical repair of VVF has been observed. Accordingly, even with VVF resulting from be- achieved by the transvesical approach for fistula exposure nign disease where the surrounding organs were well regardless of the abdominal or the laparoscopic method. preserved, surgeons insisted on performing the interposi- In the previous reports, the urinary frequency, urgency, tion in all patients.20 But, as the rate of relapse is not high incontinence, or were observed in several in cases of a single VVF Ͻ1cm following nonobstetrical

190 JSLS (2010)14:187–191 reasons, some do not recommend interposition.12,21,22 In 9. Sotelo R, Mariano MB, Garcia-Segui A, et al. Laparoscopic particular, Goyal et al12 reported that the success rate of repair of vesicovaginal fistula. J Urol. 2005;173:1615–1618. the layered closure technique without omental interposi- 10. Sundaram BM, Kalidasan G, Hemal AK. Robotic repair of tion for small (Ͻ1 cm) VVFs was 97.5% using a transab- vesicovaginal fistula: case series of five patients. . 2006; dominal or transvaginal approach. Nevertheless, in all 67:970–973. reported studies for laparoscopic or robotic repair of 11. Tiong HY, Shim T, Lee YM, Tan JK. Laparoscopic repair of VVFs, the omental transposition was performed. This re- vesicovaginal fistula. Int Urol Nephrol. 2007;39:1085–1090. sults from a definite belief of the surgeon that perfor- mance of omental interposition can prevent recurrence. 12. Goyal NK, Dwivedi US, Vyas N, Rao MP, Trivedi S, Singh PB. Based on the success rate of laparoscopic repair of VVFs A decade’s experience with vesicovaginal fistula in India. Int in our study, the omental interposition may be omitted in Urogynecol J Pelvic Floor Dysfunct. 2007;18:39–42. the Ͻ1 cm VVF developing after TAH during the laparo- 13. Choi JS, Kyung YS, Kim KH, Lee KW, Han JS. The four-trocar scopic approach if the surgeon is equipped with sufficient method for performing laparoscopically-assisted vaginal hyster- laparoscopic suture techniques. ectomy on large uteri. J Minim Invasive Gynecol. 2006;13:276– 280. CONCLUSIONS 14. Nezhat CH, Nezhat F, Nezhat C, Rottenberg H. Laparoscopic repair of a vesicovaginal fistula: a case report. Obstet Gynecol. Immediate laparoscopic nontransvesical repair without 1994;83:899–901. omental interposition might be an effective and feasible alternative to the traditional methods in select patients 15. Blaivas JG, Heritz DM, Romanzi LJ. Early versus late repair of with small-sized (Ͻ1 cm) VVF developing after TAH. vesicovaginal fistulas: vaginal and abdominal approaches. J Urol. However, our study was limited by the small number of 1995;153:1110–11102; discussion 2–3. cases and lack of randomization. Therefore, a large, pro- 16. Melah GS, El-Nafaty AU, Bukar M. Early versus late closure spective and randomized study is required. of vesicovaginal fistulas. Int J Gynaecol Obstet. 2006;93:252–253. 17. Bazi T. Spontaneous closure of vesicovaginal fistulas after References: bladder drainage alone: review of the evidence. Int Urogynecol 1. Hadzi-Djokic J, Pejcic TP, Acimovic M. Vesico-vaginal fis- J Pelvic Floor Dysfunct. 2007;18:329–333. tula: report of 220 cases. Int Urol Nephrol. 2009;41:299–302. 18. Flynn MK, Peterson AC, Amundsen CL, Webster GD. Func- 2. Hilton P. Vesico-vaginal fistula: new perspectives. Curr Opin tional outcomes of primary and secondary repairs of vesicovag- Obstet Gynecol. 2001;13:513–520. inal fistulae via vaginal cuff scar excision. Int Urogynecol J Pelvic Floor Dysfunct. 2004;15:394–398; discussion 8. 3. Wall LL. Obstetric vesicovaginal fistula as an international public-health problem. Lancet. 2006;368:1201–1209. 19. Hilton P. Urodynamic findings in patients with urogenital fistulae. Br J Urol. 1998;81:539–542. 4. Harkki-Siren P, Sjoberg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol. 1998;92:113–118. 20. Evans DH, Madjar S, Politano VA, Bejany DE, Lynne CM, Gousse AE. Interposition flaps in transabdominal vesicovaginal 5. Das Mahapatra P, Bhattacharyya P. Laparoscopic intraperi- fistula repairs: are they really necessary? Urology. 2001;57:670– toneal repair of high-up fistula: a review of 12 674. cases. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18:635–639. 21. Ayed M, El Atat R, Hassine LB, Sfaxi M, Chebil M, Zmerli S. 6. Modi P, Goel R, Dodia S. Laparoscopic repair of vesicovag- Prognostic factors of recurrence after vesicovaginal fistula repair. inal fistula. Urol Int. 2006;76:374–376. Int J Urol. 2006;13:345–349. 7. Nagraj HK, Kishore TA, Nagalaksmi S. Early laparoscopic 22. Gerber GS, Schoenberg HW. Female urinary tract fistulas. repair for supratrigonal vesicovaginal fistula. Int Urogynecol J J Urol. 1993;149:229–236. Pelvic Floor Dysfunct. 2007;18:759–762. 8. Ou CS, Huang UC, Tsuang M, Rowbotham R. Laparoscopic repair of vesicovaginal fistula. J Laparoendosc Adv Surg Tech A. 2004;14:17–21.

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