Repair of Urethrovaginal Fistula
Most urethrovaginal fistulas result in urinary incontinence and require surgical repair (Fig. 83–1). Rarely, a distal urethrovaginal fistula may be asymptomatic and not require repair. A nonirradiated primary fistula can usually be successfully repaired by a layered tension-free closure of the fistula (Figs. 83–2 through 83–4). If the surrounding tissue appears to be devascularized, the tissue has been irradiated, or the fistula is recurrent, it is probably best to interpose a labial fat pad between the urethra and the anterior vagina (see section on Martius Fat Pad Transposition) (Fig. 83–5). If the fistula is in the proximal urethra or at the bladder neck and the continence mechanism is thought to have been compromised, an anti-incontinence procedure, most commonly a suburethral sling, may be performed at the time of the fistula repair.
The repair begins with the placement of a transurethral Foley catheter. The anterior vaginal wall is then injected with a dilute hemostatic solution to facilitate dissection in the appropriate plane and decrease bleeding. A midline anterior vaginal wall incision or an inverted-U incision is made and extended on both sides of the urethral defect (see Fig. 83–2). The edges of the vagina are grasped with Allis clamps, and the vaginal wall is sharply separated from the underlying tissue (see Fig. 83–2C). This dissection should be extended laterally to the descending pubic rami and posteriorly until the urethra is mobilized as much as possible to allow a tension-free closure. Rarely, the retropubic space must be entered vaginally to facilitate this urethral mobility (see Fig. 83–5) (see section on Vaginal Urethrolysis). The edges of the wall of the urethra are then approximated with fine delayed absorbable interrupted sutures. The sutures should be placed in the extramucosal position (see Figs. 83–2 and 83–3). The initial suture line is then inverted with a second suture incorporating the pubocervical fascia (see Figs. 83–2E and 83–3). The vaginal incision is closed with interrupted 3-0 delayed absorbable sutures (see Fig. 83–2F). A Foley or suprapubic catheter should be left in place for 7 to 10 days.
FIGURE 83–1 Urethrovaginal fistula. Note the fistula is in the midportion of the urethra, and urinary incontinence is readily demonstrated through the fistulous tract.
