Conservative Management

Conservative measures can be considered for small fistulas, typically less than 2–3 mm in diameter. This consists of continuous bladder drainage with an indwelling catheter along with anticholinergic medications to manage symptoms. In properly selected patients, fistula closure can occur after 2–3 weeks [27]. Pooled data suggest a 13% spontaneous closure rate for fistulas managed with initial catheterization [28]. Ongoing drainage of urine from the vagina after placement of a foley catheter indicates a persistent fistula tract and other methods should be considered for treatment as appropriate. Prolonged foley catheter drainage in a persistent fistula will cause considerable patient discomfort and is doomed to fail.

Cystoscopic electrocoagulation of the epithelialized fistula tract in conjunction with bladder catheterization may provide some additional benefit. Stovsky et al. reported successful ablation in 11/15 patients with fistula tract diameters less than 3.5 mm [29]. Fibrin sealant has also been utilized with some success to plug the fistula tract, presumably until tissue ingrowth occurs [30]. Again, if persistent leakage is noted with indwelling urethral catheterization following electrocoagulation, other methods should be considered in the short term.

Surgical Management

The timing of intervention for VVF is a contentious issue. Classic teaching advocates delaying repair several months after diagnosis to allow for stabilization of inflamed or necrotic tissue and recovery from the inciting event. More recently, however immediate intervention has become the preferred approach, at least in uncomplicated iatrogenic fistula. Early repair can minimize patient discomfort and anguish without compromising surgical repair [12, 31, 32, 33–35]. In complex cases, however, such as those involving continued infection, obstetric etiology or radiation, a waiting period of anywhere from 1 to 12 months may be necessary to allow demarcation of inflamed or devascularized tissues [20, 36, 37]. During any such waiting period, special attention should be paid to skin protection (incontinence pads, barrier creams) and to nutritional status.

Once the decision to pursue definitive repair has been made, thoughtful surgical planning is essential to maximize chances of success. The first attempt at VVF repair is typically offers the best opportunity for success, free from some of the scarring, anatomical distortion and revascularization that often complicate salvage procedures.

VVF can be repaired via a transvaginal or transabdominal approach. There is no “correct” approach, and each option has advantages and disadvantages. Whereas vaginal repairs are typically outpatient procedures that can be done immediately and regardless of surgical history, abdominal repairs introduce the potential complications involved in abdominal surgery, often in patients who have recently had a complicated abdominal surgery. Transabdominal repairs are associated with greater blood loss and longer hospital stay [25]. Transvaginal surgery may be challenging in treating fistulas located high at the vaginal cuff in a deep vagina, or in patients with a narrowed vagina due to radiation, and in patients who are unable to be placed in a high-lithotomy position. In such patients, an abdominal or minimally invasive approach (laparoscopic/robotic) can be considered. An abdominal approach is necessary in patients requiring a concomitant ureteral reimplantation or in the case of complex fistulas involving adjacent organs. Regardless of the approach taken, ureteral catheter placement should be considered in the case of any fistula located close to the ureteral orifices to avoid inadvertent injury to these structures.

It should be noted that in certain extreme cases where repair is not feasible or not possible, urinary diversion should be considered. This is most common in situations involving active pelvic malignancies, multiple failed repairs, severe radiation damage or other cases of extreme tissue loss [42–44].

Transabdominal Repair

The classic transabdominal VVF repair was described by O’Conor in 1980 [45]. Transabdominal approaches for fistula repair include supravesical or transvesical approaches, and laparoscopic/robotic techniques. The O’Conor transabdominal VVF repair has been well described [45]. The patient is positioned in a low lithotomy position, with access to the vagina and abdomen. Ureteral catheters may be placed and are recommended if the fistula is near the ureteral orifices or the trigone. A lower midline incision is performed and the bladder is mobilized. The bladder is then bivalved vertically to the level of the fistula, and dissection is continued distally to open the vesicovaginal space, 2–3 cm distal to the fistula site. Following mobilization of the vaginal wall from the bladder wall distal to the fistula tract, the fistula tract is excised, and the vaginal wall is closed with running synthetic absorbable suture (SAS). The bladder is closed in multiple layers with running SAS. An additional layer of tissue can be placed between the suture lines utilizing an omental interposition flap or peritoneal flap. It is important to secure the interpositional flap distally beyond the fistula.

A later adaption, known as the transvesical approach, mitigated some of the morbidity associated with the complete bivalving of the bladder. Instead, the bladder is opened via an anterior wall midline cystotomy. The VVF tract is visualized on the posterior wall, were it is then circumscribed and excised. Following mobilization of the vesicovaginal space surrounding the fistula site, the vaginal and vesical tissues are closed separately. A flap of adjacent bladder tissue may be advanced to avoid overlapping suture lines as described by Gil-Vernet [46].

Interest in minimizing the morbidity of transabdominal VVF repair led to the advent of minimally invasive approaches. First reported in 1994 by Nezhat et al., laparoscopic VVF repair has been described in several case series in both transvesical [47–49] and extravesical [50] approaches, with various modifications, with or without the utilization of omental or peritoneal flaps. A literature review found success rates across multiple case series to be 93.5%, comparable to open repair, with a complication rate of 2.3% [51]. Advantages of minimally invasive surgery, such as improved visualization, decreased blood loss, shorter length of stay and decreased convalescence are well established. One particular advantage of minimally invasive transvesical techniques is the use of a limited posterior cystotomy, typically less extensive than anterior cystotomy in typical open cases and, as such, is likely less morbid than the formal bivalving of the bladder required in the classical O’Conor procedure [52]. Potential drawbacks of laparoscopic VVF repair include the longer operative time, potential injury to intraabdominal structures (as compared to the transvaginal approach) and the advanced laparoscopic skill necessary to successfully complete the procedure.

The advent of robotic surgery helped to overcome some of the perceived drawbacks of pure laparoscopy, most notably a steep learning curve pertaining to dissection and suturing. By the mid-2000s series of robotic-assisted laparoscopic VVF repair began to appear in the literature. The largest series to date by Bora et al. described robotic assisted laparoscopic repair of 30 VVF. Average fistula size was 10.3 mm and 11 of the 30 fistulas were characterized as “complex” (prior failure, prior radiation, obstetric cause). Their technique involved cutting down posteriorly directly on to the fistula, guided by manipulation of a traversing open-ended catheter. Eighteen patients underwent interposition flaps (epiploic, omental, peritoneal). They reported two recurrences, with an overall success rate of 93.3%. No complications were reported [52]. A recent review performed by the same group of smaller published cases and case series of robotic VVF repair corroborated the impressive success rate [53]. However, it must be cautioned, that such an approach should not be attempted by those who are unskilled in robotic techniques.

Transvaginal Repair

The transvaginal approach for fistula repair is shown in Fig. 31.3 [7, 54, 55]. The patient is placed in the dorsal lithotomy position, and a rectal pack is placed. Labial retraction sutures are placed as well as a weighted speculum. A self-retaining ring retractor with hooks aides in visualization. Cystoscopy is performed to localize the fistula tract, and a guide wire is placed though the fistula into the vagina. A 10–12 French foley catheter should be placed though the fistula site, using the previously placed guide wire. This catheter provides traction of the fistula toward the introitus throughout the case. Ureteral stents are placed if the fistula is in close proximity to the ureteral orifices. A urethral catheter is placed, and a supra-pubic catheter may also be utilized for bladder drainage. An inverted U-shaped incision is made which circumscribes the fistula site. Anterior and posterior vaginal wall flaps are developed after hydro-dissection with sterile saline and retracted using the ring retractor. An alternative to the inverted U incision is the Latzko procedure. In this case an elliptical incision is made around the fistula tract including a small rim of vaginal epithelium, and the surrounding vaginal wall is mobilized for eventual closure [56]. In the case of either approach, the fistula is then closed in an interrupted fashion, typically using double-armed synthetic absorbable suture (SAS), The perivesical tissue is then closed over the initial suture line in an interrupted imbricated fashion, 90° with respect to the first layer. A peritoneal flap or a Martius flap can be positioned over the imbricated layer of perivesical tissue. The posterior vaginal wall flap is advanced over the suture line anteriorly to complete the closure.