An abdominal approach to vesicovaginal fistula (VVF) repair should be considered in large, complex, supratrigonal fistulas in the setting of ureteral involvement, small-capacity bladder requiring augmentation, previously irradiated tissue, immobile vaginal cuff, or poor-quality vaginal tissue. In addition, in young, sexually active women with high, supratrigonal fistulas and loss of vaginal length, minimally invasive abdominal techniques may preserve vaginal length while minimizing morbidity. Finally, patients with prior failed vaginal repairs in the setting of irradiated or ischemic tissues may be better served with an abdominal approach and use of well-vascularized tissue interposition with healthy pedicled tissue or flaps. Transvesical or extravesical techniques can be performed via an open, infraumbilical incision or minimally invasive approach (i.e., laparoscopy with or without robotic assistance).
Timing
Most VVFs in the developed world occur as a result of iatrogenic injury during pelvic surgery. The majority of patients present 7 to 14 days postoperatively with continuous urinary incontinence. Preoperative evaluation includes a thorough history and physical examination, including the temporal relationship between prior pelvic surgery and onset of incontinence. Identification and characterization of the fistulous tract and surrounding tissue quality using careful vaginal examination, cystoscopy, vaginoscopy, and methylene blue dye test are key. All patients should undergo upper tract imaging (i.e., retrograde pyelography, intravenous urogram, computed tomography urogram, or magnetic resonance urography) to rule out upper tract involvement. Timing and surgical approach should be individualized based on the inciting event, fistula characteristics, patient factors, and surgeon’s expertise. Because of the detrimental effect on the patient’s quality of life, the consensus has shifted toward early repair (within 2 weeks) in appropriate patients. Repair in patients with friable, irradiated tissue or recently failed VVF repairs should be delayed to allow stabilization of the fistulous tract and diminution of surrounding inflammation. In some cases, a unique approach through healthy uninvolved tissue may be ideal.
Basic surgical principles of successful repair include preoperative treatment of urinary tract infection, adequate operative exposure, mobilization of the fistula tract, watertight yet tension-free closure of healthy tissue in multiple layers, avoidance of overlapping suture lines, utilization of interposition grafts (when appropriate), and adequate postoperative urinary drainage.
Patients should be counseled about the options for tissue interposition, the need for prolonged postoperative catheter drainage, and the likely use of two urinary catheters to maximize drainage postoperatively. In addition, postoperative use of antimuscarinics can be helpful in minimizing bladder spasms and preventing undue tension on bladder suture lines.
Preoperative Preparation and Planning
Preoperative antibiotics should be offered per American Urological Association guidelines in patients with positive urine cultures to sterilize the urine and minimize risk of postoperative infection. Deep vein thrombosis (DVT) risk should be assessed and sequential compression devices or pharmacologic thromboprophylaxis used when appropriate per current AUA guidelines. An orogastric tube should be placed to help decompress the stomach, especially if a laparoscopic technique is used. The patient should be paralyzed after induction of anesthesia and placed in the appropriate degree of Trendelenburg position needed to keep the bowels out of the surgical field. Although not absolutely required, preoperative mechanical bowel preparation can be helpful in both open and minimally invasive approaches to improve fistula exposure, reduce the need for bowel handling, and potentially prevent postoperative constipation.
Instruments
For the standard transvesical approach (i.e., open, abdominal) a basic genitourinary set with a Sims retractor, a vaginal manipulator (i.e., a sponge stick, end-to-end anastomosis [EEA] sizer, or Lucite stent) should be available. Self-retaining retractors such as the Balfour or Bookwalter are key. Additional handheld Richardsons, Dever, or Sweetheart retractors may be needed depending on the patient’s body habitus. A cystoscopy set, sensor wire, two 5-Fr open-ended ureteral catheters, a size 8- or 10-Fr silicone Foley catheter, 16-Fr Foley catheter and a 22-Fr Foley catheter (if suprapubic tube placement is planned) will be needed. Methylene blue and a Toomey syringe should also be available on the sterile field to distend the bladder.
Patient Positioning
A low dorsal lithotomy positioning with padded Yellowfin stirrups are preferred. The patient is positioned on thick foam padding to protect pressure points and prevent sliding in a steep Trendelenburg position during the operation. The patient’s arms are tucked bilaterally, and a safety strap is applied.
After the surgical site has been shaved, the abdomen is prepped with chlorhexidine. Betadine paint is used for the vagina and perineum. Cystoscopy is performed, and bilateral 5-Fr ureteral catheters can be placed at this time to aid in identification of the ureters and the orifices. If the VVF is large and prevents adequate cystoscopic distention and visualization of the bladder, a laparotomy pad can be used to temporarily pack the vagina. A 16-Fr urethral Foley catheter is placed, the bladder is drained, and the Foley catheter clamped. If possible, a small (8- or 10-Fr) Foley catheter is placed transvaginally through the fistula tract to aid in subsequent intraoperative identification.
Operative Technique
Open Approach
Incision
A midline infraumbilical incision is made and carried down through the rectus fascia and transversalis fascia ( Fig. 64.1 ). Care is taken to avoid entry into the peritoneum, if possible. The retropubic space is developed, and the self-retraining retractor is placed. The Foley catheter is unclamped and filled with dilute methylene blue dye.
O’Conor Technique
An O’Conor vesicovaginal approach involves mobilizing and then bivalving the bladder ( Fig. 64.2, A ). After lysis of adhesions, a vertical cystotomy is carried down to the fistula tract. At this juncture, the 8-Fr Foley catheter in the fistula tract and the 16-F4 urethral catheter can be removed to aid in visualization. After removal of any devitalized tissue, bladder and vaginal wall flaps are mobilized widely (1–2 cm) to allow tension-free closure. Care must be taken to avoid wide, aggressive excision to avoid unnecessary loss of vaginal length and bladder capacity.
The vaginal flaps are reapproximated transversely using 3-0 synthetic absorbable suture (SAS) on an small half-circle (SH) needle. Because the peritoneum is not entered, a peritoneal flap can be prepared and secured over the vaginal wall repair. If the surgeon opts to place an suprapubic tube, a separate stab incision can be made at this point. The cystotomy is repaired vertically in two layers using a 3-0 SAS to avoid overlapping suture lines with the vaginal wall repair. The 16-Fr catheter is replaced, and the bladder is filled to evaluate suture line integrity. A closed-suction drain is inserted. The fascia and skin are closed in standard fashion. Ureteral catheters can be removed if there is no concern for ureteral injury or kinking at the end of the case.
Gil-Vernet Technique
Alternatively, the Gil-Vernet technique can be used. It involves making a smaller cystotomy to identify the fistula. Rather then extending the cystotomy to the fistula tract, the fistula is visualized, circumscribed, and excised ( Fig. 64.3 ). Similarly, the bladder and vaginal wall flaps are mobilized ( Fig. 64.4 ) and reapproximated tension free in three layers, consisting of one vaginal wall layer and two bladder layers as previously described.
