Obstetrical fistulae typically have significant tissue ischemia due to prolonged pressure from the fetal head on the bladder wall. Furthermore, fistulae from radiation damage may have surrounding ischemic tissue which may take several months to a year to stabilize. As such, most experts agree that waiting several months to fix such fistulae increases likelihood of success (Fig. 21.1) [3]. However, when to fix an iatrogenic fistula has been a subject of controversy for many years [4]. Each case should be managed individually, as both early repair and delayed repair may be successful in the appropriate circumstance [5–8]. In general, fistulae which are recognized in the immediate postoperative period can be immediately repaired. Delaying in cases of immediate recognition only causes additional psychological suffering, given the significant amount of leakage that patients will experience while waiting for repair. In cases where tissue edema and inflammation prevent successful repair, a waiting period of several weeks to months may be appropriate.

Determining the location of a fistula in cases of severe vaginal urinary leakage is often the most challenging part of an incontinence evaluation. While voiding cystourethrograms and plain cystograms can often demonstrate the presence of a fistula, they often fail to demonstrate the exact location of vesicovaginal fistulae, as well as the presence of multiple fistulae (Fig. 21.2). Additionally, ureteral injury can be present in up to 12% of cases of vesicovaginal fistulae, and recognition of this preoperatively is essential [9]. CT urography has largely replaced intravenous pyelography as a diagnostic modality of choice when evaluating upper tract damage or fistula. Cystoscopy is an essential component in the evaluation of any woman with unexplained or continuous incontinence. Typically, cystoscopy can show a fistulous tract, or at least suggest fistula due to severe inflammatory changes (Fig. 21.3). Retrograde pyelogram at the time of cystoscopy can usually demonstrate ureteral extravasation of contrast (Fig. 21.4). Alternatively, CT urography can show locations of urinary extravasation and often be diagnostic of ureterovaginal fistula (Fig. 21.5).

The abdominal route may be preferred in women who have poor vaginal access, ischemic tissue from radiation, or those in whom a laparoscopic approach is contraindicated. Women with multiple fistulae including other organs (i.e., enterovaginal fistulae) are often better served with an open abdominal approach. Large, well-vascularized adjuvant tissue flaps are a major advantage available with open abdominal approaches and may decrease recurrence risk in such cases. Complications related to open repair include wound infection, incisional hernia, and increased bleeding risk.

Choosing a transvaginal route and avoiding intraperitoneal access is often a preferred method in most fistulae, provided that the surgeon has access to the site. Specifically, for distally located fistulae, the transvaginal route is recommended, as fistula repair can be performed in an outpatient setting. Some practitioners prefer the Latzko partial colpocleisis to repair apical fistulae, as this method has rather high success rates [10–12]. Most women handle postoperative pain well with the transvaginal route. Complications specific to the transvaginal route include vaginal shortening and vaginal stenosis which may lead to dyspareunia .

Several authors have described laparoscopic and robotic-assisted laparoscopic repair of vesicovaginal fistulae [13, 14]. The advantage of utilizing robotic technology is the ability to have excellent magnified views of the repair, along with the ability to suture for those surgeons not experienced in laparoscopic suturing techniques. Robotic and laparoscopic repairs are often a preferred route in apical fistulae that are unable to be reached vaginally, as they provide superior visualization to defects in this area when compared to the open route. One potential disadvantage that could lead to increased risk for recurrence is the difficulty in obtaining an interposed omental flap although peritoneal flaps are typically easy to obtain during laparoscopic repair.

In a recent report, authors compared intraoperative data and outcomes of 12 robotic-assisted repairs to 20 open surgical repairs [15]. All subjects in the robotic group and 90% of those in the open cohort were managed successfully. Not surprising, mean blood loss was significantly less in the robotic group (88 mL vs. 170 mL, p < 0.05). Mean hospital stay was also shorter in the robotic group (3.1 vs. 5.6 days, p < 0.05). Another single-institution experience noted a mean operative time of 214 min, and a median length of stay of 1 day [16]. In the authors’ experience, laparoscopic and robotic-assisted repaired patients can typically be discharged home after a 23 h stay. Neither group had a significant difference in complication rate . Complications relevant to laparoscopic repair include port-site hernias, bowel injury, and adjacent organ injury.

Many fistulae are surrounded by significant inflammation, which can lead to excessive bleeding and poor visualization intraoperatively. Careful dissection is of utmost importance when performing repair, as the surgeon must obtain several layers of closure to prevent recurrence. Complications may occur if the initial dissection of the vaginal epithelium is too deep, and additional layers of closure are unattainable. Excess bleeding may result when improper tissue planes are entered. In cases where flaps are too thin for a good watertight closure, adjuvant tissue flaps utilizing omentum (in abdominal repair) or a Martius flap (in vaginal repair) are crucial.

The authors do not routinely excise the entire fistula tract. Nevertheless, in cases of prior malignancy or in postradiation fistulae, one should obtain a biopsy to ensure that there is no malignancy at the site of the fistula. Any nonviable tissue should always be removed in order to obtain better healing. Avoidance of cautery is important, as excess cautery can compromise blood supply to tissue flaps and jeopardize healing. Hence, significant bleeding should be controlled with interrupted suture.