Preoperative Preparation and Planning
Traditionally, it has been recommended to wait a minimum of 3 months after vesicovaginal fistula (VVF) diagnosis or last attempted repair before proceeding with repair because this may reduce the amount of inflammation and necrosis encountered at the time of fistula surgery. However, generally, we will perform serial examinations and operate when the tissue quality appears good, often at 6 to 8 weeks after diagnosis. This helps minimize the psychological distress many of these patients experience secondary to significant urinary leakage. Some advocate fulgurating a small fistula tract, less than 2 to 3 mm in diameter, after initial diagnosis with cystoscopic electrocauterization with minimal current and leaving a catheter in place for approximately 2 weeks. In our experience, however, this technique rarely eradicates the fistula.
One of the most imperative aspects of preoperative planning is to select the best surgical approach for fistula repair, either vaginal or abdominal. Although the vaginal approach requires surgeon familiarity with the technique, it can be used for the majority of vesicovaginal fistulas. Although exposure with this approach is easier for distal fistulas and the majority of fistulas seen in the developed world occur after hysterectomy and are located near the apex, it remains an excellent option for most patients. There are, however, several factors that affect exposure, including the size of the vaginal hiatus, total vaginal length, and laxity of the vaginal tissues. It may be a difficult approach in a nulliparous woman with a proximal or apical lesion. Therefore, an abdominal approach should be considered if the surgeon is less comfortable with the vaginal approach, if concomitant intraabdominal surgery is planned, in nulliparous women, or in some patients with prior failed vaginal attempts at fistula closure.
Another important perioperative consideration is adequate evaluation of the patient’s upper tracts. Whenever a patient presents with a VVF, a concomitant ureterovaginal fistula may be present in more than 12% of patients. Evaluation for ureterovaginal fistulas may be accomplished through delayed phase contrast computed tomography, intravenous pyelography, or retrograde ureteropyelography. If there is any evidence of ureteral involvement during workup, the patient may require ureteroneocystostomy, and an abdominal approach to VVF repair is reasonable.
Cystoscopy should be performed at some point in the preoperative setting to adequately identify the fistula tract and determine its proximity to the ureteral orifices. If the fistula is near a ureteral orifice, consideration should be given to placement of a ureteral catheter at the time of VVF repair to aid in preservation of the ureter. A thorough pelvic examination should also be performed to help determine the vaginal location of the fistula and to determine the laxity of the vaginal tissues. Vaginoscopy may be performed at the time of cystoscopy to further describe the position and size of the fistula in relation to the vaginal anatomy.
Patient Positioning and Surgical Incision
Instruments needed include a basic genitourinary set, cystoscopy set, Thorek scissors, Breisky vaginal retractors, weighted posterior vaginal retractor, Lone Star retractor with hooks or other self-retaining retractor, an 8-Fr 3-mL balloon catheter, 24-Fr catheter, 5-Fr ureteral catheter (depending on the location of the fistula), Heaney needle driver, and absorbable suture (3-0 or 4-0 polyglactin suture for bladder mucosa, 2-0 or 3-0 polyglactin suture for detrusor, 2-0 polyglactin suture for vaginal skin flap closure).
Patient Positioning and Exposure
The patient is placed in the dorsal lithotomy position with moderate Trendelenburg positioning with sequential compression devices on her lower extremities. The prone jack-knife position is also an option; however, this approach is less familiar to many urologists and is infrequently used. Perioperative antibiotics should be administered, and the vagina and lower abdomen are prepped and draped. A Lone Star ring retractor, or a similar retractor, is then secured to the patient. Another option for obtaining exposure is suturing the labia to the inner thighs.
To obtain adequate vaginal exposure, the patient may require relaxing incisions at the 5 or 7 o’clock positions (or both) of the vaginal introitus. A weighted vaginal speculum can be placed initially; however, this may prevent mobilization of the apex toward the introitus. Therefore, Breisky retractors or long, right-angled retractors may be used to retract the anterior and posterior vaginal walls without preventing apical descent. At this time, sutures should be placed on either side of the fistula tract or at the lateral aspects of the vaginal cuff scar not far from the fistula to provide traction. This will pull the fistula tract into view and allow for manipulation. Although it is atypical to have a vesicovaginal fistula in a patient with an intact uterus, if a cervix is present, a tenaculum should be placed on the cervix for traction. In patients with a fistula close to the ureteral orifices, cystoscopy and ureteral stent placement should now be performed. A Foley catheter should be placed through the fistula tract from the vaginal side into the bladder to assist in retraction. If the fistula is too small, the tract may need to be dilated with the assistance of a right angle clamp or dilators to allow an 8-Fr catheter with balloon to be placed ( Fig. 63.1 ).
Obtain initial good visualization of the fistula tract with tension on a catheter through the fistula tract or sutures adjacent to the fistula.
Expose and dissect the fistula tract adequately.
Close the defect with multiple layers with nonoverlapping suture lines in a tension-free manner.
Ensure adequate coverage of the fistula with healthy tissue; consider grafts in patients who lack adequate healthy tissue coverage.
Infiltrate the area surrounding the fistula with injectable lidocaine with epinephrine solution. Incise the vaginal skin and perivesical fascia around the fistula, well outside of the scarred tissue. Use delicate dissection to avoid further tissue damage or devascularization. Develop a plane between the vaginal skin and the detrusor muscle ( Fig. 63.2 ).
The use of Thorek scissors can be helpful to develop these planes near the apex. Mobilize the detrusor wall well. Trim the fistula’s edges and close the vesical defect with one layer of interrupted, absorbable suture ( Fig. 63.3 ).