SURGICAL TECHNIQUES ■ BY NEERAJ KOHLI, MD, MBA, and JOHN R. MIKLOS, MD Meeting the challenge of vesicovaginal fistula repair: Conservative and surgical measures A number of simple adjustments to technique and timing of repair can improve the outlook for this troublesome complication. Here, 2 experts offer tips and caveats. ecent advances have improved the the index surgery can often prevent the success of vesicovaginal fistula (VVF) development or reduce the severity of VVF. Rrepair—a challenge that can test even Vesicovaginal fistula is the most common the most experienced gynecologic surgeon. type of urogenital fistula. Presentation and For example, it now is apparent that some prognosis vary, depending on location and small uncomplicated fistulae respond to con- size of the defect, as well as coexisting factors servative treatment. Further, in selected cases, such as tissue devascularization and previous laparoscopic repair can eliminate the need for radiation. However, surgical repair is associ- complicated laparotomy. ated with a high cure rate if it is performed by In addition, timing of fistula repair no an experienced surgeon. longer requires long periods of observation, and good surgical technique for identifying Most US cases and repairing bladder injuries at the time of follow gynecologic surgery esicovaginal fistula was first documented KEY POINTS Vin the mummified remains of Egyptian Queen Henhenit (11th Dynasty, 2050 BC), ■ Surgical risk factors include prior pelvic which were examined in 1923 by Derry.1 surgery, history of pelvic inflammatory disease, pelvic malignancy, endometriosis, Although the exact incidence of VVF in the infection, diabetes, and anatomic distortion. United States is unknown, the primary cause is gynecologic surgery, especially hysterecto- ■ Conservative therapy should be my. The defect is estimated to occur in 0.01% reserved for simple fistulae that are less than 1 cm in size, diagnosed within 7 days ■ Dr. Kohli is chief, division of urogynecology and reconstruc- of the index surgery, lacking associated tive pelvic surgery, Brigham and Women’s Hospital, and assis- carcinoma or radiation, and subject to tant professor, department of obstetrics and gynecology, at least 4 weeks of constant bladder Harvard Medical School, in Boston, Mass. Dr. Miklos is direc- drainage. tor, Atlanta Urogynecology Associates, and clinical instructor, department of obstetrics and gynecology, Medical College of ■ In surgical repair, the Latzko partial Georgia, Atlanta, Ga. colpocleisis or fistulectomy with flap- splitting closure is preferred. 16 OBG MANAGEMENT • August 2003 Meeting the challenge of vesicovaginal fistula repair TABLE gery, a history of pelvic inflam- matory disease, pelvic malig- Classification of vesicovaginal fistulae17 nancy, endometriosis, infec- CLASSIFICATION DESCRIPTION tion, diabetes, and anatomic Simple • Fistula is less than 2 to 3 cm in size and near distortion. If these risk factors the cuff (supratrigonal) are present, the patient should • Patient has no history of radiation or be counseled accordingly prior malignancy to gynecologic surgery. • Vaginal length is normal Correct classification Complicated • Patient has had previous radiation therapy crucial to surgical • Pelvic malignancy is present success • Vaginal length is shortened roper classification of VVF • Fistula is greater than 3 cm in size Pcan help the gynecologic • Fistula is distant from cuff or has surgeon plan operative inter- trigonal involvement vention. Obstetric vesicovagi- nal fistulae usually are catego- rized according to their cause, to 0.04% of gynecologic procedures. complexity, and site of obstruction. In con- A study of 303 women with genitourinary trast, gynecologic fistulae are generally classi- fistula found that the defect was related to fied as simple or complicated (TABLE). gynecologic surgery in 82% of cases, obstetric These levels may have important impli- events in 8%, radiation therapy in 6%, and cations for the surgical approach and progno- trauma or fulguration in 4%.2 Rare causes of sis.4 For example, simple vesicovaginal fistu- VVF include lymphogranuloma venereum, lae are usually uncomplicated surgical cases tuberculosis, syphilis, bladder stones, and a with good prognosis. Complicated vesico- retained foreign body in the vagina. In rare vaginal fistulae, on the other hand, can chal- instances, spontaneous vesicouterine fistulae lenge even highly practiced and skilled gyne- were reported following uncomplicated vagi- cologic surgeons and are associated with a nal birth after cesarean section.3 high rate of recurrence. Gynecologic surgery may lead to VVF Women typically present within due to extensive dissection between the blad- specific intervals after the various der and the uterus, unrecognized bladder antecedent events (pelvic surgery, childbirth, laceration, inappropriate stitch placement, radiation therapy) with a primary complaint and/or devascularization injury to the tissue of constant, painless urinary incontinence. If planes. Concurrent ureteric involvement has the fistula is related to traumatic childbirth, been reported in as many as 10% to 15% of most patients experience urine leakage with- vesicovaginal fistula cases. in the first 24 to 48 hours. Following pelvic In developing countries, vesicovaginal surgery, symptoms usually occur within the fistulae are far more common and generally first 30 days. In contrast, radiation-induced related to obstetric factors such as obstructed fistulae develop over a much longer interval labor (due to unattended deliveries), small secondary to progressive devascularization pelvic dimensions, malpresentation, poor necrosis, and may present 30 days to 30 years uterine contractions, and introital stenosis. after the antecedent event. Risk factors. Conditions that may predis- Some patients report exacerbation dur- pose patients to VVF include prior pelvic sur- ing physical activities, which can sometimes 18 OBG MANAGEMENT • August 2003 Meeting the challenge of vesicovaginal fistula repair FIGURE 1 Vesicovaginal fistula Mucosa Pubocervical Bladder fascia Vesicovaginal fistula Vaginal epithelium Rectum Vagina Urethra Anus Pelvic cross section depicting high vesicovaginal fistula. lead to erroneous diagnosis of uncomplicated Determine the location of the fistula in stress incontinence. If the fistula is small, relation to the vaginal apex and bladder intermittent leakage with increased bladder trigone and assess the quality of surrounding distention or physical activity may be noted. tissue (eg, presence of inflammation, edema, Other patients may complain of vaginal or infection). Fistulas near the vaginal apex discharge or hematuria. may require a more complicated abdominal If there is concurrent ureteric involve- approach, and those close to the trigone may ment, the patient may experience constitu- be associated with increased risk of ureteral tional symptoms (such as fever, chills, and injury during repair. flank pain) or even gastrointestinal symptoms. If the fistula is particularly small, no tract Physical findings. Any pooling of fluid in may be apparent. In such cases, bimanual the vagina that is noted should be sent for exam with careful palpation of the anterior analysis if the diagnosis is unclear. Next, per- wall may help isolate the fistula (eg, when form a careful speculum exam that allows there is a surrounding zone of induration). visualization of the entire anterior vaginal Office tests. If no fistula is noted despite wall to identify the fistula tract (FIGURE 1). In highly suspicious signs and symptoms and IMAGE: Maura Flynn IMAGE: many cases, the fistula is grossly visible. careful examination, a simple office test can August 2003 • OBG MANAGEMENT 21 Meeting the challenge of vesicovaginal fistula repair FIGURE 2 Abdominal repair Placement of omental flap Bladder and vaginal closure Abdominal repair of vesicovaginal fistula, with closure of bladder defect and posterior cystotomy and separate closure of vaginal defect. Note the omental flap pictured in the insert. be performed. Using a catheter, fill the blad- presence of blue staining suggests vesicovagi- der with a dyed solution such as normal nal or urethrovaginal fistula, while red staining saline with indigo carmine and repeat the (Pyridium) suggests ureterovaginal fistula. pelvic exam with a half-speculum to visualize Other testing. Further assessment is recom- the anterior wall. Ask the patient to cough mended to rule out concurrent pathology and bear down, and identify the fistula by and formulate an appropriate treatment plan. visualizing urine leakage. Routine testing should include a urinalysis If this test fails to locate the fistula, insert and culture to exclude coexisting urinary a tampon and ask the patient to perform 10 to tract infection, an electrolyte panel to evalu- 15 minutes of exertional maneuvers, includ- ate renal function, and a complete blood cell ing stair climbing and jumping in place. count to rule out systemic infection. Then remove the tampon. Visualization of Cystoscopy should be performed to dye beyond the most distal edge of the tam- visualize the fistulous tract, assess its loca- pon confirms the presence of a fistula. tion in relation to the ureters and trigone, A variation of this technique is the double- assure bilateral ureteral patency, and dye test: Give the patient oral phenazopyri- exclude the presence of a foreign body or dine (Pyridium), fill the bladder with the suture in the bladder. blue-tinted solution, and insert a tampon.