Surgical Technique

Vesicovaginal fistulas are treated with different surgical techniques, depending on their cause and location. Small vesicovaginal fistulas that are not responsive to nonsurgical management, are usually repaired easily (12). The edges of the fistula are removed, and the defect is closed. Latzko's technique is used commonly for fistulas that are surrounded by severe fibrosis and close to the bladder neck or urethral meatus. Lee et al. (13) recommend an abdominal approach for fistulas in the upper part of a narrow vagina, multiple fistulas, those associated with other pelvic abnormalities, and fistulas close to the ureter. A combined abdominal and vaginal approach is used in some instances (14). Laparoscopy can be an alternative to laparotomy for managing vesicovaginal fistulas (15). Proposed advantages include magnification during the procedure, hemostasis, and shorter hospital stay and postoperative recovery.

The basic principles for laparoscopic repair of vesicovaginal fistula include adequate exposure, excision of fibrous tissue from the edges of the fistula, approximation of the edges without tension, the use of suitable suture material, and efficient postoperative bladder drainage.

After induction of general anesthesia and placement of patient in dorsal lithotomy position, a 10-mm intraumbilical incision is made for insertion of the operative laparoscope coupled with the CO2 laser. Any other cutting modality such as scissors, or ultrasonic or radio frequency energy can be used. Three 5-mm trocars are inserted in the lower abdomen for the suction-irrigator probe, grasping forceps, and bipolar forceps (16). The abdominal and pelvic cavities are inspected for any coexisting pathology. A simultaneous cystoscopy is done, and both ureters are catheterized to aid in their identification and protection during excision and closure of the fistula. A urethral catheter is pulled through the fistula into the vagina to facilitate identification during excision.

A digital rectovaginal examination is carried out to exclude rectal involvement. The bladder is carefully dissected away from the vagina using laparoscopic scissors

Postsurgical vesicovaginal fistulas usually present 7 to 21 days after surgery.

The basic principles for laparoscopic repair of vesicovaginal fistula include adequate exposure, excision of fibrous tissue from the edges of the fistula, approximation of the edges without tension, the use of suitable suture material, and efficient postoperative bladder drainage.

and gentle countertraction. An opening is made into the vagina, avoiding the bladder and rectum, and an inflated glove in the vagina helps maintain pneumoperitoneum. The anterior vaginal wall is elevated with a grasping forceps, and the fistula is identified with the previously inserted catheter, which also delineates the posterior bladder wall. The bladder is filled with water, and a cystotomy is made above the fistula. The water is evacuated as the bladder is distended by pneumoperitoneum from the cystotomy. The fistula tract, vesicovaginal space, and ureters are observed laparoscopically (Fig. 1). The vesicovaginal space is further developed laparoscopically using sharp dissection. The bladder is freed posteriorly from the vaginal wall. The fistula is identified, held with a grasping forceps, and excised (Fig. 2). Adequate bladder dissection and mobilization are essential to eliminate tension upon suturing.

Initially, the vaginal wall opening of approximately 1.5 cm is closed with one layer of interrupted polyglactin (Vicryl) suture (Fig. 3). Then the vesical defect is repaired in one or two layers with interrupted 2-0 or 3-0 polyglactin sutures, using intra-or extracorporeal knotting. Defects in the vagina and bladder are closed separately. Hemostasis in the vesicovaginal space and fistula area is essential. A peritoneal flap is obtained superior and lateral to the bladder dome, close to the round ligament and diverted toward the bladder base. The flap is used to separate the vesicovaginal space. The omentum can also be mobilized and introduced between the bladder and vaginal wall. Using two interrupted sutures of 3-0 polyglactin, the peritoneal or omental flap is anchored to the anterior vaginal wall. The bladder is filled in a retrograde fashion with 300 mL of diluted indigo carmine to confirm the integrity of the vesical wall. No intraperitoneal drainage is used. A suprapubic or transurethral catheter is inserted and ureteral catheters are removed. Prophylactic antibiotic can be administered postoperatively. The bladder catheter is left in place for 10 to 20 days and then a, cystogram is performed to verify the bladder integrity.

FIGURE 1 ■ The fistula tract, vesicovaginal space and ureters are observed laproscopically.

FIGURE3 ■ The fistula tract is excised using CO2 laser.

FIGURE2 ■ Vesicovaginal space is further developed laparoscopically.

FIGURE3 ■ The fistula tract is excised using CO2 laser.

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