it is a complecated case and treatment is mondatory

1. VESICO VAGINAL FISTULA
PRESENTER: Dr. Krishan Suyal
1

2. VESICO-VAGINAL FISTULA
• Vesicovaginal fistula (VVF) is an abnormal opening between
bladder and vagina that results in continuous and unremitting
urinary incontinence.
2

3. congenital or acquired
Congenital are very rare
and associated with other
urogenital malformations
Obstetric =developing world
over 90 % of fistulas are of
obstetric etiology
Surgical/gynaecological
=industrialized world, the
most common cause
(>75 %) gynaecologic and
pelvic surgeries
Radiation Malignancy
miscellaneous causes
CAUSES/ETIOLOGY
3

4. CLASSIFICATION OF VVF
SIMPLE VVF
• <5cm size
• No h/o of pelvic malignancy or
radiation
• Vaginal length normal
• Healthy tissue
COMPLEX VVF
1. >5cm
2. H/o pelvic malignancy or
radiation
3. Vaginal length shortened or
scarred
4. Involving urethra, vesical neck,
ureter, intestine
5. Previous unsuccessful
attempt of repair
4

5. PRESENTATION
1. Continuous leak of urine per vagina - “CLASSIC SYMPTOM”
- Immediate (post op)
- Delayed (post pelvic radiations i.e months upto years)
• Surgical injury - first post op day
• Obstetric injury – 7 to14 days
• Small fistula: only in certain positions; pass urine normally
• Large fistula: not void at all but leak
• Menouria: cyclic heamaturia at time of menstruation
2. Recurrent cystitis, perineal skin irritation, vaginal fungal infection 5

6. EVALUATION AND DIAGNOSIS
• History:
- Etiology, attempts of repair, comorbidities
• General & genital examination:
- Examination with speculum “always to be performed”;
Precise assessment - location, size, number of fistulae, tissue mobility,
accessibility of fistula to vaginal repair, determination of degree of
tissue inflammation, edema and infection.
6

7. EVALUATION AND DIAGNOSIS
3 SWAB TEST ( Vaginal Gauze test):
• Three separate sponge swabs placed
into vagina one above another
• Bladder filled with methylene blue
through rubber catheter
• Following some exertional
manuevers, swabs removed after 10
mins
7

8. EVALUATION AND DIAGNOSIS
3 SWAB TEST (Results):
• Discolouration of topmost or middle swab - VVF
• Uppermost wet but not discoloured-
Ureterovaginal fistula
• Lower most discoloured with upper two dry-
Urethrovaginal fistula
8

9. EVALUATION AND DIAGNOSIS
Double Dye test:
• Oral phenazopyridine, fill bladder with blue tinted solution, insert
tampon.
• Blue stain- VVF or urethrovaginal fistula
• Yellow orange stain (pyridium) – ureterovaginal fistula
9

10. EVALUATION AND DIAGNOSIS
• CBC, Urine analysis, Sr.creatinine
• Urine for culture and sensitivity
• Intravenous urogram (IVU)
- to exclude ureter injury or fistula (10% VVFs associated ureter fistula)
• Cystoscopy
- Gold standard to asses size, shape, number and location of fistulas
• Biopsy of fistula
- Prior h/o pelvic malignancy
10

11. 11

12. EVALUATION OF VVF
12

13. Conservative management
Medical therapy
Surgical therapy
MANAGEMENT
• Conservative management
• Surgical management
13

14. PRINCIPLES OF MANAGEMENT
• Ensure adequate nutrition
• Eliminate infection
• Achieve unobstructed urinary drainage
• Beware of malignant cause of fistula
14

15. CONSERVATIVE MANAGEMENT
• Indications
- Newly diagnosed
- <2-3mm
- Simple injuries
- No devascularization or thermal injury spread
• Trial of indwelling catheterization and anticholinergic medication for
at least 2 to 3 weeks.
• Failure: persistently open even after 3 weeks
15

16. PRINCIPLES OF SURGICAL REPAIR
• Adequate exposure of fistula tract with debridement of devitalized
and ischemic tissue
• Removal of involved foreign bodies or synthetic materials from region
of fistula, if applicable
• Careful dissection and/or anatomic separation of involved organ
cavities
• Watertight closure
• Use of well-vascularized, healthy tissue flaps for repair (atraumatic
handling of tissue)
• Multiple-layer closure, tension-free, nonoverlapping suture lines
• Adequate urinary tract drainage
16

17. TIME TO REPAIR
• Controversial
• Obstetric - 3 months after delivery
• Surgical/gynaecolgical
- repair immediately
- Otherwise after 10-12 weeks
• Radiation fistula after 6-12 months
• If repair fails reattempt after 3 months

18. Vaginal
approach
Vaginal Flap
splitting
Latzko
technique
Abdominal
approach
Tansperitoneal
Combined
18
Transvesical
SURGICAL APPROACHES

19. Vaginal approach for VVF Repair
Vaginal flap technique/Flap splitting technique
19

20. Vaginal approach: Flap splitting technique
• Dorsal lithotomy position
• Rectal packing and cystoscopy done
• Ureteral catheters placed if needed
Fistula tract cannulation:
• Foley (10 to 12 Fr), gentle downward traction maintained to pull VVF toward introitus
• Fistula tract is carefully circumscribed
Vaginal wall flaps:
• Dissect in a proximal, distal, and lateral direction away from fistula tract. Each mobilized
2 to 4 cm from fistula tract, exposing underlying perivesical fascia.
First layer repair:
• Interrupted 3-0 or 4-0 absorbable sutures in a transverse or vertical fashion, incorporates
bladder wall and fistulous tract

21. Vaginal approach: Flap splitting technique
Second layer repair:
• Interrupted 2-0 or 3-0 absorbable sutures, to invert previous layer by
imbricating perivesical fascia and deep musculature of bladder
Third layer repair:
• vaginal wall flaps closure
Vaginal wall closure:
• Running, locking, absorbable 2-0 suture
• Antibiotic impregnated vaginal packing placed
• Urethral Foley and suprapubic catheters placed for 10 to 14 days.
21

22. Vaginal approach: Flap splitting technique
22

23. Vaginal approach: Flap splitting technique
23

24. Vaginal approach for VVF Repair
Latzko procedure
24

25. Vaginal approach: Latzko technique
Denuding vaginal epithelium around fistula tract:
• Fistula tract isolated
• Vaginal epithelium surrounding VVF tract denuded circumferentially -
1 to 2 cm.
First layer repair:
• Denuded areas reapproximated over fistula tract with interrupted
absorbable sutures but not placed into bladder wall or vesical
mucosa.
Second layer repair:
Edges of vaginal wall reapproximated creating a partial colpocleisis

26. 26

27. 27

28. Vaginal approach: Latzko technique
Advantages:
• Minimal blood loss
• No need for ureteral reimplantation (even for a fistula adjacent to
ureter, because sutures are not placed through the bladder)
• Short convalescence
Disadvantages:
• Possibility of vaginal shortening
• Creation of directly overlapping suture lines
28

29. VAGINAL V/S ABDOMINAL APPROACHS
• Avoids laparotomy and splitting of bladder
• Recovery is shorter with less morbidity
• Less blood loss
• Procedure can be done in an outpatient setting
• Postoperative pain is minimal
• Results comparable
• Vaginal shortening may be an issue in Latzko operation
29

30. ABDOMINAL APPROACH
INDICATIONS
• High inaccessible fistula
• Multiple fistula
• Involvement of uterus or bowel
• Need for ureter re-implantation
• Complex fistula
• Associated pelvic pathology
• Surgeon preference
30

31. 31

32. Abdominal Approaches for VVF Repair
Suprapubic intraperitoneal or Extraperitoneal Approach
32

33. Abdominal approach : Suprapubic
intraperitoneal or Extraperitoneal Approach
Position:
• Low lithotomy position with access to vagina
• Ureteral catheters may be placed
Incision and Dissection:
• Lower midline (O’Conor and colleagues)
• Bladder approached extraperitoneally
• In some cases, peritoneum entered
• Bladder opened vertically(bivalved), extended down to the opening of VVF
and distally, stay sutures placed on bladder edges to assist in retraction.
• VVF tract excised and vesicovaginal space created. Vagina dissected 2 to 3
cm beyond VVF

34. Abdominal approach : Suprapubic intraperitoneal or
Extraperitoneal Approach
• key to the operation is mobilization of bladder from vagina caudal
to (beyond) VVF tract.
Repair:
• Vagina closed with running absorbable suture.
• Interpositional flap of greater omentum is mobilized and secured 1 to
2 cm distally beyond excised VVF tract.
• Bladder closed in several layers.
• Suprapubic tube and urethral catheter left for postoperative drainage.
34

35. 35

36. Abdominal Approaches for VVF Repair
Transvesical Approach
36

37. Abdominal approach: Transvesical approach
Incision, Dissection & Repair:
• Bladder opened through a vertical cystotomy but not bivalved
• VVF tract circumscribed and excised transvesically
• Vaginal edges mobilized from bladder
• Vagina and bladder closed sequentially
• A V-shaped flap of adjacent posterior bladder wall may be brought
down as a flap to close a large gap or to minimize overlapping suture
lines
37

38. Adjuvant Procedures in the Repair of Vesicovaginal Fistula:
Tissue Interposition
• Martius Flap
• Peritoneal Flap
• Greater omental flap
• Other flaps and grafts
- Gracilis flap
- Bladder mucosa as free graft
- Rectus abdominis
38

39. Tissue Interposition: Martius Flap
• Reliable source of tissue - low or distal fistulae
• Preferential tissue for fistula involving the trigone, bladder neck and
urethra.
Consisting of:
• Adipose tissue, connective tissue
• Blood supply - inferiorly from posterior labial vessels, superiorly from
external pudendal artery and laterally from obturator artery.
• Lateral blood supply is sacrificed during mobilization of the flap
39

40. Tissue Interposition: Martius Flap
Division of flap:
• Either its most superior or inferior margin (basing the blood supply on
the inferior or superior vascular pedicle, respectively), depending on
where flap will be transferred
Procedure:
• Flap harvested after first two layers of closure of VVF but before
advancing final vaginal wall flap over repair
• Vertical incision made over labia majora
40

41. Tissue Interposition: Martius Flap
Procedure:
• Borders of dissection include labiocrural fold laterally, labia minora and
bulbocavernosus muscle medially and Colles fascia covering urogenital
diaphragm posteriorly
• Flap harvest is accomplished in a lateral to medial fashion
• For a posterior-based flap, main vascular supply to flap is located at base of
labia majora.
• Anterior segment is clamped and transected anterior to pubic symphysis
41

42. Tissue Interposition: Martius Flap
Procedure:
• With flap having been mobilized, a tunnel created from labial incision to
the site of fistula repair
• A hemostat used to transfer flap from harvest site
• Flap placed over the fistula repair and secured with interrupted absorbable
sutures
• Vaginal wall flap advanced over Martius flap and closed
• Labial incision closed
• Pressure dressing may be applied to labial skin incision
“Eilber and colleagues (2003) reported that 33 of 34 (97%) patients
undergoing repair of a distal VVF with a Martius flap were cured after the
first operation”
42

43. Tissue Interposition: Martius Flap
43

44. Tissue Interposition: Martius Flap
44

45. Tissue interposition: Peritoneal Flap
Uses:
• In conjunction with repair of a high-lying posthysterectomy VVF
Procedure:
• Peritoneum and preperitoneal fat identified, isolated and mobilized
from caudal origin of vaginal wall flap using sharp dissection
• Peritoneum not opened but mobilized and advanced over fistula
repair and secured with interrupted absorbable sutures
45

46. Tissue interposition: Peritoneal Flap
“success reported in 9 of 11 patients with high VVF
undergoing peritoneal flap placement (Raz et al, 1993)”.
“Later study from the same institution reported on use of peritoneal
flaps in 83 patients, of whom 80 were cured after first operation
(Eilber et al, 2003)”.
46

47. Tissue interposition: Peritoneal Flap
47

48. Tissue interposition: Greater Omentum
Uses:
• Adjunct during transabdominal VVF repair (most common)
Favorable properties of omentum:
• Ability to be mobilized on a well-vascularized pedicle into deep pelvis
without tension
• Inherent lymphatic properties
• Healing even in presence of infection
• Ease with which epithelialization occurs on its surface
48

49. Tissue interposition: Greater Omentum
Blood supply:
• Principally from right and left gastroepiploic arteries
• Distal branches of gastroduodenal and splenic arteries
Procedure:
• Omental flap secured with absorbable suture to healthy tissue at a
location distal to and beyond closed VVF tract, between the vagina
and bladder
“Orford and Theron (1985) reported a 93% cure rate with
use of an omental pedicle graft in 52 patients undergoing VVF”
49

50. Tissue interposition: Other Flap and Graft Techniques
(Gracilis muscle flaps)
Procedure:
• Muscle is mobilized through a thigh incision from its distal attachment on
tibial condyle
• Tunneled cephalad into vagina subcutaneously and secured over fistula.
• Bilateral gracilis muscle flaps can be used for total vaginal reconstruction.
50

51. Tissue interposition: Other Flap and Graft Techniques (Bladder
mucosa as a free graft )
Procedure:
• Bladder approached extraperitoneally and a small cystotomy
performed
• Fistula tract identified and denuded of mucosa circumferentially for
approximately 1 cm
• Free graft of bladder mucosa harvested from edge of cystotomy and
placed over denuded VVF tract and secured in place with absorbable
suture
51

52. Tissue interposition: Other Flap and Graft Techniques (Rectus
abdominis flaps)
Procedure:
• Subcutaneous tissue elevated off anterior rectus sheath.
• Anterior rectus sheath superior to the arcuate line elevated off the rectus
abdominus muscle.
• Rectus muscle elevated off the posterior rectus sheath.
• RAM flap divided superiorly at its tendon insertion to the rib.
• Posterior sheath incised, so the RAM flap could be passed through into
abdominal cavity.
• Rectus muscle completely transected from its attachment , keeping
attached only by its inferior blood supply.
• Flap transposed to lie between the bladder and vagina.
52

53. Tissue interposition: Other Flap and Graft Techniques (Rectus
abdominis flaps)
53

54. Robotic-Assisted Laparoscopic Repair of Vesicovaginal Fistula
Procedure:
• Peritoneum between bladder and
vagina incised
• Posterior bladder wall incised vertically
and dissection continued until catheter
going across fistula seen
• Incision carried downward as far as
fistula tract
54

55. Robotic-Assisted Laparoscopic Repair of Vesicovaginal Fistula
Repair:
• Vaginal closure initiated at apex of incision in one layer using
continuous transverse 2-0 absorbable suture
• Interposition of omentum or pericolic or mesenteric fat over vaginal
suture line
• A suture is then placed at anterior vaginal wall, distal to vaginal
closure. This suture is used to anchor part of omental flap
• Bladder closure is subsequently performed in two layers: first,
mucosal closure with continuous 3-0 absorbable suture, seromuscular
closure with interrupted 2-0 absorbable suture
55

56. Robotic-Assisted Laparoscopic Repair of Vesicovaginal Fistula
“Gupta and colleagues evaluated robotic-assisted laparoscopic versus
open repair for recurrent VVF without any significant statistical
difference in success rate (100% vs. 90%), mean operative time,
complication rate, use of interpositional flap (omental vs.
peritoneum), or complications ”.
“The most significant difference between two groups was shorter
average hospitalization (3.1 vs. 5 days) favoring robotic-assisted
group, with decreased morbidity as opposed to open surgery”.
56

57. POSTOPERATIVE CARE
• Bladder should be drained for 14-21 days
• Excellent hydration to ensure irrigation of bladder and to prevent
clots that could obstruct bladder
• Catheter blockage should be prevented
• Cystogram is to evaluate integrity of bladder before discontinuing
bladder drainage
57

58. INSTRUCTION ON DISCHARGE
• Contraceptive advice - spacing for 1-2 years
• Abstinence for 3 months
• Maintain hygiene
• If pregnancy occurs elective C/section is indicated as when fetus
attains maturity
58

59. CONCLUSION
• Optimal approach for VVF repair depends on surgeon expertise
• The surgeon’s experience and skill set guide the selection of surgical
approach, taking into account cause, localization, size, time of
presentation, and complexity of fistula.
59