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Vesicovaginal Fistula
Last Updated: June 25, 2006

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  AUTHOR INFORMATION Section 1 of 9   

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Author Information Introduction Indications Relevant Anatomy And Contraindications
Workup Treatment Complications Outcome And Prognosis Bibliography

Author: Valerie J Riley, MD, Director, Urogynecology and Continuing

Reconstructive Pelvic Surgery, Department of Obstetrics and Education
Gynecology, Lehigh Valley Hospital and Health Network, CME available for
Pennsylvania this topic. Click
here to take this
Coauthor(s): John Spurlock, MD, Director of Urogynecology CME.
and Pelvic Reconstructive Surgery, Department of Obstetrics and
Gynecology, St Luke's Hospital of Bethlehem
Patient Education
Editor(s): Jeffrey B Garris, MD, Chief, Assistant Professor,
Click here for
Department of Obstetrics and Gynecology, Division of
patient
Urogynecology and Reconstructive Pelvic Surgery, Tulane
education.
University School of Medicine; Francisco Talavera, PharmD,
PhD, Senior Pharmacy Editor, eMedicine; David Chelmow,
MD, Professor, Division of Obstetrics and Gynecology, Program
Director, OB/GYN Residency Program, Tufts University School
of Medicine; Consulting Staff, Tufts Womens Health Associates,
Tufts-New England Medical Center; Frederick B Gaupp, MD,
Consulting Staff, Department of Family Practice, Assumption
Community Hospital; and Lee P Shulman, MD, Professor of
Obstetrics and Gynecology, Feinberg School of Medicine,
Northwestern University; Chief, Division of Reproductive
Genetics, Department of Obstetrics and Gynecology, Prentice
Women's Hospital, Northwestern Memorial Hospital

Disclosure

  INTRODUCTION Section 2 of 9   

Author Information Introduction Indications Relevant Anatomy And Contraindications
Workup Treatment Complications Outcome And Prognosis Bibliography

Vesicovaginal fistula (VVF) is a subtype of female urogenital

fistula (UGF). VVF is an abnormal fistulous tract extending
between the bladder and the vagina that allows the continuous
involuntary discharge of urine into the vaginal vault. In addition
to the medical sequelae from these fistulas, they often have a
profound effect on the patient's emotional well-being. This article
reviews the etiology of VVF, the surgical principles of repair,
and the techniques developed for their repair.

History of the Procedure: The earliest evidence of a VVF was

found in 1923, when Derry examined the mummified body of
Queen Henhenit (2050 BC). These dissections revealed a large
VVF in a markedly contracted pelvis. The first clear documented
reference to genital fistula was reported in the Ebers papyrus in
approximately 2000 BC. However, not until 950 AD did
Avicenna correlate the combination of pregnancy at a young age
and difficult labor with the formation of a vesicovaginal
communication. The term fistula (previously called ruptura) was
not used until 1597, when Luiz de Mercado first coined the term.

The first basic surgical principles for the repair of VVFs were
described in 1663 by Hedrik von Roonhuyse. He stressed the use
of a speculum and the lithotomy position to gain adequate
exposure and denudation of the margin of the bladder wall, with
reapproximation of the edges using sharpened swan quills. Later,
using Roonhuyse's technique, Johann Fatio documented the first
successful VVF repair in 1675. However, not until the 19th
century did successful repair of VVFs become common. In 1834,
Jobert de Lamballe published a report of his VVF repairs in
which skin flaps were used in the vagina. Later, he advocated the
use of tension-free closures using vaginal-releasing incisions.

James Marion Sims published his famous discourse on the

treatment of VVF in 1852. Using leaden or silver wire, as John
Peter Mettauer had done successfully in 1838, Sims achieved
success on his 30th surgical attempt on a slave named Anarcha.
Sims emphasized the importance of good exposure, adequate
resection of the fistula and scarred vaginal edges, and the critical
importance of continuous postoperative bladder drainage. Sims
disparaged the popular technique of coagulation (by the
application of silver nitrate), stating it proved entirely ineffective
except in the rare case of a very small fistula. In 1861, Maurice
Collis was the first to report a layered closure technique, and, in
1893, Schuchardt described a pararectal incision to facilitate
improved exposure for the repair of a high VVF.

During the early 20th century, several additional techniques were

used to improve outcome for the repair of VVF. In 1914, Latzko
published his partial colpocleisis technique for repair of
posthysterectomy VVF, in which he employed the resection of
scarred vaginal mucosa and a layered horizontal closure. Latzko's
procedure has been cited, with his 95-100% success rates noted,
in numerous surgeons' experiences. In 1950, O'Conor and
Stovsky popularized the transabdominal approach and also
proposed the use of electrocoagulation as an initial treatment
modality in women with VVFs of 3.5 mm or less, citing a 73%
success rate.

Additionally, numerous surgeons are credited for the

development of various flaps for interposition between the
bladder and vaginal walls to minimize the failure of VVF repairs.
The list includes Garlock in 1928 (pedicled gracilis muscle flap),
Martius in 1928 (pedicled bulbocavernosus flap), Ingelman-
Sundberg in 1960 (pubococcygeus, bulbocavernosus, rectus
abdominis, and gracilis), and Kiricuta and Goldstein in 1972
(pedicled omental flaps).

This historical outline of surgical advances is by no means

complete. Countless surgeons not listed above have helped raise
awareness of VVF with the public and in the medical
community, while making substantial contributions in the
research and surgical management of this morbid condition.

Problem: A VVF is an abnormal communication between the

urinary bladder and the vagina that results in the continuous
involuntary discharge of urine into the vaginal vault. An accurate
diagnosis is paramount before consideration of repair. A variety
of methods are available to the clinician, and any excessive or
suspicious vaginal discharge in a patient who recently underwent
pelvic surgery or who has a history of pelvic radiotherapy should
be evaluated promptly for a UGF.

Frequency: In developing countries, the predominant cause of

VVF is prolonged obstructed labor (97%). VVFs are associated
with marked pressure necrosis, edema, tissue sloughing, and
cicatrization. The frequency of VVF is largely underreported in
developing countries.

The magnitude of the fistula problem worldwide is unknown but

believed to be immense. In Nigeria alone, Harrison (1985)
reported a vesicovaginal fistula rate of 350 cases per 100,000
deliveries at a university teaching hospital. The Nigerian Federal
Minister for Women Affairs and Youth Development, Hajiya
Aish M.S. Ismail, has estimated that the number of unrepaired
VVFs in Nigeria is between 800,000 and 1,000,000 (2001). In
1991, the World Health Organization identified the following
geographic areas where obstetric fistula prevalence is high:
virtually all of Africa and south Asia, the less-developed parts of
Oceana, Latin America, the Middle East, remote regions of
Central Asia, and isolated areas of the former Soviet Union and
Soviet-dominated eastern Europe.

In contrast to developing countries, countries that practice

modern obstetrics have a low rate of UGFs and VVF remains the
most common type. Less frequently, UGFs may occur (1)
between the bladder and cervix or uterus; (2) between the ureter
and vagina, uterus, or cervix; and (3) between the urethra and
vagina. Of note, a ureteric injury is identified in association with
10-15% of VVFs.

The majority of UGFs in developed countries are a consequence

of gynecological surgery. Consequently, the incidence may
change as surgical management changes. The incidence of VVF
in the United States is debated. Although most authors quote an
incidence rate of VVF after total abdominal hysterectomy (TAH)
of 0.5-2%, others suggest only a 0.05% incidence rate of injury
to either the bladder or ureter.

Lee, in a series of 35,000 hysterectomies, found more than 80%

of genitourinary fistulas arose from gynecological surgery for
benign disease. Uncomplicated TAH accounted for more than
70% of these surgeries. The indications for these TAH surgeries
excluded the more complex diagnoses, such as pelvic
inflammatory disease (PID), endometriosis, and carcinoma;
instead, they were performed primarily for diagnoses such as
abnormal bleeding, fibroids, and prolapse. In approximately 10%
of cases of VVF, obstetrical trauma was the associated etiology.
Radiotherapy and surgery for malignant gynecologic disease
each accounted for 5% of cases.

Notably, a rise in incidence of UGFs paralleled the switch in

policy toward the preference of performing a total hysterectomy
over a supracervical hysterectomy.

Etiology:

Developing countries
Numerous factors contribute to the development of VVF in
developing countries. Commonly, these are areas where the
culture encourages marriage and conception at a young age, often
before full pelvic growth has been achieved. Chronic
malnutrition further limits pelvic dimensions, increasing the risk
of cephalopelvic disproportion and malpresentation. In addition,
few women are attended by qualified health care professionals or
have access to medical facilities during childbirth; their
obstructed labor may be protracted for days or weeks.

The effect of prolonged impaction of the fetal presenting part in

the pelvis is one of widespread tissue edema, hypoxia, necrosis,
and sloughing resulting from prolonged pressure on the soft
tissues of the vagina, bladder base, and urethra. Typically in
these countries, the UGF is large and involves the bladder,
urethra, bladder trigone, and the anterior cervix. Complex
neuropathic bladder dysfunction and urethral sphincteric
incompetency often result, even if the fistula can be repaired
successfully. Other cultural factors that increase the likelihood of
obstetrical UGFs include outlet obstruction due to female
circumcision and the practice of harmful traditional medical
practices such as Gishiri incisions (anterior vaginal wall
incisions) and the insertion of caustic substances into the vagina
with the intent to treat a gynecologic condition or to help the
vagina to return to its nulliparous state.

Developed countries

VVFs in developing countries are attributed predominantly to

inadvertent bladder injury during pelvic surgery (90%). They
involve a relatively limited focal bladder injury leading to
smaller VVFs than are observed in developing countries.
Numerous authors highlight the risk of various types of bladder
trauma during pelvic surgery. Such injuries include unrecognized
intraoperative laceration of the bladder, bladder wall injury from
electrocautery or mechanical crushing, and the dissection of the
bladder into an incorrect plane, causing avascular necrosis.

Suture placement through the bladder wall in itself may not play
a significant role in VVF development. However, the risk of
formation of a hematoma or avascular necrosis after a suture is
placed through the bladder wall can lead to infection, abscess,
and subsequent suture erosion through the bladder wall. This
wall defect permits the escape of urine into the vagina and may
be followed by an eventual epithelialization of the track.
Gynecologic procedures are the most common iatrogenic factor.
Symmonds evaluated 800 genitourinary fistulas over a 30-year
period at the Mayo Clinic. Of these, 85% of the VVFs were
related to pelvic operations and 75% were related to
hysterectomy, with more than 50% being secondary to simple
uncomplicated total abdominal or vaginal hysterectomy.
Symmonds also found that 5% of these VVFs were obstetric and
10% occurred after radiotherapy. Obstetric UGFs in modern
centers include vaginal lacerations from forceps rotations,
cesarean delivery, hysterectomy, and ruptured uterus.

Other types of pelvic surgery (eg, urologic, gastrointestinal

surgery) also contribute to the incidence of VVFs; such surgeries
include suburethral sling procedures, surgical repair of urethral
diverticulum, electrocautery of bladder papilloma, and surgery
for pelvic carcinomas. Other less common causes of VVFs
include pelvic infections (eg, tuberculosis, syphilis,
lymphogranuloma venereum), vaginal trauma, and vaginal
erosion with foreign objects (eg, neglected pessary). Lastly, a
congenital urogenital abnormality may exist that includes a VVF.

Risk factors that predispose to VVFs include prior pelvic or

vaginal surgery, previous PID, ischemia, diabetes,
arteriosclerosis, carcinoma, endometriosis, anatomic distortion
by uterine myomas, and infection, particularly postoperative cuff
abscess. Tancer found prior cesarean delivery to be the most
common factor predisposing to vault fistula after abdominal
surgery in his series of 110 cases; here, 29% were associated
with prior cesarean delivery. Of interest, Tancer also noted 67%
of the VVFs in his series occurred in the absence of any risk
factors. He also noted that 24 patients incurred a bladder injury
during hysterectomy; the injury was recognized intraoperatively
and received immediate intraoperative repair (often by a
consulting specialist). Despite prompt identification, treatment,
and postoperative continuous bladder drainage for 7-10 days, a
VVF could not be averted.

Clinical: The uncontrolled leakage of urine into the vagina is the

hallmark symptom of patients with UGFs. Patients may complain
of urinary incontinence or an increase in vaginal discharge
following pelvic surgery or pelvic radiotherapy with or without
antecedent surgery. The drainage may be continuous; however,
in the presence of a very small UGF, it may be intermittent.
Increased postoperative abdominal, pelvic, or flank pain;
prolonged ileus; and fever should alert the physician to possible
urinoma or urine ascites and mandates expeditious evaluation.
Recurrent cystitis or pyelonephritis, abnormal urinary stream,
and hematuria also should initiate a workup for UGF.

The time from initial insult to clinical presentation depends on

the etiology of the VVF. A VVF secondary to a bladder
laceration typically presents immediately. Approximately 90% of
genitourinary fistulas associated with pelvic surgery are
symptomatic within 7-30 days postoperatively. An anterior
vaginal wall laceration associated with obstetric fistulas typically
(75%) presents in the first 24 hours of delivery. In contrast,
radiation-induced UGFs are associated with slowly progressive
devascularization necrosis and may present 30 days to 30 years
later. Patients with radiation-induced VVFs initially present with
symptoms of radiation cystitis, hematuria, and bladder
contracture.

  INDICATIONS Section 3 of 9   

Author Information Introduction Indications Relevant Anatomy And Contraindications
Workup Treatment Complications Outcome And Prognosis Bibliography

Symptomatic VVF merits appropriate treatment. Further details

regarding the indications for a specific procedure are described in
Surgical objectives or principles.

Section 4 of
RELEVANT ANATOMY AND 9   
 
CONTRAINDICATIONS
Author Information Introduction Indications Relevant Anatomy And Contraindications
Workup Treatment Complications Outcome And Prognosis Bibliography

Contraindications: In general, no absolute contraindications

exist for the attempted correction of a VVF in patients who can
medically tolerate a surgical procedure.

  WORKUP Section 5 of 9   

Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications
Outcome And Prognosis Bibliography

Lab Studies:

 Upon examination of the vaginal vault, any fluid collection noted can be tested for
urea, creatinine, or potassium concentration to determine the likelihood of a
diagnosis of VVF as opposed to a possible diagnosis of vaginitis.
  Once the diagnosis of urine discharge is made, the physician must identify its
source.

 The differential diagnosis for the discharge of urine into the vagina includes
single or multiple vesicovaginal, urethrovaginal, or ureterovaginal fistulas and
fistula formation between the urinary tract and the cervix, uterus, vagina, vaginal
cuff, or (rarely) ureteral fistula to a fallopian tube.

 A full vaginal inspection is essential and should include assessment of tissue

mobility; accessibility of the fistula to vaginal repair; determination of the degree
of tissue inflammation, edema, and infection; and possible association of a
rectovaginal fistula.

 Urine should be collected for culture and sensitivity, and patients with positive
results should be treated prior to surgery.

 In patients with a history of local malignancy, a biopsy of the fistula tract and
microscopic evaluation of the urine is warranted.

Imaging Studies:

 Radiologic studies should be employed prior to surgical repair of a VVF.

o An intravenous urogram (IVU) is necessary to exclude ureteral injury or

fistula because 10% of VVFs have associated ureteral fistulas.

o If suspicion is high for a ureteral injury or fistula and the IVU findings are
negative, retrograde ureteropyelography should be performed at the time
of cystoscopy and examination under anesthesia.

o A Tratner catheter can be used to assist in evaluation of a urethrovaginal

fistula.

 Fibrin occlusion therapy is used for the treatment of a variety of fistulas, such as
enterocutaneous, anorectal, bronchopleural, ureterocutaneous, and, more recently,
VVFs. Fistulograms are a valuable adjunct to fibrin occlusion therapy.

Diagnostic Procedures:

 Intraoperative assessment for bladder or ureteral injury may be performed by

administering indigo carmine intravenously and closely observing for any
subsequent extravasation of dye into the pelvis.

o Cystourethroscopy to assure bilateral ureteral patency and absence of

suture placement in the bladder or urethra has been advocated by some
 authors as a standard for all pelvic surgery.

o Alternatively, intraoperative back-filling of the bladder with methylene

blue or sterile milk before completing abdominal or vaginal surgery also
may help detect a bladder laceration.

o Retrograde filling of the bladder also can be used during surgery to better
define the bladder base in more difficult dissections.

 In the office, the evaluation should include a complete physical examination and
detailed review of systems. A cystoscopic examination with a small scope (eg,
19F) may be used to identify VVF in the bladder or urethra, to determine the
number and location and proximity to ureteric orifices, and to identify and remove
abnormal entities such as calculi or sutures in the bladder.

 In the office, as with the operating room setting, the bladder can be filled with
sterile milk or methylene blue in retrograde fashion using a small transurethral
catheter.

o Placement of tampons in tandem in the vaginal vault and observation for

staining of the tampons by methylene blue may help to identify and locate
fistulas.

o Staining of the apical tampon would implicate the vaginal apex or

cervix/uterus/fallopian tube; staining of a distal tampon raises suspicion of
a urethral fistula.

o If the tampons are wet but not stained, oral phenazopyridine (Pyridium) or
intravenous indigo carmine then can be used to rule out a ureterovaginal,
ureterouterine, or ureterocervical fistula.

o Evidence of staining or wetting of a tampon should then prompt the

physician to proceed with additional diagnostic testing prior to proceeding
with definitive management.

 Water cystoscopy may be inadequate in the face of large or multiple fistulas.

 A cystoscopic examination using carbon dioxide gas may be used with the patient
in the genupectoral position. With the vagina filled with water or isotonic sodium
chloride solution, the infusion of gas through the urethra with a cystoscope
produces air bubbles in the vaginal fluid at the site(s) of a UGF (flat tire sign).

 Combined vaginoscopy-cystoscopy: Andreoni et al describe their technique of

simultaneously viewing 2 images on the monitor screen (both cystoscopic and
vaginal examinations). They use a laparoscope and clear speculum in the vagina
and they use regular cystoscope in the bladder to enhance visualization and
 identification of VVFs. Transillumination of the bladder or vagina by turning off
the vaginal or bladder light source allows for easier identification of the fistula in
the more difficult cases.

 Color Doppler ultrasonography with contrast media of the urinary bladder may be
considered in cases where cystoscopic evaluation is suboptimal, such as in those
patients with severe bladder wall changes like bullous edema or diverticula. Color
Doppler ultrasonography demonstrated a VVF in 92% of the patients studied by
Volkmer and colleagues using diluted contrast media and observing jet
phenomenon through the bladder wall toward the vagina.

  TREATMENT Section 6 of 9   

Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications
Outcome And Prognosis Bibliography

Medical therapy:

Conservative management

If VVF is diagnosed within the first few days of surgery, a transurethral or suprapubic
catheter should be placed and maintained for up to 30 days. Small fistulas (<1 cm) may
resolve or decrease during this period if caution is used to ensure proper continuous
drainage of the catheter.

In 1985, Zimmern concluded that if the fistula is small and the patient's vaginal leakage
of urine is cured with Foley placement, the fistula has a high spontaneous cure rate with a
3-week trial of Foley drainage. He also noted that in general, if at the end of 30 days of
catheter placement the fistula has diminished in size, a trial of continued catheter
drainage for an additional 2-3 weeks may be beneficial. Finally, Zimmern concluded that
if no improvement is observed after 30 days, a VVF is not likely to resolve
spontaneously. Under these circumstances, prolonged catheterization only increases the
risks of infection and offers no increased benefit to fistula cure.

In their series, Davitz and Miranda found complete resolution of 4 VVFs with continuous
bladder drainage maintained for 19-54 days. Tancer noted spontaneous closure in 3 of
151 patients (2%). In these 3 patients, continuous bladder catheterization was provided
within 3 weeks of index hysterectomy; none had an epithelialized fistula tract, and 2 had
transvesical sutures that were removed at the time of the initial cystoscopic examination.
The size of the VVFs was not documented.

Elkins and Thompson noted some success with continuous bladder drainage.
Unfortunately, the rate of success was unpredictable for the individual patient; the rates
ranged from 12-80%. Successful cases were characterized by the following criteria:
continuous bladder drainage for up to 4 weeks, the VVFs were diagnosed and treated
within 7 days of index surgery, VVFs were less than 1 cm, and they were not associated
with carcinoma or radiation.

Surgical therapy:

Surgical objectives or principles

Guidelines to follow intraoperatively to minimize VVF formation are identical to those

followed at the time of index surgery to prevent a fistula complication. A summary of
these guidelines follows.

Adequate exposure of the operative field should be obtained to avoid inadvertent organ
injury and to ensure prompt identification of any injury incurred.

Minimize bleeding and hematoma formation. The closure of dead space at the anterior
vaginal wall upon completion of an anterior colporrhaphy will prevent hematoma
formation. This technique employs intermittently incorporating pubocervicovaginal
fascia with the vaginal mucosal layer as the vaginal wall is sutured.

Widely mobilize the bladder from the vagina during hysterectomy to diminish the risk of
suture placement into the bladder wall. A minimum of a 1- to 2-cm margin of dissection
of the bladder from the vaginal cuff should be developed prior to cuff closure.

Dissect the pubocervicovaginal endopelvic fascia between the vagina and the bladder in
the appropriate plane. Dissection may be easier with a sharp technique compared to a
blunt technique; the key is to prevent trauma and separation of bladder wall fibers as the
bladder is mobilized off the anterior vaginal wall. The principle of traction and
countertraction of the bladder and uterus works well to effect a bloodless dissection at the
areolar pubocervicovaginal fascial plane.

If scarring is present at the pubocervicovaginal fascia and dissection is difficult, consider

performing an intentional anterior extraperitoneal cystotomy. This technique enables the
surgeon to assess the anatomic boundaries of the bladder wall with digital palpation. If
scarring is present at the pubocervicovaginal fascia and dissection is difficult, consider
employing an intrafascial technique of hysterectomy to best dissect the endopelvic fascial
plane.

Intraoperative retrograde filling and emptying of the bladder or mild traction on a

temporarily placed small Foley catheter inserted into the fistula itself are helpful to
optimally identify anatomical planes and reveal intraoperative bladder lacerations.

Consider supracervical abdominal hysterectomy instead of TAH. The incidence of UGF

formation is lower for supracervical versus total hysterectomy.

If an intraoperative bladder injury does occur, Tancer argues strongly for widely
mobilizing the bladder from the underlying structures (fascia and vagina, cervix, or
uterus). In doing so, the surgeon can effect a VVF closure under no tension.

For repairing a cystotomy at the trigonal area, a transverse closure is preferable over a
vertical one. Vertical closure would be more likely to produce ureteral obstruction
because the ureteral orifices would be drawn inward toward each other. Ureteral catheters
should be considered in repair of a cystotomy involving or encroaching on ureteric
orifices.

Consider performing cystourethroscopy when performing pelvic surgery.

Cystourethroscopy to assure bilateral ureteral patency and the absence of suture
placement in the bladder or the urethra has been advocated by some authors as a standard
for all pelvic surgery.

Preoperative details:

Timing of repair

The occurrence of a UGF is an anguishing experience for both the patient and the
surgeon. The timing of repair should be dictated by the overall medical condition of the
patient and the tissue quality surrounding the fistula. While the emotional status of the
patient should not be underestimated, it also should not play a dominant role in the
decision process of when to repair a VVF.

Controversy surrounds the length of delay between diagnosis and surgical repair of a
noninfected VVF in a patient who has not undergone radiation treatment. Complicating
the analysis of data is the fact that no definition has been established for "early" and
"late" intervals. Traditionally, late referred to waiting for an 8- to 12-week interval
between index surgery and repair. Longer intervals are universally accepted as the
standard of care in infected or irradiated tissue. A 1-year interval for radiation-induced
fistulas is recommended to ensure full resolution of tissue necrosis.

Margolis and Mercer simply recommend delaying surgery until inflamed and infected
tissue has been treated and the infection and inflammation have resolved. O'Conor agrees
that the exact timing for repair depends on when the tissue health is adequate; most of his
patients were brought to surgery approximately 3 months after index surgery. During the
waiting period, he discouraged indwelling catheter usage and generally advocated vaginal
estrogen therapy. Consideration to adjunctive steroid therapy may be contemplated.

Carr and Webster suggest a strategy of examining the fistula at 2-week intervals and
proceeding to surgery when the tissue is pliable, not infected, and not inflamed. In their
experience, this typically occurred 4-8 weeks after index surgery.

In Persky's series of 7 patients, a 100% success rate was noted with repair performed
between 1 and 10 weeks. All of these patients had an interposition graft of peritoneum
and omentum placed.

In a retrospective analysis of 25 patients with VVF referred between 1970 and 1980,
Blandy and colleagues noted success with all early and late repairs. Only 12 patients were
referred before 6 weeks and, therefore, were candidates for early repair. The remaining
13 were referred after 6 weeks. The surgical technique employed in all cases was midline
cystotomy to the level of the fistula, ureteral catheterization, bladder mobilization from
vagina, closure of the vaginal defect with 3-0 chromic catgut in interrupted fashion, and
placement of an omental interposition graft. Urethral catheterization was employed for
10-12 days. A suprapubic catheter also was placed in approximately half of the patients.
Ureteral stents were removed after 5-10 days.

Blaivas documented his philosophy "to repair fistulas as soon as possible and, preferably,
by a vaginal approach" in his 1995 article that examined the repair of 24 VVFs between
1989 and 1993. Early repairs were defined as those that occurred within 12 weeks of
index surgery. Success rates for early repair were similar to those for late repair as long
as general principles of surgery were followed. He concluded that no benefit was noted
by delaying surgery once evidence of any inflammation, induration, or infection was
resolved.

Lee found a correlation between increased surgical failure and VVF repair performed
very early (10-15 d). In his experience, a delay of 8-12 weeks from index surgery or
failed repair ensures a full resolution of inflammation and edema and provides an
adequate blood supply, thereby optimizing success of VVF repair. However, he exempts
certain cases from this general rule. These include fistulas diagnosed within hours of
surgery and obstetrical lacerations.

Contraindications to early closure of fistulas, as per Huang et al, include multiple

unsuccessful closures in the past, an associated enteric fistula with pelvic phlegmon, or
previous radiation. These types of fistulas require a delay in their repair of a minimum of
4-8 months and should include usage of an interposing flap/buttress.

Medications

Estrogen replacement therapy in the postmenopausal patient may assist with optimizing
tissue vascularization and healing. Oral hormone replacement therapy/estrogen
replacement therapy (HRT/ERT) alone has been found to suboptimally estrogenize
urogenital tissue in 40% of patients. Treatment with estrogen vaginal cream is
recommended for patients with VVFs who are hypoestrogenic. A 4- to 6-week treatment
regimen prior to surgery is commonly recommended. It may be used alone or in
combination with oral HRT/ERT. Dosages range from 2-4 g placed vaginally at bedtime
once per week. Alternatively, the patient may place 1 g vaginally at bedtime 3 times per
week.

Corticosteroid and nonsteroidal anti-inflammatory therapy is theorized to minimize early

inflammatory changes at the fistula site. However, its efficacy has not been proven.
Because it also carries potential risks for impairment of wound healing, when early repair
is planned, cortisone is not recommended for the treatment of VVF.

Acidification of urine to diminish risks of cystitis, mucus production, and formation of

bladder calculi may be a consideration, particularly in the interval between the diagnosis
and surgical repair of VVF. Vitamin C at 500 mg orally 3 times per day may be used to
acidify urine. Alternatively, methenamine mandelate at 550 mg plus sodium acid
phosphate at 500 mg 1-4 times per day also can be administered to achieve urine
acidification.

Urised is effective for control of postoperative bladder spasms. It is a combination of

antiseptics (methenamine, methylene blue, phenyl salicylate, benzoic acid) and
parasympatholytics (atropine sulfate, hyoscyamine sulfate).

Sitz baths and barrier ointments, such as zinc oxide preparations, can provide needed
relief from local ammoniacal dermatitis.

Intraoperative details:

Antibiotic prophylaxis

Antibiotic prophylaxis for VVF repair was the focus of study in a paper from the Benin
Republic by Tomlinson and Thorton. In their series of 79 patients who underwent repair
of a VVF by a single surgeon, they found intraoperative ampicillin did not reduce the
odds of failed repair. However, patients given prophylactic antibiotic therapy did have
fewer urinary infections and required less antibiotic therapy postoperatively.

Patient positioning

Lawson position: This position is ideal for proximal urethral and bladder neck fistulas.
The patient is placed in a prone position with the knees spread and ankles raised in the air
and supported by stirrups. Combining it with reverse Trendelenburg positioning enhances
visualization with this technique. Elkins found this technique to work best for him.

Jackknife position: This is ideal for proximal urethral and bladder neck fistulas. The
patient is placed in a prone position with the hips abducted and flexed and the table
jackknifed.

Dorsal lithotomy position: Dorsal lithotomy position with standard Trendelenburg

positioning provides excellent access for repair of a high VVF.

To excise or not to excise: The fistula tract excision debate

In their experiences, Raz, Vasavada, Margolis, and Mercer note that routine excision of
the fistula tract is not mandatory. They emphasize the risks of increasing the size of the
fistula tract with attempts to resect it. Additionally, these surgeons contend that the
fibrous ring of the fistula may add to the strength of the repair and prevent postoperative
bladder spasms. Cruikshank reported a 100% success rate in his series of 11 patients with
fistula repair without tract excision. Elkins and Thompson state that a small fistula may
be resected, but large tracts should only be freshened. They warn of the risk of
overexcising fistula edges, thereby causing an increase in the size of the fistula. They
point out further risks of intracystic bleeding and blood clot formation from the mucosal
edge of the bladder with fistula resection. Subsequent blockage of the catheter
postoperatively would then increase the risk of failure of the VVF repair.

In contradistinction, Iselin and colleagues strongly feel excision of the fistula tract
ensures closure of all layers with viable tissue, thereby optimizing wound healing. In
their series of 20 patients who had undergone hysterectomy, a 100% cure rate was
obtained with full excision of the fistula tract. They emphasize lack of complications,
such as symptomatic vaginal shortening, with their technique.

De-epithelialization of the fistula tract can be accomplished by various techniques. Screw

curette is one method. In 1977, Aycinena described the use of a common type of screw to
strip away or curet the epithelial lining of small VVFs. He then simply allowed
spontaneous healing to occur. Seven patients were reported in this series, all of whom
were treated successfully. Experts in the field caution that this procedure is efficacious
only in the smallest of VVFs. Other methods used to de-epithelialize the fistula tract
include electrocoagulation and sharp knife dissection.

Techniques of repair

The best chance for a surgeon to achieve successful repair is by using the type of surgery
with which he or she is most familiar. Techniques of repair include (1) the vaginal
approach, (2) the abdominal approach, (3) electrocautery, (4), fibrin glue, (5) endoscopic
closure using fibrin glue with or without adding bovine collagen, (6) the laparoscopic
approach, and (7) using interposition flaps or grafts.

The literature documents excellent success rates for both the vaginal and abdominal
approaches if the following general surgical principles are followed: (1) complete
preoperative diagnosis, (2) exposure, (3) hemostasis, (4) mobilization of tissue, (5) tissue
closure under no tension, (6) watertight closure of bladder with any cystotomy repair, (7)
timing to avoid infection and inflammation of tissue, (8) adequate blood supply at area of
repair, and (9) continuous catheter drainage postoperatively.

Vaginal approach

Minimal blood loss, low postoperative morbidity, shorter operative time, and shorter
postoperative recovery time are characteristics of the vaginal approach, making it an
attractive option. Additionally, the vaginal approach obviates bowel manipulation,
reducing operative morbidity, particularly in patients with radiation-associated fistulas.

Angioli et al emphasize that the absolute contraindications for vaginal repair of VVF are
the concomitant presence of fistulas with other abdominopelvic organs, such as ureters
and small and large bowel, and multiple VVFs.

 Exposure

Suturing of the labial folds to the ipsilateral thigh provides improved visibility of the
vaginal vault.

Procedures used to facilitate exposure in the vagina include Dührssen and Schuchardt
incisions. As early as 1856, Baker advocated the use of an episiotomy incision to afford
greater exposure in the vaginal repair of fistulas that were located high in the vaginal
vault. Vaginal incisions used to improve exposure include the Dührssen incision and the
Schuchardt incision.

The Dührssen incision is a deep vaginoperineal incision or extended episiotomy initially

proposed for usage in other types of vaginal surgery. Its application to fistula surgery was
recommended by Mackenrodt in 1894.

In 1893, Schuchardt introduced a parasacral incision as an extension of a Dührssen

incision, whereby a deep vaginoperineal incision is carried cephalad to the vault apex and
then posteriorly toward the tip of the coccyx. Schuchardt's paravaginal incision is
performed by incising the posterior vaginal wall in a direction angled toward the ischial
tuberosity, going through the levator ani and the coccygeus muscle, to ultimately gain
access into the ischiorectal fossa.

In 1984, Maisonneuve described the same procedure in his attempts to gain better access
in vaginal repair of fistulas. Hemorrhage is an expected complication encountered using
this technique. The obstetrician's mediolateral episiotomy procedure is a modified
Schuchardt paravaginal incision.

 Catheterization of the fistula tract

Exposure and access to a VVF can be facilitated by catheterization of the fistula with a
bulb catheter, such as a Fogarty catheter. An uninflated catheter may thread the fistula
where the bulb is inflated, then traction is placed on the catheter to draw the VVF into the
field. A small VVF may be probed first with a lacrimal duct probe and dilated with
cervical dilators to permit placement of a pediatric catheter/ureteral bulb catheter.

 Low-tension closure

The critical issue of closure of suture lines without any tension is a tenet of surgical repair
of VVF. In an attempt to reduce strain at the site of anterior vaginal wall closures,
surgeons employ several strategies, including extensive vaginal wall dissection and
mobilization from the underlying vesicovaginal endopelvic fascia.

Alternatively, a surgeon may opt to create lateral radial or circumferential relaxing

incisions similar to those first described by Jobert de Lamballe in the mid 1800s. The
relaxing incisions are the full thickness of the vaginal wall without extension into the
endopelvic fascia. The margins are not reapproximated; instead, they may be sutured in
running fashion for desired hemostasis.

A significant danger to performing lateral relaxing incisions is further devascularization

of the vaginal tissue. An alternative approach that avoids this potential complication is to
employ vascularized flaps or grafts at the site of fistula repair, such as a Martius
bulbocavernosus fibromuscular pedicle with or without an intact skin patch. Such grafts
are essential in the repair of large fistulas and radiotherapy-related fistulas, where large
areas of devascularized and scarred vaginal walls commonly are observed (see
Interposition flaps and grafts).

Surgical procedures for the vaginal approach

 Latzko partial colpocleises procedure

Numerous authors hold this time-honored procedure, with success rates of 93-100%, to
be the standard for repair of simple posthysterectomy VVFs.

In 1942, Latzko published his modification of the Simon colpocleisis procedure designed
for repair of obstetric VVFs. The Simon colpocleisis technique applied a transverse
closure of the vagina beneath the fistula defect. Unfortunately, it often resulted in the
formation of a symptomatic diverticulum between the bladder and cervix. Latzko
advocated the prerequisite of total hysterectomy to obviate such a complication.
Additionally, he strongly cautioned strict adherence to 2 additional prerequisite
conditions. First, adequate preoperative vaginal vault length must be present because the
vagina is shortened by 1.5 cm. Second, the fistula must be located at the vaginal apex "so
that the posterior margin of the fistula and the scar of the vaginal vault coincide."

Advantages of the Latzko procedure include simplicity of technique, high success rate,
low morbidity, no impairment in bladder capacity, and no compromise of ureteral
orifices, even with fistulas lying close to the orifices.

Several surgeons describe symptomatic vaginal vault foreshortening with the Latzko
procedure. However, in the experience of Elkins and Thompson, significant shortening in
vaginal length was not noted unless the patient had antecedent shortening.

In performing the Latzko procedure, Robertson found he never needs to place a ureteral
catheter, even when the fistula margin lies adjacent to a ureteral orifice, because the
ureter is turned into the bladder, preventing ureteral occlusion. Some authors state that
the presence of a cervix is a contraindication for a Latzko procedure. However, Elkins
and Thompson do not agree. They report that a juxtacervical VVF can be repaired
vaginally if the cervix can be drawn down adequately out of the surgical field of closure.

Latzko technique: Vaginal mucosa is sharply denuded in a circular fashion at a distance

of 1.5 cm from the fistula opening. The fistula at the bladder mucosa is not disturbed. A
double row of sagittally oriented sutures is placed in the raw surfaces on either side of the
fistula, with the second row imbricating the first. Suturing of the vaginal wall is then
performed, providing a third layer of closure. The vaginal wall in contact with the bladder
becomes the posterior vesical wall and eventually is reepithelialized with transitional
epithelium.

 Flap-splitting techniques

In this technique, the vaginal wall is incised circumferentially around the fistula and
widely dissected from the underlying endopelvic fascia in a standard anterior
colporrhaphy technique. Leaving the tract unresected, the bladder is closed, tension-free,
in 2 layers. The surgery is completed with the vaginal closure over the bladder defect.

Elkins, DeLancey, and McGuire published their experiences with repair of VVF from
January 1985 through May 1989. Martius grafts were needed as an adjunctive technique
to a flap-splitting technique in less than 40% of cases. They did not find adjunctive
techniques necessary when the genital tract fistulas were small (4 cm), nonrecurrent,
well vascularized, and not radiation-induced.

Numerous surgeons, such as Margolis, Mercer, and Raz, have found this procedure as
efficacious as the Latzko technique. It has better applicability for large VVFs while not
foreshortening the vaginal vault. The authors note the risk of possible ureteral
compromise.

Technique: The vaginal wall is incised circumferentially around the fistula, leaving a rim
of intact vaginal wall encircling the fistula tract. At the lateral sides of the fistula incision,
the skin incisions are extended toward the vaginal apex in a parallel fashion. One incision
is carried further than the other, thereby incising a J shape in the vaginal wall.

The anterior and posterior flaps are widely dissected from the underlying endopelvic
fascia. The fistula tract is closed with 3-0 chromic or Dexon suture in a continuous
fashion. This closure includes the full thickness of vaginal skin previously left intact at
the fistula tract, along with the partial thickness of the bladder wall.

A second layer of closure in the endopelvic fascia is performed with 3-0 Dexon suture; it
is placed perpendicular to the prior suture line. The distal vaginal flap is trimmed. The
proximal flap is advanced beyond the fistula repair site, reaching the trimmed distal
margin, and reapproximated in a running fashion.
Zimmern et al describe their preference for an asymmetric J incision in the anterior
vaginal wall whereby the lower curve of the J loops around the fistula site. This
modification enables the surgeon to advance one flap over the fistula repair and prevent
overlapping suture lines. Martius grafts were added in cases where fistula closure was
tenuous. Tension-free closure of viable tissue, avoidance of overlapping suture lines, and
continuous postoperative bladder drainage were factors considered crucial to success.
Their 1-year success rates ranged from 90-100%.

 Vaginal cuff excision

Technique: The patient is placed in dorsal lithotomy position. Cystoscopy is performed.

Traction on the fistula site is obtained by placing a Foley catheter into the fistula tract
from a vaginal approach, inflating the balloon, and placing traction sutures at 1-cm
distances from the fistula. The vaginal mucosa is denuded circumferentially for a radius
of 3-5 mm from the vaginal cuff, including the fistula. This incision is then extended
obliquely to the bladder wall so as to resect the fistula tract and vaginal cuff scar in a
funnel-shaped specimen.

The defect is closed in 4 layers. First, the bladder is closed with interrupted 4-0 sutures;
the subvaginal pubocervicovaginal fascia then is closed in 2 layers with interrupted 3-0
sutures. This is followed by a vaginal wall closure. Each of the 4 layers employed
polyglycolic acid suture material.

Intravenous indigo carmine and cystoscopy is used to ensure bladder and ureteral
integrity. A suprapubic catheter is the preferred method of bladder drainage and is
maintained for approximately 3 weeks postoperatively.

The premise on which Iselin and colleagues base their surgical technique is that scarred
tissue margins do not heal well, if at all. In comparison, fresh viable margins provide for
optimal results in the repair of posthysterectomy VVF. They advocate a total excision of
the fistula tract and vaginal cuff scar. In their series of 20 patients, all were successfully
repaired and no symptomatic vaginal shortening or other complications were
encountered.

Flynn et al, in their retrospective study of 40 patients who underwent vaginal cuff scar
excision for VVF repair from February 1998 to December 2002, reported a 100% success
rate at the 3-month postoperative evaluation. They also reported at this evaluation that
94% of the patients denied urinary dysfunction problems and of the 34 patients who had
resumed sexual activity, only 2 women complained of mild deep dyspareunia.

Abdominal approach

Exposure: As with the transvaginal approach, exposure with the transabdominal approach
can be augmented with the use of traction sutures and with catheterization of the fistula
with a Fogarty catheter. Similarly, in 1893, Weinlechner proposed the use of a ball with
an attached wire in the combined transvaginal and transabdominal repair of VVF. The
wire was threaded through the fistula transvaginally and then grasped through the
cystotomy. Traction on the wire elevates the tract into the surgical field.

Absolute indications for abdominal approach include (1) the need for concomitant
abdominal surgery, such as augmentation cystoplasty and ureteral reimplantation; (2) the
inability to adequately expose the fistula vaginally; (3) a complex presentation of VVF
involving the ureters, bowel, or other intraabdominal structures; and (4) involvement of
the VVF with ureteric orifices (Langkilde).

The classic positioning of the patient for abdominal procedures is supine, with
Trendelenburg orientation. However, modifying this by flexing the patient's hips and
abducting and supporting her legs in stirrups is wise. Simultaneous access and
examination of the vaginal vault may assist with laparotomy procedures.

The choice of incision may include suprapubic V, Pfannenstiel, or midline vertical. In

1887, Bardenheuer recommended a transverse suprapubic incision. Turner-Warwick et al
prefer the suprapubic V incision, noting that it provides superior access to the lower
abdomen and pelvis. Several others advocate a longitudinal suprapubic incision because
it allows the surgeon the ability to more easily obtain an omental graft.

 Transvesical extraperitoneal technique

In 1885, Trendelenburg introduced the first transvesical extraperitoneal method of

vesicovaginal repair. With the patient placed in a steep Trendelenburg position, a
transvesical incision is performed to visualize the fistula. The bladder mucosa adjacent to
the fistula is circumscribed and removed. The bladder is dissected off the vagina and the
bladder, and vaginal defects are closed separately.

 Transperitoneal technique

The transperitoneal technique was developed by von Dittel in 1803 for the repair of
VVFs. In his procedure, a laparotomy was performed. The bladder was dissected from
underlying gynecologic organs involved. The defects in the bladder and vagina or cervix
were closed separately.

In 1913, Legueu described his transvesical transperitoneal suprapubic method. He

combined both the Trendelenburg and the von Dittel techniques, whereby the peritoneal
cavity is accessed by laparotomy and a sagittal incision is made in the bladder. This
cystotomy incision is extended to the fistula. The bladder is mobilized off the vagina, and
the bladder and vaginal defects are closed separately.

Unfortunately, transperitoneal surgeries were technically complex and fraught with high
morbidity and mortality at the time. Unless ureteral or coabdominal surgery was
necessary, numerous surgeons (eg, Fritsch, Wertheim, Latzko) favored the vaginal
approach techniques.

In the age of modern medicine, surgeons have the benefit of performing invasive
surgeries with sterile fields, antibiotics, and other medical advances. As such, Margolis,
Mercer, O'Conor, and Sokol find the extravesical transperitoneal procedure of great
benefit when the bladder is densely adhered to the endopelvic fascia and underlying
structures (eg, lower uterine segment, cervix, anterior vaginal wall).

 O'Conor and Sokol technique

This method was introduced as an intraperitoneal or transperitoneal technique. In 1951,

O'Conor and Sokol published a Legueu-type technique for the suprapubic repair of
trigonal and supratrigonal VVFs. According to an article published by O'Conor in 1980,
O'Conor and Sokol developed their technique after they observed Barnes' technique for
the resection of adherent bladder diverticula in 1934. O'Conor then was able to trace
Barnes' technique back to a similar procedure performed by Ward; he disclaims any
claim to originality of their procedure. To their credit, their large studies, with success
rates higher than 85%, did much to popularize the suprapubic technique.

Among the successful cases of repaired VVF are patients with complex and difficult
repairs, such as radiation-associated cases. The authors stressed that it was key to bisect
and widely mobilize the bladder from the vagina in order to produce a closure with
separate tension-free layers.

The procedure can be performed extraperitoneally; however, in complex cases, the

transperitoneal approach is preferred because it allows for the addition of interposition
grafts. Advocates of their technique cite the advantages of high success rate, optimum
surgical access to the fistula and ureters, and the ability to add an interposition graft with
this procedure.

Technique: Using an infraumbilical incision, laparotomy is performed and the peritoneal

cavity is entered. The posterior wall of the bladder is dissected free as much as possible.
The bladder then is bivalved at the dome. This incision is extended posteriorly to the
level of the fistula. Stay sutures are placed sequentially along the incisional margins
every few centimeters to permit traction and elevation of the bladder wall in order to aid
in exposure and dissection.

Ureteral orifices and the location of fistula(s) are identified, and ureteral catheters are
placed if necessary. The fistula tract and scarred and necrotic tissue are resected.
Dissection of the posterior wall of the bladder from the underlying endopelvic fascia and
vagina is completed. The bladder and vagina are closed in separate layers. The bladder is
closed with a 2-0 chromic suture in continuous running fashion beginning at the apex and
extending through the full muscle layers and imbricated with a second layer with
interrupted 1-0 chromic sutures. Commonly, peritoneal or interposition grafts are added.
A suprapubic catheter is brought out laterally to the sagittal closure. A transurethral
catheter may be placed and discontinued on postoperative day 4 or 5; the suprapubic
catheter is removed on postoperative day 14.

 Vesical autoplasty

Gil-Vernet and colleagues presented a bladder wall flap procedure in 1989 as an

alternative technique for the repair of complicated VVF. The approach may be
transvesical, extraperitoneal, or transperitoneovesical. Advantages cited by the authors
are the capability of repairing large VVFs without compromising bladder capacity, a low-
tension closure, direct and easy identification, and preservation of the submucosal
ureteral portion.

Technique: The bladder is entered through a transverse incision at the dome.

Catheterization of the ureters is performed. The fistula tract is completely excised with
the assistance of stay sutures secured around the fistula tract. The bladder wall is
carefully mobilized off the endopelvic fascia and vaginal wall. The vaginal defect is
closed with a single-layer closure. A bladder flap is constructed to close the bladder
defect. Incisions are made at the superolateral angles of the bladder defect and extended
cephalad toward the dome. The anterior margin of the flap is drawn down over the
bladder defect to meet the caudal margin of the bladder defect. It is sutured in place with
3-0 catgut through the submucosal and muscular layers in interrupted fashion with
sutures not less than 10 mm apart. The ureteral catheters are removed, and the anterior
cystotomy is closed in a single extramucosal layer. When a transperitoneal approach is
chosen, Gil-Vernet prefers to also add an interposition graft.

 Bladder mucosal autologous grafts

The use of autologous bladder mucosa grafts was first introduced in 1947 as a technique
designed for urethral reconstruction. Since that time, research performed in a canine
model by J.W. Coleman and his associates at Cornell University demonstrated that
autographs of bladder mucosa as large as 4 cm could be used successfully to cover large
defects in canine bladder walls. The application of a free bladder mucosal graft for repair
of difficult VVF was developed by Ostad and his associates. They published their series
of 6 patients with a 100% success rate. The follow-up interval ranged from 2-6 years.

All of the VVFs were high, large, multiple, or recurrent and occurred posthysterectomy;
one patient had a history of pelvic irradiation. Three were repaired early (<3 mo from
index surgery), and 3 were repaired late. Simplicity of technique, high success rates, lack
of the need for interposition grafts, and decreased patient morbidity were notable
advantages to this procedure. Exact fistula sizes were not documented.
Reepithelialization of the denuded mucosa donor site is believed to occur spontaneously
over the following 4-6 weeks.

Technique: After gaining access to the peritoneal cavity with either a Pfannenstiel or
infraumbilical low vertical midline incision, an extraperitoneal cystotomy is performed at
the anterior bladder wall. Ureteral catheters are placed. Bladder mucosa is denuded
circumferentially at the fistula site at a distance of 1 cm. The fistula tract and vaginal wall
are left undisturbed. A free bladder mucosal graft is sharply dissected from its underlying
muscularis layer at the edge of the anterior cystotomy margin. This graft of mucosa is
then secured over the fistulous tract with interrupted 4-0 chromic catgut sutures that are
placed into the superficial muscularis at a distance of 2-3 cm. The anterior cystotomy is
closed in 2 layers. A transurethral catheter is used for 24 hours. A suprapubic Malecot
drain is left in place for 2-3 weeks, and a cystogram is obtained prior to its removal.

Electrocautery

In a series of 15 patients, Stovsky et al reported a 73% cure rate with electrocoagulation

in a highly selected patient group. The fistulas that were successfully managed with
electrocautery as the sole treatment modality were small in size. Only 4 fistulas were
large enough to be cystoscopically identified with a true fistula opening; the remaining 11
were identified as either pinhole openings or bladder mucosal dimples. Details of their
technique include both vaginal and cystoscopic routes and fulguration with a Bugbee
electrode and placement of a large Foley catheter for a minimum of 2-3 weeks. Care was
taken to use low-current settings in order to minimize the potential of thermal damage
and enlargement of the fistula.

In contradistinction, Margolis and Mercer in 1994 concluded the risk of destruction of

viable tissue with usage of electrocoagulation in the repair of fistulas is too great to
warrant its application. They classified this technique as worthy of historical interest
only.

Fibrin glue

Cronkite et al introduced fibrin glue in the 1940s. They combined fibrinogen and
thrombin for use as a sealant in skin grafting procedures. Success was unpredictable, and
this technique was largely abandoned until the 1970s. Matras and associates published
their experiences with fibrin glue for interfascicular nerve repair in animals in 1972. In
1985, Matras reported on the use of a fibrin sealant in maxillofacial surgery.

Occlusion therapy using fibrin glue is considered useful and safe for intractable fistulas.
Fibrin glue facilitates healing by recruiting macrophages and providing a semisolid
support structure rich in growth and angiogenic factors. This system continues to support
the fibroblast to connective tissue transition.

Most of the data are from European investigators because the US Food and Drug
Administration regulated against commercially prepared fibrin agents until recently. A
fibrin-sealant technique has been used to treat a variety of fistula types, including
pancreatic, maxillofacial, enterocutaneous, anorectal, bronchopleural, and
gastrocutaneous. Proponents of its use note that it is employed as a minimally invasive
and technically simple outpatient surgery that lacks significant morbidity. The
commercial fibrin glue presently used in the United States is Tisseel.

Fibrin occlusion of a VVF was first developed by Pettersson and associates in 1979. The
VVF was incurred following surgery and radiotherapy and was cured with the first
attempt. Encouraged by this, Hedelin et al performed the technique in their series of 9
patients with chronic fistulas of 7 months to 10 years in duration; all had undergone at
least one prior surgical repair attempt. They demonstrated a 50% success rate in treating
vesicocutaneous fistulas, with failure in a single patient with VVF. The VVF was 2 cm
long; width was not reported.

In 1998, Venkatesh and Ramanujam published their experiences using autologous fibrin
glue to treat 30 patients with recurrent anorectal and urethrovesicorectal fistulas. All
patients had undergone at least one prior failed surgery to repair their fistulas.
Granulation tissue was removed by curettage; extensive debridement was not necessary.
Cryoprecipitate and thrombin were dispensed simultaneously into the fistula tract, filling
it immediately with the coagulum. Approximately half of the patients required 2
applications. The overall success rate was 60%. Failure rates were high if the tract was
short and straight. The 2 urethrovesicorectal fistulas failed to heal, and the authors
presumed urinary contamination played a role in the mechanism.

Tsurusaki et al reported on a case in which fibrin glue was used successfully to heal an
intractable kidney transplant ureteral fistula. Urinary leakage occurred from a
ureterocutaneous fistula at the ureteroureterostomy site. The tract was injected from the
cutaneous side on postoperative days 104, 121, and 136 under x-ray fluoroscopic
guidance. Success was achieved immediately on the third injection. The stent and
nephrostomy tube were removed, and no recurrence was noted at the time of publication
11 months later. For optimal success, they mandate delineating the fistula by radiographic
techniques before fibrin occlusion therapy and caution proper placement of the double-
lumen catheter before injection.

Electrocautery and endoscopic closure using fibrin glue and bovine collagen

Morita and Yokue published a case report of successful closure of a radiation-induced

and markedly fibrosed VVF measuring 5 mm. They buttressed the fibrin glue in the
fistula tract between collagen cushions at the proximal and distal sites of the fistula to
prevent its mechanical disruption by the efflux of urine from the bladder.

Technique: After performing electrocoagulation of the fistula, a cystoscope was

introduced transurethrally into the bladder, and 1 mm of bovine collagen was injected
submucosally under direct visualization around the fistula opening. Fibrin glue was
injected transvaginally into the fistula tract. A second application of 1 mm of bovine
collagen was then injected transvaginally into the vaginal mucosal layer around the
fistula tract. A transurethral Foley was used for 3 weeks.
Laser welding

Dogra and Nabi reported their success in the repair of a 3-mm VVF in the supratrigonal
area of the bladder. They used a Nd-Yag laser to fulgurate the fistula opening and the full
tract. A transurethral catheter was used for 3 weeks. The authors emphasize that the Nd-
Yag laser has the advantage over electrocoagulation of precise and accurate destruction
of the areas involved.

Laparoscopic approach

Nezhat and colleagues assessed the laparoscopic closure of intentional and unintentional
bladder lacerations in a series of 20 cystotomies. In this study, the only complication
noted was a single VVF that required reoperation. This fistula was successfully repaired
laparoscopically with a single-layer closure. In another laparoscopic dissection for benign
disease, a VVF resulted postoperatively and was successfully repaired laparoscopically at
a later surgery. Also, see Omental J flap.

Sotelo et al demonstrated a 93% cure rate in the laparoscopic repair of vesicovaginal

fistulas in 15 selected patients who had clear indications for abdominal approach surgical
treatment. Their technique involved cystoscopy, catheterization of the fistula tract,
dissection of the bladder from the vagina, laparoscopic cystotomy, excision of the tract,
adequate dissection of the bladder from the vaginal wall, cystotomy, and colpotomy
closure with interposition of a flap of healthy tissue.

Melamud and colleagues reported their successful attempt in the repair of a VVF in a 44-
year old woman. Their approach was a minimally invasive laparoscopic approach using
the DaVinci robotic system. In their technique they added fibrin glue between the bladder
and vagina to separate the suture lines. Factors contraindicating a vaginal approach
surgical technique were not elucidated in this paper.

Transurethral suture cystorrhaphy (TUSC)

McKay reported his results using transurethral suture cystorrhaphy in his initial series of
5 patients with VVF. In selected cases of small uncomplicated vesicovaginal fistulas with
a maximum of 5-6 mm, he concluded that this technique offered multiple advantages
including minimal intervention, outpatient setting, reduced operating time, and reduced
morbidity. Essential to the technique are suprapubic visualization with a shorter scope
such as an arthroscope, large-caliber sheaths used transurethrally to allow passage of
relatively large curved needles, self-righting needle driver, and adequate fulguration of
the fistula tract and the surrounding bladder mucosa.

Interposition flaps or grafts

Rotated vascularized pedicle flaps are an important adjunct to surgical techniques

employed in the repair of VVF. They increase success by enhancing granulation tissue
formation, increasing neovascularity to the area, and obliterating dead space. They also
provide a barrier layer between the bladder suture line and the vaginal suture line. Elkins
cautions not to expect this procedure to provide structural periurethral support and not to
expect success if the fistulous space is not completely closed, closed under tension, or
closed with only nonviable tissue.

 Vaginal approach interposition grafts or flaps

 Martius flap
o Martius first described his procedure in 1928 as a technique employed in
VVF repair. He isolated the bulbocavernosus muscle and its overlying
fibroadipose tissue as a pedicled graft for VVF repair. Its application today
extends to numerous types of vaginoplasties performed for urethral,
vaginal, and rectal disorders that include VVF, vaginal scarring and
atresia, urethrovaginal fistulas, and rectovaginal fistulas.
o Various modifications of Martius' original procedure have been published.
Success rates range from 85-100%. Elkins, DeLancey, and McGuire
describe a modified Martius graft technique used in their series of 37
complex fistulas in 35 patients. In their 1990 publication, 12 patients had
large obstetric VVF (>4 cm), 6 patients had obstetric fistulas with urethral
sloughing, 6 patients had recurrent obstetric or posthysterectomy fistulas,
5 had radiation-induced fistulas, and 6 had rectovaginal fistulas. They
observed an 86.5% success rate.
o In their modification, only the fibroadipose tissue in the labium majus was
isolated. It was composed of fibrous septa, round ligament, and a
superficial fibrous layer; it did not contain bulbocavernosus muscle. These
surgeons highlight the risk of hemorrhage with the classic Martius graft
technique because it requires a deep plane of dissection to isolate the
bulbocavernosus muscle. The fibroadipose tissue isolated in their
dissection possessed sufficient blood supply and strength for success.
Additionally, they note that the dual blood supply to this tissue and the
bulbocavernosus muscle (dorsally via internal pudendal artery and
ventrally via external pudendal artery) enables the surgeon the choice of
using a flap with a superior or inferior base. Of note, mild dyspareunia
over the graft site is a potential complication, which may be difficult to
avoid and remedy.
o Martius technique modified by Elkins, DeLancey, and McGuire: A
vaginal flap-splitting procedure is performed with wide tissue
mobilization. A double row of inverting interrupted sutures is placed in the
bladder. The bladder is back-filled with methylene blue to assure closure
integrity. Then, 3-4 chromic stay sutures are placed at the margins of the
repaired fistula.
o The graft is obtained through a vertical incision over the labium majus. It
is separated from the underlying vestibular bulb and bulbocavernosus
muscle and then tunneled beneath the labium minora and through the
paracolpium to finally reach and overlay the 2-layer bladder closure. It is
 secured at its distal end with 4-corner stay sutures. The vaginal wall is
closed using interrupted chromic or Vicryl sutures, and then the labial
incision is closed. A Penrose drain is placed at the bed of the graft and
brought out at a lateral site if any persistent bleeding is noted. This drain is
then removed on the third to fifth postoperative day.
 Full-thickness fasciocutaneous Martius flaps
o VVFs treated with multiple surgeries, pelvic radiotherapy-associated
VVF, and large obstetric fistulas often are complicated with marked tissue
devascularization, necrosis, and cicatrization. In order to successfully
repair such VVFs, surgeons are faced with greater difficulties in
attempting to comply with surgical principles of adequate blood supply to
the operative bed, low-tension closure, and closure of dead space. Vaginal
vault caliber and pliability also must be preserved for optimal success.
o Whereas most small (<4 cm) VVFs can be repaired with a flap-splitting
technique, large (>4 cm) VVFs are complicated by increased rates of
vaginal stenosis and atresia when repaired in this manner. In Elkins,
Delaney, and McGuire's publication in 1990, the authors point out that
reapproximating the vaginal margins over the graft is not always necessary
because the graft has the capability of supporting the growth of
granulation tissue, thereby promoting healing by secondary intention.
However, in cases where the vaginal incisions were left open, significant
morbidity was noted; increased rates of infection, marked vaginal scarring,
and vaginal stricture were encountered.
o Full-thickness Martius grafts to preserve vaginal depth may be considered
as an adjunct to transvaginal flap-splitting surgery for the repair of large
vaginal fistulas and will obviate the risks associated with nonclosure of
vaginal incisions as described by Elkins. Symmonds found Martius-type
pedicles with an intact island of skin from the medial non–hair-bearing
portion of the labium to work well with both VVF and rectovaginal fistula
repairs. This skin is secured at the vaginal defect site in the vagina,
ensuring a low-tension closure at the bed of the vaginal fistula site.
o Margolis and Elkins et al developed a modified Martius graft procedure
whereby an island of non–hair-bearing skin from the area just distal to the
inguinal ligament is preserved with the underlying cutaneous tissue and
bulbocavernosus graft.
 Gracilis muscle flap
o The predominant application for this flap is in total vaginal reconstruction
following pelvic exenteration.
o The gracilis muscle reaches to cover the medial portion of the groin, the
vulva, the perineum, and the lower abdomen. Its major blood supply is a
branch of the profunda femoris entering the upper one third of the muscle.
This dominant vascular pedicle is the point of rotation for the flap and
supports the entire muscle and overlying skin island.
 Peritoneal flap
o Raz describes an 82% success rate in his series of 11 patients with VVF
repaired with the flap-splitting technique combined with an adjunctive
 peritoneal flap procedure. All patients selected for the procedure possessed
fistulas high in the vaginal vault adjacent to the posthysterectomy cuff, 10
had failed prior repair(s), and none had a history of pelvic radiotherapy.
Crucial to the technique is proper development of the anterior vaginal wall
flap beyond the posterior wall of the bladder. The authors state the risk of
bladder injury is minimized if the dissection is performed "just below the
vaginal wall and the perivesical fascia is not violated."
o Surgical technique: With the patient in the dorsal lithotomy position, the
fistula tract is gently dilated to 12F, and an 8F Foley is inserted through
the fistula. Inflating the balloon enables traction on the catheter and
facilitates exposure. Cystoscopy and placement of ureteral stents are
performed if the fistula encroaches on the ureteric orifices. A suprapubic
catheter is placed.
o The anterior vaginal wall is incised in an inverted J fashion, with the long
end extending toward the vaginal apex. The incision curves under the
fistula, which then is circumscribed. The anterior and posterior flaps are
mobilized widely to a distance of 2-4 cm from the fistula. The rim of
vaginal wall encircling the fistula tract is left intact. A row of 4-0
polyglycolic acid sutures is placed in the raw fascia and incorporates a
partial thickness of the bladder wall. The sutures are tied after removal of
the catheter from the tract. A second layer of 2-0 polyglycolic sutures is
placed into the fascia and the bladder wall, applied at least 1 cm from the
first row in order to fully imbricate the first layer.
o Attention now is turned to developing the peritoneal flap. Dissection
between the vaginal wall and bladder is continued cephalad at the
posterior flap. Continuing dissection just beyond the posterior wall of the
bladder exposes the peritoneum at the anterior cul-de-sac. It is not
transected. Instead, it is mobilized carefully from the posterior bladder
wall and brought down to reach beyond the fistula site and be secured over
the fistula repair suture line with 2-0 polyglycolic sutures. Closure
integrity is assessed with indigo carmine. Trimming of the anterior vaginal
flap is performed. The posterior vaginal flap is brought distally over and
beyond the site of the peritoneum suture line and reapproximated with the
anterior vaginal wall with 2-0 polyglycolic sutures in a running technique.
Vaginal packing is employed. The transurethral catheter is removed on
postoperative day 14, and the suprapubic catheter is removed when a
cystogram shows no evidence of failure of repair.
o Lentz reported his series of 6 patients with VVF repaired transvaginally
with complete resection of the fistula tract, performance of layered
closure, and placement of a peritoneal flap between the bladder and
vaginal suture lines. Primary repair was successful and had no
complications in all cases. To ensure adequate reperitonealization of the
pelvis after the index surgery so that a peritoneal flap could be adequately
secured, he suggests a surgical delay of 2-3 months after diagnosis.

 Abdominal approach interposition grafts or flaps

 Omental J flap
o Omentum, with its rich lymphatic and vascular supply, is ideal as an
interposition graft. In approximately one third of patients, the omentum
has sufficient length to extend to the pelvis without tension. The remaining
patients require mobilization from the right or left gastroepiploic artery to
form a pedicle of sufficient length. The right is preferred because it has a
better blood supply.
o The omentum may be mobilized off the transverse colon, and ligation and
division of the short gastric branches may be required. The omentum can
be mobilized on the right gastroepiploic artery from the transverse colon.
Absorbable sutures must be used at the distal omentum in order to avoid
contact of permanent suture at the bladder.
o A number of surgeons have performed VVF repair with an omental J flap
under laparoscopic technique and have found it to be a good alternative to
the traditional abdominal approach.
 Peritoneal flap
o As with transvaginal approach, peritoneal flaps may be used during a
transabdominal approach to provide an additional layer between the
bladder and vaginal cuff at the time of repair of a VVF.
o In an effort to decrease the likelihood of VVF formation, it has been
suggested as a technique to be employed at the time of repair of both
incidental and intentional cystotomies that occur during simple and
complicated pelvic surgeries
 Rectus abdominis muscle flap
o Kanavel first described using a flap isolated from the rectus abdominis
muscle for repair of a space of Retzius defect in 1921.
o In 1965, Banerji published his experience with rectus abdominis
musculofascial pedicle grafts in the treatment of 7 patients with VVFs. All
of the fistulas resulted from obstetric trauma. Of 7 patients, 4 were cured.
o Menchaca and his colleagues improved Kanavel's success with
modification of the procedure. By securing the free end of the pedicle flap
to periurethral fascia, a 100% success rate was observed in their series of 3
patients. All of the VVFs were large posthysterectomy fistulas for which
prior unsuccessful repairs had been attempted; 2 had prior radiotherapy.
 Autologous bladder mucosa interposition graft
o Brandt and colleagues enrolled 80 patients with VVFs into their
prospective multicenter study. All VVFs were secondary to gynecologic
surgery; 90% of the fistulas were supratrigonal, and 10% were
infratrigonal. The repairs were performed within 1-3 months of index
surgery or were prior failed VVF repairs. The technique demonstrated a
96.3% success rate. A healthy well-vascularized bed free of any fibrotic
tissue was considered essential for the success of the procedure.
Advantages associated with this technique were nonentry into the
peritoneal cavity, small cystotomy needed for access, and ease of
obtaining an interposition graft.
o Technique: The procedure begins with a transvesical approach. An
 incision in the anterior bladder wall is performed above the fistula site.
The fistula tract is resected sharply, with care to remove all fibrosis at the
bladder, fascial, and vaginal levels and includes a 3- to 5-mm area free of
scarring. The vaginal defect is closed with 3-0 chromic sutures. The
bladder is mobilized off the underlying tissue. A site is selected at the
bladder dome for harvesting of the donor mucosal graft. The graft is
dissected from the muscularis and interposed between the bladder and
vaginal walls so that the mucosal surface faces the vagina. The bladder
wall is then closed over the graft using 5-0 continuous catgut. The anterior
cystotomy is closed in 2 layers with 3-0 interrupted chromic sutures.
o Vyas and colleagues report of a 91% success rate using mucosal autografts
for repair of VVF. A transabdominal approach was used for fistulae above
the trigone and a combined abdominal and vaginal approach for fistulae
involving the trigone. The fistula was circumscribed with sharp dissection
and scar tissue from prior surgeries was removed; however, they made no
attempt to separate the vesical and vaginal layers. The vaginal layer of the
fistula was closed with interrupted 4-0 polyglactin sutures. The graft was
secured to the margins of the fistula with 3 or 4 interrupted sutures.
 Free supporting graft
o Moharram and El-Raouf report their 100% success rate in the repair of
urogenital fistulas in 26 women using a retropubic transvesical approach
with placement of a support graft from the anterior abdominal wall fat.
After a wide dissection between the bladder and the vagina and the fistula
tract was completely excised, the vagina was closed in 2 layers using 0
polyglactin in a transverse line. The first layer was continuous; the second
layer was in interrupted fashion. The free graft of abdominal wall fat was
placed over the first suture line and sealed under the second set of sutures.
The bladder was closed in 2 layers. The first layer was continuous and the
second was in interrupted fashion. Also used were ureteric, suprapubic,
and urethral catheters.
 Human dura mater interposition graft
o In a prospective study of 11 patients with VVF, Alagol and colleagues
used solvent dehydrated, gamma-radiated human dura mater. They
reported a 100% success rate. Surgical technique included a transvesical
extraperitoneal approach. The fistula was circumscribed to removed
scarred edges at the fistula; the tract was left intact. The bladder was
widely dissected from the vagina. Interrupted sutures of 3-0 polyglactin
were placed in the vaginal layer followed by placement of a 2 x 2 cm dura
mater graft and secured with 3 interrupted sutures. The bladder mucosa at
the fistula was closed in interrupted fashion with same suture material.
The cystotomy was closed in 2 layers, first with continuous 3-0
polyglactin and then with 1-0 interrupted polyglactin sutures in the
muscularis. A urethral catheter was left in place for 5 days; the suprapubic
catheter was kept in place for 14 days. The fistula size ranged from 5-21
mm (average 9 mm). According to the authors, the beneficial qualities of
humandura mater include its excellent tissue compatibility, stability, good
 elasticity, and absorbability.
 Broad ligament flaps
o Singh, Pavithran, and Nanda describe their plastic reconstruction
technique for the repair of mega vesicovaginal fistulae resulting from
obstetric complications. This type of flap would not be necessary in the
discussion of those fistula typically encountered in developed countries.

Postoperative details:

Bladder drainage: The consensus is overwhelming in the literature that continuous

bladder drainage postoperatively is vital for successful UGF repair. A large-caliber
catheter minimizes the potential for catheter blockage by blood clots, mucus, and
calcaneus deposits. However, to date, no prospective randomized trials have
demonstrated the superiority of any single type of catheter drainage.

Type and duration of catheter drainage: For fistulas involving the lower portion of the
bladder trigone, bladder neck, or urethra, transurethral bladder catheters should not be
used. Symmonds finds a large suprapubic catheter for 7-60 days preferable to minimize
excess tension on the suture line and to ensure nonobstructed continuous drainage. In
posthysterectomy VVF repairs, both transurethral and suprapubic catheters may be
placed. The urethral catheter may be discontinued on the fifth to seventh day. If vesical
integrity is noted 2 weeks later on a cystogram, the suprapubic catheter may be removed.
Surgeries to repair pelvic radiotherapy-associated VVFs require longer periods of
drainage.

Acidification of urine to diminish risks of cystitis, mucus production, and formation of

bladder calculi is a consideration for patients with an indwelling catheter. Vitamin C at
500 mg orally 3 times per day may be used to acidify urine. Alternatively, methenamine
mandelate at 550 mg plus sodium acid phosphate at 500 mg 1-4 times daily also can be
administered to achieve urine acidification.

Estrogen replacement therapy in the postmenopausal patient may assist with optimizing
tissue vascularization and healing (see Medical therapy).

Control of postoperative bladder spasms: Urised is effective for control of postoperative

bladder spasms. It is a combination of antiseptics (methenamine, methylene blue, phenyl
salicylate, and benzoic acid) and parasympatholytics (atropine sulfate, and hyoscyamine
sulfate).

Antibiotic therapy: The use of antibiotic therapy postoperatively is controversial. Many

physicians administer oral antibiotic prophylaxis to patients with VVF postoperatively
until the Foley catheter is discontinued. Others check closely for the development of a
urinary tract infection and administer antibiotic therapy when urine cultures are positive
for bacterial growth. Close follow-up and prompt evaluation for any urinary tract
infections and antibiotic therapy, when indicated, are mandatory.
Minimizing Valsalva maneuvers: Stool softeners and a high-fiber diet postoperatively
minimize Valsalva maneuvers in the patient.

Examinations: Avoid pelvic and speculum vaginal examinations during the first 4-6
weeks postoperatively because the tissue is delicate.

Pelvic rest: Prohibit coitus and tampon use for a minimum of 4-6 weeks. Other authors
advocate strict pelvic rest for 3 months.

Follow-up care: See Postoperative details.

  COMPLICATIONS Section 7 of 9   

Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications
Outcome And Prognosis Bibliography

Integral to all major surgeries are risks of infection; hemorrhage; injury to other organs,
particularly the ureters; surgical failure of fistula repair; possible new fistula formation;
thromboembolism; and death. Preoperatively, patients should be informed of the
possibilities of sexual dysfunction or dissatisfaction, new-onset incontinence, and the
progression of preexisting urge and/or stress incontinence symptoms. Authors also
mentioned recommendations for cesarean delivery for subsequent pregnancies.

Abdominal approach procedures carry additional risks of abdominal and pelvic

adhesions. Vaginal approach procedures carry increased risks of dyspareunia, tenderness
at the site of the donor Martius graft, and diminished vaginal length and caliber.

  OUTCOME AND PROGNOSIS Section 8 of 9   

Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications
Outcome And Prognosis Bibliography

See Techniques of repair.

  BIBLIOGRAPHY Section 9 of 9   

Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications
Outcome And Prognosis Bibliography

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Vesicovaginal Fistula excerpt

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Vesicovaginal Fistula
 

This is a connection established between the bladder and the

vagina so that the patient presents with urinary incontinence.

 This is an injury, often secondary to an obstetric

manipulation, gynecologic surgery, radiation or invasive
cancer of the cervix. Patients will present with constant
leakage of urine. 
DIAGNOSIS 

Cystoscopy usually reveals the fistulous opening between the

bladder and vagina. 

Vaginography, which is performed by inserting a catheter into

the vagina, instilling a radio-opaque solution and taking the
appropriate x-rays, will usually show the vesicovaginal,
ureterovaginal and/or rectovaginal fistula. If the fistula is very
small and not readily apparent, it may be necessary to instill
methylene blue via a catheter and detect any staining on a
vaginally-placed tampon. If no methylene blue dye is found
staining a vaginal pledget, then intravenous indigo carmine
should be administered; and if staining is detected, a
ureterovaginal fistula may be responsible. If the staining is
found only at the string end of the tampon, then the leakage
probably represents urethral incontinence and not leakage
from a vesicovaginal fistula.

TREATMENT

Repair is usually undertaken some 8-12 weeks after the injury.

This time delay allows resolution of wound inflammation
prior to attempting corrective surgery. In postmenopausal
patients, estrogen replacement prior to surgery may improve
the chances of successful closure. Treatment options include
the following: 

A. Conservative 

For very small fistulae, an indwelling Foley catheter to remain

in place for about 4 weeks may result in closure. 

B. Endoscopic 

Cauterizing a very small fistulous tract in the bladder and/or

the vagina may allow healing of the fistulous tract. Curetting
with a fine probe may possibly seal a fine fistulous tract by
allowing fresh margins to heal. 

C. Surgery 
 1. Transvesical approach. 

This approach is usually done when the fistula is located at the

level of the ureteral orifices or higher or if the vagina is
stenotic. After opening the bladder, ureteral stents are placed
to identify the ureters. The fistula is exposed, circumscribed
and excised, thus allowing closure of the individual vaginal
and bladder layers. Omentum can be useful to interpose
between suture lines to improve healing rates. 

2. Vaginal approach. 

This approach is ideal for low-lying fistulae with an adequate

vagina. The fistula is excised and surrounding tissues gently
mobilized to allow layered closure. Immediately prior to the
repair, cystoscopy and ureteral catheterization may be
reasonable to allow identification of the ureteral orifices. 

Postoperative care. 

A light vaginal pack is used for 24 hours. A Foley catheter is

left for about 14 days. The appropriate anti-spasmodics are
used to prevent bladder spasms and damage to the repair site.
Antibiotics are also administered. Patients are also instructed
to avoid intercourse for at least 6 weeks after surgery to allow
complete healing of the repair site.

© 1999 urologyweb, LLC All Rights Reserved.

 What is Fistula?
Fistulae are holes that are created between the vaginal wall and the bladder
(vesicovaginal fistula VVF), and holes created between the vaginal wall and the rectum
(rectovaginal fistula RVF). Fistula has severe physical and social consequences and is
one of the most degrading morbidities resulting from pregnancy and childbirth. As these
holes are formed as a result of pregancy and child birth the term Obstetric fistula is
commonly used as an umbrella term. It can be caused by obstructed labour due to FGM
type 3 or FGM type 4 , where cuts are made into the vagina, or by child marriage and
early pregnancy. For this reason FORWARD at its strategic review in 2002 formally
adopted the challenge of addressing child marriage, an issue contributing to and
associated with Fistula and FGM.

In Northern Nigeria maternal morbidity as a result of fistula is particularly high, with an

estimated 70% of the 150,00 cases, in Nigeria, occurring in the North. For this reason,
FORWARD has been working on a Project in Nigeria in Kano State, working with girls
and women who have suffer with this condition.

Causes of Fistula
Approximately 80% of fistula cases reported in Nigeria are due to unrelieved obstructed
labour during childbirth. Obstructing labour is directly related to the custom of early
marriage in Nigeria (frequently below the age of 18 and sometimes before the onset of
menstruation, as early as 11 years old). Early marriage invariably leads to early sexual
contact and subsequent pregnancy at a time when a young girl is not adequately
physically developed to permit the passage of a baby with relative ease. This can lead to a
prolonged and obstructed labour and damage leading to the misery of fistula. The same
phenomenon also occurs in women whose growth has been stunted as a result of poor
nutrition or malnourishment.

About 15% of fistula cases are caused by the harmful practice of female genital
mutilation. The 'gishiri' cut, a form of female genital mutilation, is commonly practised
in Nigeria amongst the Hausa people. This traditional practice, performed by untrained
traditional birth attendants, is used in the treatment of a wide variety of gynaecological
ills and is commonly employed during pregnancy and labour. A cut is made in the
anterior wall of the vagina with an unsterilised sharp instrument, if the cut is made too
deep, a hole is created between the bladder and the vagina resulting in VVF. The
rationale for the 'gishiri' cut defies scientific explanation, but belief in its effectiveness
persists.

Consequences of Fistula
The immediate physical consequences of VVF are urinary incontinence and / or faecal
incontinence due to RVF and related conditions, such as dermatitis. If nerves to the lower
limbs are damaged, women may suffer from paralysis of the lower half of the body.

As well as the physical consequences the social consequences for those who suffer from
fistula are also severe. Many victims of obstructed labour, in which the fistulae
subsequently occur, will also have given birth to a stillborn baby, thus leaving the woman
childless. In some areas, a high percentage of fistulae occur during the first pregnancy. In
a society where childbearing is so highly valued this gravely affects the woman's future.
If the fistula is not repaired, and the woman remains incontinent and childless, she is
likely to be abandoned by her husband, on whom she is economically dependent. In
addition, she may be ostracised by society as being considered to have brought shame on
her family. Victims, therefore, become social outcasts.

Fistula leaves such women physically, emotionally and socially traumatised. With no
education, no vocational training, no gainful employment or visible means of livelihood,
they travel a long road of rejection and pain.

Prevention and Treatment of Obstetric Fistula

Obstetric fistula was eradicated in western countries at the end of the 19th century when
caesarean section became widely available. Obstetric fistula continues to plague women
throughout the developing world and the key to ending fistula is to prevent it from
happening in the first place. Ways to accomplish this are to ensure that there are skilled
attendants at birth, and to guarantee a swift surgical intervention if obstructed labour
occurs. Poverty, the empowerment of women, family planning and importantly
FORWARD's key issues FGM and child marriage are critical areas to address for the
eradication of fistula.

The success and recovery rate from an operation to correct simple fistula is very high -
almost 90%. This essentially involves repairing a hole in the bladder or rectum and can
usually take place through the vagina without the need for major incision. The operation
is delicate and specially trained surgeons and support staff are required. Counselling is
also required to heal non-physical wounds and is necessary for a complete recovery.

In some cases, woman who have also suffered severe nerve damage may require
prolonged physical therapy. Unfortunately, for some women, the damage is beyond repair
and continual care is required. New surgical techniques are being pioneered to improve
results and address more severe tissue damage.

Approaches Towards Eliminating Fistula

Research and observations have shown that patients with fistulae are a particularly
disadvantaged group in relation to both socio-economic status and education. The
majority of patients are from rural areas, low in literacy levels and lacking in physical and
economic access to medical care. Since many do not attend antenatal clinics, high risk
conditions and medical and obstetric complications endangering the life or impairing the
health of the expectant mother and baby will not be detected early enough to adopt
precautionary measures. Many women in rural communities are taken to hospital only
when the situation is hopeless and often too late.

In the short term, better use of existing obstetric services and increased provision of
effective health services in rural areas will lower the incidence of fistula. However, in the
longer term there is a need for an holistic approach to address both the direct and indirect
causes of fistula and other maternal morbidities, including of course an end to female
genital mutilation and child marriage. Ultimately, improving the education and economic
empowerment of young women will remove the conditions that lead to the occurrence of
fistula. Such improvements would lead women to seek safer obstetric practices, including
the use of family planning, delay childbearing, and seek prenatal and antenatal care
during pregnancy. It has been found that women with a formal education have a maternal
mortality rate one fourth that of women with no formal education.

A fistula represents a nonanatomic epithelialized connection between two or more body

spaces.

 General Considerations
o Vesicovaginal fistulae (VVF) are the most common acquired fistula of the
urinary tract.
o VVF have been known about since ancient times
o 1663 Hendrik von Roonhuyse first described surgical repair
o 1852, James Marion Sims published his now famous surgical series
describing a method of surgical treatment of VVF using silver wire in a
transvaginal approach.
 Etiology
o The most common cause of VVF differs in various parts of world.
 In the industrialized world, the most common cause (75 percent) is
injury to the bladder at the time of gynecologic surgery; usually
abdominal hysterectomy
 Obstetric trauma accounts for very few VVF in the United States
and other industrialized nations.
 In the developing world, VVF most commonly occur as a result of
prolonged labor
 Obstetric fistulas tend to be larger, located distally in the
vagina, and may involve the proximal urethra.
o Other causes of VVF include urologic or gynecologic instrumentation,
pelvic malignancy (cervical cancer, etc.), inflammatory diseases, radiation
therapy, and trauma.
 Presentations
o The most common complaint is constant urinary drainage per vagina
although small fistulas can present with intermittent wetness that is
positional in nature.
 VVF must be distinguished from urinary incontinence due to other
causes.
o Patients may also complain of recurrent cystitis, perineal skin irritation
due to constant wetness, vaginal fungal infections, or rarely, pelvic pain.
o When a large VVF is present, patients may not void at all and simply have
continuous leakage of urine into the vagina.
o VVF following hysterectomy or other surgical procedures may present
upon removal of the urethral catheter or 1 to 3 weeks later with urinary
drainage per vagina.
  VVF resulting from hysterectomy are usually located high in the
vagina at the level of the vaginal cuff
o VVF resulting from radiation therapy may not present for months to years
following completion of radiation.
 Evaluation
o History: etiology, chronology, h/o prior pelvic or GU surgery
o Physical examination
 A pelvic examination with a speculum should always be performed
in an attempt to locate the fistula and assess the size and number of
fistulae.
 Palpate for masses or other pelvic pathology that may need to be
addressed at the time of fistula repair.
 An assessment of inflammation surrounding the fistula is necessary
as it can affect timing of the repair.
 The presence of a VVF can be confirmed by instilling a vital blue
dye or sterile milk into the bladder per urethra and observing for
discolored vaginal drainage.
 A double dye test can confirm the diagnosis of urinary fistula as
well as suggest the possibility of an associated ureterovaginal or
urethrovaginal fistula.
o Urine culture and urine analysis
o Cystoscopy and possible biopsy of the fistula tract is performed if
malignancy is suspected.
 Note the location of fistula relative to ureters; repair of the fistula
may require reimplantation of ureters if the fistula involves the
ureteral orifice.
o Voiding cystourethrography
 Some small fistulas may not be seen radiographically unless the
bladder is filled to capacity and a detrusor contraction is provoked.
 Assesses for vesicoureteral reflux.
 Examines for multiple fistulae including urethrovaginal fistula.
Assesses size and location of fistula.
o Intravenous urography and/or retrograde pyeloureterography
 Assesses for concomitant ureteral injury and/or ureterovaginal
fistula.
o Cross-sectional pelvic imaging (MRI/CT) if malignancy is suspected.
 Therapy
o Nonsurgical management
 Catheter drainage is the initial treatment in most cases.
 Fulguration of the fistula followed by catheter drainage has been
shown to have some efficacy in small (less than 5 mm),
uncomplicated fistulae.
 Adjuvant measures (such fibrin glue, etc.) have been used
o Surgical management
 Success rates approach 90 to 98 percent regardless of surgical
approach.
  Adherence to basic surgical principles are essential to
achieve success in the repair of all urinary fistula.
 Choice of the optimal surgical approach to VVF is
controversial
 Numerous factors to consider.
 No single approach is applicable to all VVF.
 Transabdominal, transvaginal, transvesical
approaches described
 Regardless of approach:
 Maximal urinary drainage (urethral and
suprapubic catheters) is maintained
postoperatively.
 A cystogram is usually obtained 2 to 3
weeks following repair to confirm
successful closure.

Table I: Principles of Vesicovaginal Fistula Repair

 Good hemostasis.
 Judicious use of cautery.
 Adequate exposure of the fistula tract.
 Watertight closure of each layer.
 Well-vascularized, healthy tissue for repair.
 Multiple layer closure.
 Tension-free, nonoverlapping suture lines.
 Adequate urinary drainage after repair.
 Prevention of infection (use of pre-, post-, and intraoperative antibiotics).
 Adequate preoperative nutritional repletion

Table II: Abdominal versus Transvaginal Repair of Vesicovaginal Fistula

  ABDOMINAL TRANSVAGINAL

Length of 4-7 days 1-2 days

hospitalization
Timing of repair Usually delayed 2-6 months from the time of May be done
initial injury immediately in the
absence of infection
Location of ureters Fistula located near ureteral orifice may Reimplantation
relative to fistula necessitate reimplantation may not be
tract necessary even if
 fistula tract is
located near
ureteral orifice
Sexual function No change in vaginal depth Potential risk of
vaginal shortening
or stenosis
Location of fistula Fistula located low on the trigone or near the Fistula located high
tract/depth of bladder neck may be difficult to expose at the vaginal cuff
vagina may be difficult to
expose and repair
transvaginally
Use of adjunctive Omentum, peritoneal flap, intestine Labial fat pad
flaps (Martins fat pad);
peritoneal flap;
gracilis muscle;
labial
myocutaneous flap
Relative Large fistulas; located high in a deep vagina; Uncomplicated
indications radiation fistulas; failed transvaginal approach; fistulas, low
small capacity bladder requiring augmentation; fistulas, vaginal
need for ureteral reimplantation; inability to exposure may be
place patient in the lithotomy position difficult some
nulliparous patients.

A Selection of Essays: Vesicovaginal Fistula (VVF): Only

to a Woman Accursed
Document(s) 3 de 21
Kikelomo Bello

Introduction

This paper examines the various factors that contribute to the incidence of vesicovaginal
fistula (VVF), a condition that arises from obstetric complications. The goal is to present
the gender-based factors that lead to VVF, as well as a comparison of the client–provider
relationship within two existing health systems, the modern/orthodox system and the
traditional health system, in terms of accessibility, acceptability, and adaptability.

Causal Factors for Vesicovaginal Fistulae

VVF is a health condition caused by the interplay of numerous physical factors and the
social, cultural, political, and economic situation of women. This interplay determines the
status of women, their health, nutrition, fertility, behaviour, and susceptibility to VVF
(WHO 1989).

Physical Causes
The physical factors that influence the incidence of VVF include obstructed labour,
accidental surgical injury related to pregnancy, and crude attempts at induced abortion.
Obstructed labour leads to VVF when prolonged and unrelieved pressure on the woman's
pelvic wall causes a puncture in the bladder.

Surgical procedures that cause VVF are of two types. The first, which may be termed
orthodox medical accidental injury, refers to injury caused to the bladder during obstetric
operations performed within the formal/modern health care system, such as the hospital.
Such procedures include caesarean sections and difficult forceps delivery.

A table prepared for a comparative report by Kelly (1979) presented the cause of fistulae
in 161 patients in Africa, particularly Ethiopia, and in Britain. Some subjects became
VVF patients as a result of operative delivery performed in orthodox hospitals. Table 1
shows a breakdown of the causes.

Table 1. Main cause of fistulae

Cause Africa Britain Total

Obstetric

 Pressure necrosis 121 7 128

121 3 124
 Caesarean section 0 2 2
0 2 2
 Caesarean hysterectomy

Surgical

 Abdominal hysterectomy
2 26 28
2 15 17
 Vaginal hysterectomy and/or
0 10 10
repair
0 1 1
 Aldridge sling

Other 5 0 5
Total 128 33 161

Source: Kelly (1979).

A study carried out by Mustafa and Rushwan (1971) in Khartoum in the late 1960s
confirmed that the major cause of VVF is prolonged, obstructed labour which is often
followed by instrument delivery (mainly forceps) and gynecological operations. Between
1966 and 1968, 91 (74.8%) of the women studied demonstrated VVF resulting from
obstructed labour, 25 (20.5%) from instrument delivery, and 6 (4.7%) from gynecological
operations.

The second form of surgical procedure that may lead to VVF is performed within the
traditional health care system. These procedures are commonly employed during
pregnancy and labour, and lead not only to VVF, but may also cause hemorrhages and
sepsis. Examples include female circumcision, the Gishiri cut,(1) and Angurya, a
traditional practice in which tissue is removed from the vagina by traditional surgeons for
the treatment of coital pain, infertility, obstructed labour, amenorrhea, dyspareunia, vulva
rash, goitre, and generalized body aches and pains (Sambo 1990; Tahzib 1985; Harrison
1985).

In an unpublished paper, Darrah and Froude (1975) estimated that some 40% of the
patients attending Zaria hospital (Nigeria) with VVF had received Gishiri cuts. This
finding is substantiated by a study conducted by Tahzib (1983) involving 1443 VVF
patients at the Ahmadu Bello University Teaching Hospital, Zaria, between January 1969
and December 1980. In a table titled "Aetiological factors leading to fistula," Tahzib
showed that 1209 (83.8%) of VVF resulted from prolonged labour, 188 (13.0%) from
Gishiri cuts, 14 (1.0%) from surgical trauma, 10 (0.7%) from infections, and 22 (1.5%)
from "other" causes including congenital injuries, insertion of caustic materials into the
vagina, and so on.

Sociocultural Factors Affecting the Prevalence of VVF

The World Health Organization (WHO) argues that poor socioeconomic development is
the basic underlying factor responsible for maternal ill-health, including the prevalence of
obstetric fistulae. It further argues that the standards of health in developing countries are
low and that natural hazards such as malnutrition and infections remain largely
unchecked. The situation worsens where health services are deficient or absent,
particularly in isolated rural areas. Logistic problems compound the problem, including
the failure of existing health systems to provide appropriate health care that is accessible,
acceptable, and adaptable; the sole development of urban areas to the marginalization or
total exclusion of rural areas; unequal distribution of government resources; and the lack
of appropriate basic infrastructure such as roads, water, health centres, schools, and
electricity (WHO 1989).
Marriage and Child Birth
The sociocultural factors that contribute to the prevalence of VVF in women focus on
their status in society. For example, girls are given in marriage at very young ages in
some cultures, often before or during the process of puberty, and childbearing is seen as
an indicator of the attainment of "married woman" status. This helps to explain why VVF
sufferers are often very young girls.

Study results on VVF vary geographically. In Africa, where the problem appears to be
most prevalent, studies have shown that at least 70% of women with fistulae are aged 30
years and under. Tahzib's 1983 study, in fact, showed that 5.5% (80) of VVF sufferers
were under 13 years of age (see also Murphy 1981; Mustafa and Rushwan 1971; Tahzib
1985; Harrison 1985). In some parts of the continent, therefore, children beget children.
Another finding of these case studies is that women often develop VVF during their first
pregnancy.

Table 2. Age factors.

Fistula patients
Control groups

New Long terma Ab Bc

Age group % No. % No. % No. %

Age at marriage

< 12 14 8 15 2 4
12–13 40 23 44 20 44
14–15 34 17 33 23 51
16–17 7 2 4
   
18–19 2
20–24 1 2
25–29 1
Not known 2 1 2

Total 100 52 100 45 100    

Age at birth of first child

12–13 12         24 12
14–15 21 46 22
16–17 31 61 30
18–19 18 24 12
20–24 16 42 20
25–29 9 4
Never pregnantd 2

Total 100         207 100

a
Long-term patients: 52 patients who had been incontinent for 2 years or more.
b
Control group A: 45 patients suffering from post-partum cardiac failure.
c
Control group B: 207 patients treated for post-partum cardiac failure between 1969 and
1972.
d
Fistula caused by gishiri cut administered for treatment of infertility.
Source: Adapted from Margaret Murphy (1981).

In Asia, the same trend holds true, except that a greater concentration of women with
VVF fell within the 20 to 24 year age group (except in Bangladesh, where almost half
were under 20 (Begum 1989)). This suggests that the age of marriage in Asia is generally
higher than it is in Africa (WHO 1991).

The case is different in Latin America, in that VVF has only been reported in Ecuador. A
study by Calle (1989) indicated that 75% of the women with fistulae were primiparous,
but the numbers were reported to be so small as to make the findings inconclusive.

It is possible that there are more women and children with VVF than appear in the data.
This possibility is supported by a 1991 WHO statement that data used in most analyses,
except those of Murphy (1981), were obtained from hospital records (WHO 1991). It can
be argued that these hospital records show only the incidence of VVF which were
actually treated in hospitals.

Medical search

esico-vaginal fistula

This is a fistula between the bladder and the vagina. It may be a cause of true incontinence.

The vast majority result from pelvic surgery and irradiation. About 50% are due to simple
abdominal or vaginal hysterectomy.

Obstetric injuries are now an uncommon cause in developed countries. Most are the result of
operative delivery such as forceps. Pressure necrosis from obstructed labour with
compression of the bladder between the presenting head and the bony wall of the pelvis, is
rare.

Other uncommon causes include:

 malignancy:
o cervical
o bladder

 infection
o tuberculosis
o schistosomiasis

o granuloma inguinale

Medical search

uretero-
vaginal
fistula

This is a fistula formed between the ureter(s) and the vagina. It causes true incontinence.
 

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ecto-vaginal fistula

Rectovaginal fistula (RVF):

 RVFs are epithelial-lined tracts between the rectum and vagina - the majority of
RVFs are located at or just above the dentate line. If a fistula is below the dentate line
then this is an anovaginal fistula (i.e. not a true RVF)
 a low RVF is defined as being between the lower third of the rectum and the lower
half of the vagina; a high RVF is between the middle third of the rectum and the
 posterior vaginal fornix. RVFs may vary greatly in size - the majority are less than 2
cm in diameter
 Causes:
o most common cause is obstetric injury. Other causes in descending order of
frequency include radiation injury, inflammatory bowel disease ((IBD), most
often Crohn disease), operative trauma, infection, and neoplasm
 pathophysiology:
o there are many causes of RVFs:
 perineal lacerations during childbirth, particularly those due to
episiotomy, predispose patients to RVFs.
 perineal lacerations are more common in
 primigravidas
 in precipitous births
 deliveries using forceps or vacuum extraction
 also note that failure to recognise and correctly repair
perineal lacerations (or secondary infection of perineal
lacerations) increases the probability of developing a
RVF
 the development of an RVF may be predisposed by a prolonged
labour. Pressure on the rectovaginal septum can produce necrosis and
a consequent RVF
 IBD (Crohn's and ulcerative colitis) have been associated with
developments of RVF
 radiation therapy used in pelvic malignancy may be complicated by
development of a RVF
 rectal or vaginal operations may cause a RVF
 pelvic operations can be complicated by the development of a RVF
 trauma
 infection may cause a RVF
 perirectal abscess/fistula and diverticulitis
 rare causes include lymphogranuloma venereum (1),
tuberculosis and Bartholin gland abscess
 Clinical features:
o the usual presentation is that of flatus or, more rarely, stool through the
vagina. Patients may also suffer recurrent episodes of cystitis or vaginitis
o the patient may also complain of a foul-smelling vaginal discharge - in
general, the passage of frank stool per vagina occurs only when the patient
has diarrhoea
o if there is associated anal sphincter damage then the patient may also
complain of faecal incontinence
o occasionally a patient with RVF is asymptomatic
 Management: refer for specialist advice
o medical management options include:
 if a fistula is secondary to trauma (including those secondary to
obstetric trauma), caused by infection or complicated by secondary
infection - in these situations then medical management including
 abscess drainage and antibiotic therapy may be employed. It may be
decided to leave the RVF to heal for a 6-12 week period. During this
period dietary modification and fibre supplements may substantially
reduce symptoms. This treatment regime may result in complete
healing of an RVF secondary to trauma. However if the RVF persists
then surgical repair may be required.
 if an RVF is due to another aetiology (e.g. IBD, neoplasm) then
management will also be dictated by the aetiological process
o surgical therapy (2): may be initial treatment or employed if failure of
medical therapy.
 obstetrical fistulas can be treated successfully by local approaches
transanally or transvaginally - episioproctotomy may be considered if
there is an associated sphincter defect
 Crohn's related fistulas usually require proctectomy if the rectum is
severely involved. Local repair can be considered in instances where
the rectum is relatively healthy and local sepsis has been controlled

 radiation-induced fistulas may be secondary to cancer recurrence,

which must be excluded. If the patient is not a candidate for a radical
resectional approach, faecal diversion alone should be performed

causes
of Medical search
female
genital
tract
fistulae

Acquired causes of female genital tract fistulae include:

 surgery
 obstetric trauma
 malignant disease
 radiotherapy

 perineal breakdown after a third degree tear