engleski

Our experience with vesicovaginal fistula repair surgery

Introduction Vesicovaginal fistula (VVF) is an abnormal opening between the bladder and the vagina that results in continuous and unremitting incontinence. The etiology of VVFs in developed countries is associated with surgical injury to the bladder during hysterectomy. The objective of this study was to review management of the VVF with an emphasis on cause, clinical presentation, treatment, outcomes and complications. Patients and Methods We operated 22 patients in the period from 1984 to 2008. Medical charts were analyzed retrospectively. The most common cause of a fistula was after transabdominal hysterectomy for benign conditions in 13 cases, for malignancy in 5 cases and 5 other cases The median age of patients was 47.00 years (range 32-62 years) and the median follow-up period was 10 months (range 2-18 months). After vaginal examination and intravesical methilene blue instillation, cystoscopy was preformed in all cases to determine the site, number and size of the fistula and its relationship with the ureteric orifice. Cystography was done in ten cases and no more information was received except extravasation of contrast media in the vagina. To determine concomitant ureteric injury, intravenous pyelography was done in all cases except in subjects with a history of iodine allergy. Results Most cases of VVFs presented with early urinary leakage (72, 72% within first and 27, 27% in the second week). 7 cases were treated with late (>3 months) and 14 with early (1-3 months) surgical repair. In three cases we discovered lesion of prevesical ureter and ureterocystoneostomia was preformed with intraoperative positioning of JJ stent. The VVFs were mainly midvaginal (60%). The VVF was repaired in all patients using the traditional techniques of tissue separation, circumscription of fistula, closure of bladder in 1 layer using 2-0 Vicryl sutures without tension, and closure of the anterior vaginal wall in 1 layer over the repaired VVF site with interposition of omentum. VVFs were successfully closed at first attempt in 18 patients, and after second procedure in 4 patients, as evidenced by the continence dye test in the operating room and from history taking at discharge and at the follow-up visits. Urethral catheters were used for urinary drainage in all cases and removed after 7- 28 days. There were no major surgical complications. Discussion VVF is a serious iatrogenic consequence, frequently associated with transabdominal hysterectomy. Successful closure of the fistula requires an accurate and timely repair, preoperative evaluation, good exposure, excision of surrounding fibrous tissue, tension- free closure and adequate postoperative urinary drainage.

vesicovaginal fistula ; urologic surgical procedures

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