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VESICOVAGINAL FISTULA

REASON FOR VISIT:

• The uncontrolled leakage of urine into the vagina


• Urinary incontinence
• An increase in vaginal discharge
• Increased postoperative abdominal, pelvic, or flank pain
• Prolonged ileus
• Fever
• Recurrent cystitis
• Recurrent pyelonephritis
• Abnormal urinary stream
• Hematuria

RISK ASSESSMENT

• Old age
• Hypertension
• Diabetes
• Bleeding disorders
• Allergies to medication/anesthesia
• Heart diseases
• Advance stage of cancer

ANESTHESIA:

• General anesthesia
• Spinal anesthesia

PREPARATION OF THE PATIENT:

• Blood tests
• Urine analysis
• Chest X-ray
• ECG
• Biopsy
• Intravenous urogram (IVU)
• Retrograde ureteropyelography
• Cystoscopy
• Tratner catheter
• Cystourethroscopy
• Combined vaginoscopy-cystoscopy
• Color Doppler ultrasonography
• CT scan
• MRI
• The patient was given prophylactic antibiotic in the preoperative
holding area
• Blood thinning medication was stopped
• Do not eat and drink any thing ____hrs prior to the procedure

POSITION OF THE PATIENT:

• Lawson position
• Jackknife position
• Dorsal lithotomy position

THE PROCEDURE

TECHNIQUES OF REPAIR

• The vaginal approach


• The abdominal approach

VAGINAL APPROACH

Exposure

• The labial folds were sutured to the ipsilateral thigh


• deep vaginoperineal incision was given/ parasacral incision was given

Latzko technique:

• Vaginal mucosa was sharply denuded in a circular fashion at a


distance of 1.5 cm from the fistula opening.
• The fistula at the bladder mucosa was not disturbed.
• A double row of sagittally oriented sutures was placed in the raw
surfaces on either side of the fistula, with the second row imbricating
the first.
• Suturing of the vaginal wall was then performed, providing a third
layer of closure.

Flap-splitting techniques

• The vaginal wall was 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 were
extended toward the vaginal apex in a parallel fashion.
• One incision was carried further than the other, thereby incising a J
shape in the vaginal wall.
• The anterior and posterior flaps were widely dissected from the
underlying endopelvic fascia.
• The fistula tract was closed with 3-0 chromic or Dexon suture in a
continuous fashion.
• A second layer of closure in the endopelvic fascia was performed with
3-0 Dexon suture; it was placed perpendicular to the prior suture
line.
• The distal vaginal flap was trimmed.
• The proximal flap was advanced beyond the fistula repair site,
reaching the trimmed distal margin, and reapproximated in a running
fashion.

Vaginal cuff excision

• The patient was placed in dorsal lithotomy position.


• Cystoscopy was performed.
• Traction on the fistula site was obtained by placing a Foley catheter
into the fistula tract from a vaginal approach,
• The balloon was inflated
• Traction sutures were placed at 1-cm distances from the fistula.
• The vaginal mucosa was denuded circumferentially for a radius of 3-5
mm from the vaginal cuff, including the fistula.
• This incision was extended obliquely to the bladder wall
• The fistula tract and vaginal cuff scar was resected in a funnel-shaped
specimen.
• The defect was closed in 4 layers.
• First, the bladder was closed with interrupted 4-0 sutures
• The subvaginal pubocervicovaginal fascia was closed in 2 layers with
interrupted 3-0 sutures.
• This was followed by a vaginal wall closure with polyglycolic acid
suture material.
• A suprapubic catheter was placed for bladder drainage and is
maintained for 3 weeks postoperatively.

ABDOMINAL APPROACH

Position

Supine with trendelenburg orientation

Transvesical extraperitoneal technique

• With the patient placed in a steep Trendelenburg position, a


transvesical incision was performed to visualize the fistula.
• The bladder mucosa adjacent to the fistula was circumscribed and
removed.
• The bladder was dissected off the vagina and
• The bladder and vaginal defects are sutured separately.

O'Conor and Sokol technique

• Abdomen was opened with an infraumbilical incision


• The peritoneal cavity was entered.
• The posterior wall of the bladder was dissected free as much as possible.
• The bladder was bivalved at the dome.
• This incision was extended posteriorly to the level of the fistula.
• Stay sutures were 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) were identified,
• ureteral catheters were placed
• The fistula tract and scarred and necrotic tissue were resected.
• Dissection of the posterior wall of the bladder from the underlying
endopelvic fascia and vagina was completed.
• The bladder and vagina were closed in separate layers.
• The bladder was 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.
• Peritoneal /interposition grafts were added.
• A suprapubic catheter was brought out laterally to the sagittal closure.
• A transurethral catheter placed
• Abdomen was sutured in layers

Vesical autoplasty

• The bladder was entered through a transverse incision at the dome.


• Catheterization of the ureters was performed.
• The fistula tract was completely excised with the assistance of stay
sutures secured around the fistula tract.
• The bladder wall was carefully mobilized off the endopelvic fascia and
vaginal wall.
• The vaginal defect was closed with a single-layer closure.
• A bladder flap was constructed to close the bladder defect.
• Incisions were made at the superolateral angles of the bladder defect
and extended cephalad toward the dome.
• The anterior margin of the flap was drawn down over the bladder defect
to meet the caudal margin of the bladder defect.
• It was sutured in place with 3-0 catgut through the submucosal and
muscular layers in interrupted fashion
• The ureteral catheters were removed
• The anterior cystotomy was closed in a single extramucosal layer.

Bladder mucosal autologous grafts

• A Pfannenstiel /infraumbilical low vertical midline incision was given


• Entered the peritoneal cavity with
• An extraperitoneal cystotomy was performed at the anterior bladder
wall.
• Ureteral catheters were placed.
• Bladder mucosa was denuded circumferentially at the fistula site at a
distance of 1 cm.
• The fistula tract and vaginal wall were left undisturbed.
• A free bladder mucosal graft was sharply dissected from its underlying
muscularis layer at the edge of the anterior cystotomy margin.
• This graft of mucosa was 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 was closed in 2 layers.
• A transurethral catheter was placed
• A suprapubic Malecot drain was placed
• Abdominal incision was closed with sutures

FINDINGS:

Fistula was present at _____

AFTER PROCEDURE:

• Continuous catheter drainage was placed


• Patient was shifted to intensive care unit
• Pulse rate, blood pressure, oxygenation was monitored

DURATION

_____hrs

POSTOPERATIVE CARE

• Take Vitamin C at 500 mg orally 3 times per day/methenamine


mandelate at 550 mg plus sodium acid phosphate at 500 mg 1-4 times
• Take estrogen replacement therapy
• Take Urised as prescribed
• Take antibiotics as prescribed
• Take stool softeners and a high-fiber diet
• Avoid pelvic and speculum vaginal examinations during the first 4-6
weeks postoperatively
• Prohibit coitus and tampon use for a minimum of 4-6 weeks.
COMPLICATIONS

• Infection
• Hemorrhage
• Injury to the ureters
• Surgical failure of fistula repair
• Possible new fistula formation
• Thromboembolism
• Sexual dysfunction
• Sexual dissatisfaction
• Incontinence
• Abdominal and pelvic adhesions
• Dyspareunia
• Tenderness at the site of the donor Martius graft
• Diminished vaginal length and caliber