Int J Clin Exp Med 2015;8(2):2364-2370 www.ijcem.com /ISSN:1940-5901/IJCEM0003245 Original Article Laparoscopic repair of iatrogenic vesicovaginal and rectovaginal fistula Lei Chu*, Jian-Jun Wang*, Li Li, Xiao-Wen Tong, Bo-Zhen Fan, Yi Guo, Huai-Fang Li Department of Obstetrics and Gynecology, Tongji Hospital of Tongji University, Shanghai 200065, China. *Equal contributors. Received October 19, 2014; Accepted January 17, 2015; Epub February 15, 2015; Published February 28, 2015 Abstract: Objective: To investigate the clinical efficacy of laparoscopic repair of iatrogenic vesicovaginal fistulas (VVF) and rectovaginal fistulas. Methods: Seventeen female patients with iatrogenic fistulas (11 cases of VVF and 6 cases of high rectovaginal fistulas) were included. All patients were hospitalized and underwent laparoscopic fistula repair in our hospital between 2008 and 2012. The mean age of the patients was 44.8 ± 9.1 years. The fistulas and scar tissue were completely excised by laparoscopy, orifices were tension-free closed using absorbable sutures, omental flaps were interposed between the vagina and the bladder or rectum, and drainage was kept after repair. Results: Laparoscopic repair of fistulas was successful in all 17 patients. No complication was found during or after repair. No reoperation was needed after the repair. The operative time was 80.2 ± 30.0 minutes (range 50-140 min- utes). The blood loss was 229.4 ± 101.6 ml (range 100-400 ml). The double J catheters were placed in 7 patients and removed 1-2 months after repair. Eight VVF patients underwent cystoscopy 3 months after laparoscopic repair and there were no abnormal findings. The follow-up time was 17.1 ± 6.5 months (range 8-29 months). Conclusion: Laparoscopic repair of VVF and rectovaginal fistulas is a safe and an effective minimally invasive procedure for treat- ment of iatrogenic fistula. Keywords: Laparoscopy, extravesical repair, vesicovaginal fistula, rectovaginal fistula Introduction have been used to repair the fistulas. The trans- abdominal approach is the standard surgical Iatrogenic vesicovaginal and rectovaginal fistu- approach for fistula repair, but this method is las are serious complications of pelvic opera- limited by large injuries and a small field of tions and vaginal delivery and may significantly vision. The laparoscopic repair of fistulas has reduce the quality of life of affected women. the advantages of minimal access surgery The vaginal passage of urine, gas, and stool including minimal wound complications, less can cause physical symptoms due to inflamma- blood loss, less postoperative pain and shorter tion and depression. Patients may also suffer hospital stays. In this study, we investigated the from significant psychosocial and sexual dys- results of laparoscopic repair in patients with function [1]. vesicovaginal and high rectovaginal fistulas and discuss the safety and effectiveness of this Most times iatrogenic vesicovaginal and recto- operation. vaginal fistulas are due to severe adhesions, excessive sewing, incorrect electric coagula- Material and methods tion hemostasis, and neglected injury of the bladder wall or rectum wall during the opera- General data tion. For patients after a vaginal delivery, vesi- covaginal and rectovaginal fistulas are caused This study included 17 female patients (11 by prolonged fetal head compression. The size cases of vesicovaginal fistulas and 6 cases of of fistulas was always large in this situation. high rectovaginal fistulas), who were hospital- Various surgical paths, such as transvaginal, ized and underwent laparoscopic fistula repair transabdominal, transrectal or a combination in our hospital between 2008 and 2012. Iatrogenic vesicovaginal and rectovaginal fistula repair Table 1. Primary diseases of all patients (11 cases of vesicovaginal fistulas and 6 cases of high rectovaginal fistulas) Primary diseases Number of cases Vesicovaginal fistula 11 Endometriosis 5 Myoma of uterus 2 Endometrial cancer 1 Ovarian cancer 1 Pelvic organ prolapsed 2 Rectovaginal fistula 6 Endometriosis 2 Endometrial cancer 1 Pelvic abscess 2 Figure 2. CT imaging of rectal perfusion in horizontal plane indicated contrast agent flowing into vaginal Myoma of uterus 1 through the fistula at anterior rectal wall (arrow). V, vaginal; R, rectum; F, fistula. Figure 1. A 58 years old female patient with endome- trial cancer received laparoscopic hysterectomy, oo- phorectomy and pelvic lymphadenectomy. However, Figure 3. Adhesion between the bladder and rectum vaginal exhaust and defecation occurred 2 weeks was excised under laparoscope until rectovaginal fis- after surgery. The patient underwent laparoscopic tulous tract was exposed. repair of rectovaginal fistula 2 months after surgery. CT imaging in the coronal plane of rectal perfusion before surgery showed contrast agent flowing into Laparoscopic repair vaginal through the rectovaginal fistula (arrow). V, vaginal; R, rectum; F, fistula. Laparoscopic repair was performed 2-7 months after the initial surgery. All patients underwent Patients with vesicovaginal and rectovaginal pelvic examination. Fistulas were confirmed by fistulas due to radiation and recurrent fistulas computed tomography, magnetic resonance were excluded from the study. The mean age of imaging, voiding cystourethrogram, defecogra- the patients was 44.8 ± 9.1 years. The original phy, and cystoscopy before operation (Figures operations were different in these patients and 1 and 2). Biopsy of the fistula orifice was per- included 13 patients after laparoscopic or formed in all patients. Final pathology was neg- abdominal hysterectomy or simple salpingo- ative for malignancy. In all patients, conserva- oophorectomy because of endometriosis (n = tive treatment was provided. All cases were 7), myoma of the uterus (n = 3), endometrial performed by the same surgeon. cancer (n = 2), and ovarian cancer (n = 1), 2 after laparoscopic salping-oophenrectomy for All patients were given general anesthesia and pelvic abscess, and 2 after pelvic floor recon- placed in the lithotomy position. In 7 patients struction for pelvic organ prolapse (Table 1). double J catheters were placed in unilateral or 2365 Int J Clin Exp Med 2015;8(2):2364-2370 Iatrogenic vesicovaginal and rectovaginal fistula repair bilateral ureteral occlusions before laparosco- course, the use of vaginal tampons, and lifting py to protect the ureter. Patients with vesico- heavy weights during the first 3 months after vaginal fistulas initially underwent cystoscopy, the repair (Figure 3). and then Methylene blue was perfused into their bladders until it could be seen in the vagi- In rectovaginal fistula patients, mechanical na. A 16 F Foley catheter was inserted into the bowel preparation was administered 1 day bladder, and gentle traction was exerted on it. before the surgery. Antibiotics were given pre- Four trocars (0.5-1 cm) were placed at the operatively. The fistulous tract and scar were umbilicus and hypogastrium. We used the cold cut off with microscissors. The vagina was light source of xenon lamp (Stryker, USA), lapa- closed with continuous 2-0 Vicryl sutures. The roscopic instruments (Wolf, Germany) and cam- rectal wall was closed in 2 layers using 3-0 era (Olympus, Japan) in all cases. Vicryl sutures. The seams of the rectum and vagina were separated as far as we could to There were pelvic adhesions in all patients. We avoid adhesions. After closure of the rectum, released adhesions between the omentum and 500 ml saline was filled into the pelvis and then the anterior abdominal wall to expose the blad- 200 ml of air was injected into the rectum to der wall and the anterior wall of the rectum first. test its integrity. The omental flap was sewn In three cases of vesicovaginal fistulas with between the rectum and the vagina. A double- damage near the ureterostoma, we started the cavity cannula was left near the seams of the operation with dissociation of the ureters. rectum. A urethral catheter was left in place for Ultracision harmonic scalpel and microscissors 2 days. Antibiotics were used for 3-4 days. were used carefully to separate the adhesive Continued double-cavity cannula irrigation and tissue between the vaginal apex and other drainage lasted from the second to the seventh organs. In patients with vesicovaginal fistulas, day after the operation and the cannula was the vagina was separated from the posterior removed on the ninth day after the operation. bladder wall until the fistula with methylene Patients were given Nutrison from the second blue was exposed. Microscissors were used to day after the operation and a semi-liquid diet completely excise the fistulous tract and scar was started on the sixth day. Pinaverium bro- tissue around it, and electrocautery was pro- mide was given in the first week to limit excre- hibited to preserve the viability of the tissue. In ment, and lubricant for intestines was given two cases with fistulas that had formed during after 1 week. All patients were instructed to pelvic reconstruction with mesh, the mesh take stool softener for 1 month. through the fistula was cut off. The vagina was closed in a single layer with continuous 2-0 Results Vicryl sutures. The urinary bladder was closed in 2 layers using 3-0 Vicryl sutures. We closed Laparoscopic repair of vesicovaginal and recto- the seromuscular layer tension-free as the first vaginal fistulas were successful in all 17 layer and serosa only as the second layer. After patients without conversion to transabdominal closure of the bladder, it was filled with 250 ml repair. No pelvic abscess or associated organ of Meilan diluent to test its integrity. Omental injury was found in any of the patients. No reop- flaps were routinely used to interpose between eration was needed after repair. The operative the bladder and vaginal apex. In some cases, time was 80.2 ± 30.0 minutes (range 50-140 redundant serosa was attached to the bladder minutes). The blood loss was 229.4 ± 101.6 ml wall. No polypropylene or biological mesh was (range 100-400 ml), and no one needed blood used. A tube drain was left in all patients at the transfusions.