Vesicovaginal fistulas (VVFs) represent a challenging scenario for both the patient and surgeon. Many considerations must take place in advance of repair, including diagnosis of the fistula (visualization, dye test, or cystogram), as well as assurance that there is no concomitant injury to the upper tracts (i.e., ureters) that can occur in up to 10% of cases. After the diagnosis of a VVF is confirmed, adequate bladder capacity should be present (e.g., ≥200 cc) before deciding on repair types. The decision to perform an abdominal approach to VVF repair is dependent on the surgeon’s preference and expertise, concomitant need for abdominal surgery (e.g., ureteral reimplant), or the need or desire for omental interposition or in cases of failed vaginal approach VVF repairs or difficult vaginal access. Preoperatively, a sterile urine should be assured, and the patient should be counseled about needing a catheter drainage for at least 2 weeks postoperative. If a patient is at risk for poor wound healing or other complicating factors exist, 3 weeks of postoperative catheter drainage may be necessary. Perioperative anticholinergics or β 3 agonists may be helpful to minimize bladder spasms. Antibiotics are usually necessary for the immediate postoperative period only, and no confirmatory data are available for the use of antibiotics for the entire duration a catheter is in place. Perhaps the main postoperative principle is adequate and unobstructed bladder drainage for the entire duration of the catheter placement.
The procedure is started by placing the patient in the lithotomy position in Yellowfin leg holders with all pressure points padded. Place a urethral Foley catheter and fill the bladder with saline mixed with 3 or 4 drops of methylene blue. Expose the vaginal cuff and watch for egress of blue saline. Cannulate the fistula with a 10- to 14-Fr Foley catheter. Be sure blue fluid fills the catheter. Pull down the catheter and occlude the fistula so the bladder can be filled. Take the patient out of lithotomy position and make a midline incision; open the peritoneum. Fill the bladder and open it ( Fig. 65.1 ).
Look in the bladder to locate the fistula, pull the catheter up so the balloon is out of the way, and open the bladder and adherent peritoneum right down to the fistula marked by the small catheter ( Fig. 65.2 ). Take both catheters out for better exposure if necessary.
Cut the peritoneum transversely to create a flap to protect the bladder and vaginal suture lines and separate them. Dissect on the vagina to completely separate the bladder from the vagina. (This may be easier if done with a sizer or translucent stent in the vagina.) This dissection is through the open fistula ( Fig. 65.3 ). When the bladder is quite free, closure can begin.
Continue freeing the bladder from the vagina widely for 1 to 2 cm to allow mobility for separate closure. It is prudent to place ureteric feeding tubes or catheters to identify the ureters and their intravesical course during bladder flap mobilization and then closure. Close the vagina in two layers vertically or transversely with inverting interrupted 2-0 synthetic absorbable sutures (SAS). Avoid tension ( Fig. 65.4 ).