V08_No_3_Final.pdf Female Urology 209Urology Journal Vol 8 No 3 Summer 2011 Salvage Repair of Vesicovaginal Fistula Aliasghar Yarmohamadi, Mohammad Asl Zare, Hassan Ahmadnia, Nasser Mogharabian Purpose: To present the long-term results of failed vesicovaginal fistula repair using flap splitting techniques. Materials and Methods: Nine women with a previous failed vesicovaginal fistula repair, aged 18 to 69 years, underwent salvage vaginal reconstruction for damaged urethra or bladder, at a five-year interval lasting from 2003 to 2007. Fistulas were repaired using an interposed pediculated vaginal wall flap. Results: The repair was successful in all the patients, even in those with rectovesicovaginal fistula or a large vesicovaginal fistula with sphincter damage. Conclusion: Pediculated vaginal wall flap is an easily-prepared, well– vascularized tissue, which provides long-term favorable outcomes. Urol J. 2011;8:209-13. www.uj.unrc.ir Keywords: recurrence, urologic surgical procedures, surgical flaps, vaginal fistula, treatment outcome Mashhad University of Medical Sciences, Mashhad, Iran Corresponding Author: Aliasghar Yarmohamadi, MD Mashhad University of Medical Sciences, Mashhad, Iran Tel: +98 511 801 2857 Fax: +98 511 841 7404 E-mail: yarmohamadiaa@mums.ac.ir Received January 2011 Accepted June 2011 INTRODUCTION A fistula represents an extra- anatomic communication between two or more epithelium or mesothelium-lined body cavities or to the skin surface (Figure 1). (1) Urogenital fistula may be congenital or acquired. Vesicovaginal fistulas (VVFs) are the most common type of acquired fistula of the urinary tract.(1-3) The etiology of VVFs differs in various parts of the world.(4) In industrialized world, the most common cause (>75%) of VVF is injury to the bladder at the time of gynecologic, urologic, or other pelvic surgeries (iatrogenic). Malignant diseases, pelvic irradiation, and obstetric trauma, including forceps lacerations and the uterine rupture, are other important causes.(1,5,6) In the developing world, where routine perinatal obstetric care may be limited, VVFs most commonly result from prolonged obstructed labor.(1,5) Vesicovaginal fistulas may be repaired through a transvaginal or transabdominal (transvesical) approach.(1,4,6) There is no “best” approach for all the patients with VVF, and excellent outcomes can be expected with both approaches, depending on the particular circumstances of the fistula.(1,4,6) Although factors, such as size, location, and need for adjunctive procedures often have an impact on choosing the approach, the most important factor is usually the surgeon’s preference.(1,6,7) The majority of VVFs in the industrialized world are amenable to a transvaginal repair.(6) There is a consensus that the best chance for success is the first surgery. (1,4,8,9) Two main subgroups of transvaginal repairs are Flap- Splitting technique and Latzko procedure.(6,9) Vesicovaginal Fistula Repair—Yarmohamadi et al 210 Urology Journal Vol 8 No 3 Summer 2011 Our aim was to present the long-term results of failed VVF repair using flap splitting techniques. MATERIALS AND METHODS From January 2003 to January 2007, 9 women with previous failed VVF repairs, aged 18 to 69 years, were recruited to this study. The first and youngest subject was an 18-year-old girl, who had a large rectovesicovaginal fistula due to a penetrating trauma to her perineum during cycling, which resulted in total urinary, fecal incontinence, and several unsuccessful surgical repairs. Three patients were young women aged 20, 22, and 23 years with a VVF due to delivery at home. Another subject was a 19-year-old woman with a VVF due to dystocia and use of devices during delivery at hospital. The next patient was a 29-year-old woman with a history of postpartum stress urinary incontinence (SUI) treated with sling surgery. Persistent urinary retention occurred immediately after the operation, which has been treated with transurethral resection of the bladder neck. Thereafter, she became totally incontinent because of a large urethrovesicovaginal fistula. The last three subjects were 52, 57, and 69-year- old women with VVFs following treatment of the uterine cervix cancer with hysterectomy and adjuvant radiotherapy. All of the patients were evaluated in the same manner. Initially, voiding cystourethrography and intravenous pyelography were performed. Thereafter, cystoscopy and vaginoscopy were carried out to evaluate the exact size, number, and location of the fistula, and biopsy if there was any history of malignancy to rule out cancer relapse. Finally, we did the main surgical procedure in jackknife position, using a pediculated vaginal wall flap technique (Figure 2). We did not use other types of flap, such as maritus. Figure 2. Vaginal wall flap technique for transvaginal VVF repair. Figure 1. Vesicovaginal fistula before repair. Vesicovaginal Fistula Repair—Yarmohamadi et al 211Urology Journal Vol 8 No 3 Summer 2011 Because the patients were unable to keep their bladder full, we could neither assess their bladder’s capacity nor perform urodynamic study to evaluate coincidental SUI. However, after the recovery from the surgery, we did so and there was only mild to moderate SUI (urodynamically defined as leak point pressure more than 60 cm H2O) in 4 patients. Fistulas repairs were done using classic method (Figure 2). Indwelling urethral catheters were kept in all the patients postoperatively until cystography confirmed successful repair of the fistula (Figure 3). Imaging studies were done 10 to 21 days postoperatively or if necessary, including persistent urine leakage. Anticholinergic medications were given to decrease the bladder irritability. Sexual intercourse was forbidden for 3 months postoperatively. RESULTS Demographic and clinical characteristics of the patients are demonstrated in Table. The patients were followed up for 51 to 100 months. Physical examination and urodynamic studies were performed annually for at least 3 years to ensure vaginal and urethral integrity, and exclude any obstruction due to urethral stricture. Significant vaginal shortening and stenosis were not observed. Urethral integrity and patency were restored in all the patients, with no incontinence. Patients were able to empty their bladder voluntarily and completely. Patients with combined VVF repair and urethral elongation, subsequently underwent a Young Diz operation. All of the patients received short-term (3 months) oral anticholinergic to prevent postoperative detrusor hyperactivity. We performed urodynamic study 3 months postoperatively. Four patients had mild to moderate SUI, who were treated successfully with conservative measures, such as Kegel exercises. Patients, number Age, Number of previous repair fistula Predisposing factors Outcome 1 18 3 Rectovesicovaginal Penetrating trauma Excellent 2 20 2 Vesicovaginal Delivery at home (obstructed labor) Excellent 3 22 2 Vesicovaginal Delivery at home (obstructed labor) Excellent 4 23 3 Vesicovaginal Delivery at home (obstructed labor) Excellent 5 19 2 Vesicovaginal Dystocia and use of devices during delivery at hospital Excellent 6 29 4 Vesicovaginal Sling surgery for stress urinary incontinence Excellent 7 52 2 Vesicovaginal Endometrial cancers with hysterectomy and adjuvant radiotherapy Excellent 8 57 2 Vesicovaginal Endometrial cancers with hysterectomy and adjuvant radiotherapy Excellent 9 69 2 Vesicovaginal Endometrial cancers with hysterectomy and adjuvant radiotherapy Excellent Demographic and clinical characteristics of the patients Figure 3. Vesicovaginal fistula after repair. Vesicovaginal Fistula Repair—Yarmohamadi et al 212 Urology Journal Vol 8 No 3 Summer 2011 DISCUSSION Vesicovaginal fistula is an abnormal opening between the bladder and vagina, causes urine leakage from the vagina.(1,2) Intra-operative injury to the urinary bladder is clearly a primary risk factor for subsequent development of a postoperative VVF.(6,9) Other risk factors include prior uterine surgery (cesarean section), endometriosis, infection, diabetes mellitus, arteriosclerosis, pelvic inflammatory disease, and prior radiation therapy.(1,10) Patients with VVF often complain from painless urinary incontinence, which occurs all the time. (10) Patients with anatomical urethral damage have usually been repeatedly operated and present with severe incontinence that is difficult to treat. Therefore, a thorough clinical and radiological evaluation is required to precisely define the extent of the anatomical defect and to assess the surrounding tissues that might be used in the reconstructive procedures.(6,11,12) Repair is usually undertaken 8 to 12 weeks after the injury. This time delay allows resolution of wound inflammation prior to attempting corrective surgery. In postmenopausal patients, estrogen replacement prior to surgery may improve the chance of successful closure. It has been stated that the best opportunity to achieve successful repair of a VVF is with the initial operation. Previous failed attempts result in scar formation and anatomic derangement, and may compromise potential reconstructive flaps. Therefore, careful pre-operative planning is essential to maximize the chance for a successful result. The low-lying fistula (subtrigonal) is best repaired through the vaginal approach.(7) The indications for tissue interposition are not well-defined, but these measures are most commonly used in the setting of irradiated tissues, obstetric fistulas, failed prior repairs, large fistulas, and fistulas with tenuous repairs. Vaginal flap or Flap-Splitting technique popularized by Raz and colleagues results in a three-layer closure without the use of an adjuvant flap and a four-layer closure if a flap is used. It can be performed as an outpatient procedure and is applicable to the most simple, uncomplicated VVFs.(1) Anterior vaginal wall usually provides sufficient tissue, especially in primary cases, to cover adequately the urethral or vesical defects. After careful dissection and removal of all scar tissues from the fistula opening, mobilization, and good closure of the communicated organs, the vaginal wall flap is interposed between layers of repair, enhancing secure healing, and is compatible with the classic surgical principles for the fistula repair. (6) Anatomical reconstruction of the damaged urethra can be achieved by using mucosal flaps from the vagina alone or with the interposition of surrounding healthy tissues that can be easily mobilized and transferred to the desired position, aiming at a significant improvement of the postoperative outcome.(5) There is no controversy concerning the necessity to interpose well-vascularized flaps between the layers of fistula closure that enhance the healing and secure a watertight repair in cases of complex VVF or previously failed repairs and in those with anatomical urethral defect.(10) The main factor in correcting a VVF is to separate communication between the bladder and vagina. (1) This can be accomplished by interpositioning tissues between the two damaged organs and obtaining a watertight tension-free closure.(4,9,10) The success rate of repairing vesicovaginal and ureterovaginal fistulas through vaginal approach is 90%.(1,7) Early repair using a transvaginal approach is recommended.(10) CONCLUSION The vaginal pediculated wall flap is easy to dissect, is close to the operative field, and its use does not cause any cosmetic, sexual, or functional problems for the patient. CONFLICT OF INTEREST None declared. REFERENCES 1. Rovner ES. Urinary tract fistula In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell- Walsh Urology. Vol 3. 9 ed. Philadelphia: Saunders 2007:2322-90. 2. Zafirakis HG, Westney OL. Vesicovaginal fistula. Vesicovaginal Fistula Repair—Yarmohamadi et al 213Urology Journal Vol 8 No 3 Summer 2011 In: Glenn JF, ed. Glenn’s urologic surgery. 7 ed. Philadelphia: Lippincott Williams & Wilkins; 2010: 130-7. 3. Webster GD, Sihelnik SA, Stone AR. Urethrovaginal fistula: a review of the surgical management. J Urol. 1984;132:460-2. 4. Hohenfellner R. Commentary: Management of vesicovaginal fistula. In: Whitehead ED, Leiter E, eds. Current Operative Urology. Harper and Row, Philadelphia 1984:981-5. 5. Hendren WH. Construction of female urethra from vaginal wall and a perineal flap. J Urol. 1980;123: 657-64. 6. Eilber KS, Kavaler E, Rodriguez LV, Rosenblum N, Raz S. Ten-year experience with transvaginal vesicovaginal fistula repair using tissue interposition. J Urol. 2003;169:1033-6. 7. Zimmern PE, Hadley HR, Raz S. [Vaginal approach to non-irradiated vesicovaginal fistula]. J Urol (Paris). 1984;90:355-9. 8. Flisser AJ, Blaivas JG. Outcome of urethral reconstructive surgery in a series of 74 women. J Urolo. 2003;169:2246-9. 9. Kirschner CV, Yost KJ, Du H, Karshima JA, Arrowsmith SD, Wall LL. Obstetric fistula: the ECWA Evangel VVF Center surgical experience from Jos, Nigeria. Int Urogynecol J Pelvic Floor Dysfunct. 2010;21:1525-33. 10. Ijaiya MA, Rahman AG, Aboyeji AP, et al. Vesicovaginal fistula: a review of nigerian experience. West Afr J Med. 2010;29:293-8. 11. Rangnekar NP, Imdad Ali N, Kaul SA, Pathak HR. Role of the Martius procedure in the management of urinary-vaginal fistulas1. J Am Coll Surg. 2000;191:259-63. 12. Hendren WH. Construction of a female urethra using the vaginal wall and a buttock flap: Experience with 40 cases* 1. J Pediatr Surg. 1998;33:180-7.