Vaginal Repair of Vesicovaginal Fistula
Surgical treatment of benign pelvic conditions causes approximately 90% of vesicovaginal fistulas, with total abdominal hysterectomy being the most common cause. The point at which the fistula first becomes symptomatic is determined to a major degree by its cause, its site of origin, and the method of catheter drainage. Immediate postoperative leakage probably represents an unrecognized perforation or laceration somewhere in the lower urinary tract. Many fistulas occur secondary to trauma, crushing injuries from clamps, or suture penetration into the lower urinary tract, which may result in devascularization, necrosis, and invariably fistulous development between the second and tenth postoperative days.
If a vesicovaginal fistula is diagnosed within 7 days of occurrence, is less than 1 cm in diameter, and is unrelated to malignancy or irradiation, bladder drainage alone for up to 4 weeks allows spontaneous healing in 12% to 80% of cases; however, the outcome is very unpredictable. Cystoscopic cauterization of small lesions may also be successful. Standard management of the vesicovaginal fistula dictates an interval from injury to repair of 3 to 6 months in surgical and obstetric fistulas, and up to 1 year in irradiation-induced fistulas, to ensure complete resolution of necrosis and inflammation. However, recently, some have championed the early closure of small fistulas with good results.
Most vesicovaginal fistulas can be closed transvaginally. Simple vesicovaginal fistulas are usually repaired with the Latzko technique (Fig. 90–1), whereas more complex procedures usually require excision of the tract and a layered closure of the defect (Fig. 90–2). If the fistula encroaches on one or both ureteral orifices (Fig. 90–3), the ureters should be catheterized at the onset of surgery. Intraoperative placement of a pediatric Foley catheter through the fistula and into the bladder helps to evert the fistula edge, thus improving descent and stability for dissection (Fig. 90–4).
The Latzko technique of partial colpocleisis may be used for repair of posthysterectomy vesicovaginal fistulas, with reported cure rates of between 93% and 100% after the first attempt. As a simple procedure, it offers the advantages of a short operating time, minimal blood loss, and low postoperative morbidity. Inadequate vaginal length is not a problem unless the vagina is already shortened. In the Latzko operation, the vaginal mucosa is mobilized around the fistula margin in the shape of an ellipse for at least 2.5 cm in all directions, with closure of the subvaginal tissue and vaginal mucosa in layers using 2-0 or 3-0 interrupted absorbable sutures (see Fig. 90–1). The vaginal wall in contact with the bladder reepithelializes transitional epithelium.
For complicated or larger fistulas, a classic technique is best. This involves circumscribing the vaginal mucosa in the region of the fistula (see Fig. 90–2A). Sufficient vaginal mucosa is separated from the underlying pubocervical fascia to permit a tension-free closure of the tissues. This usually requires a fair amount of mobilization of the vagina (Figs. 90–5 and 90–6
