Vesico vaginal fistula

A presentation delivered in surgical CPC MTI LRH in Aug 2017.

1. Dr.farman ullah PGR Urology LRH. Vesico -vaginal fistula

2. <2-3cm in size Supra trigonal No hx of pelvic malignancy or radiation Vaginal length is normal Healthy tissue Good access >3cm Trigonal or below Hx pelvic malignancy or radiation Vaginal length shortened Associated with scarring Involving urethra,vesical neck,ureter,intestinal Previouse unsuccesful attempt of repair

3. VVF usually presents with continouse leak of urine per vaginum (true incontinece ) CLASSIC SYMPTOM immediate(post op) or delayed onset of leakage(post pelvic radiations i.e months upto years) Leakage after surgical injury occur from the first post op day Obstetrical fistula =symptoms takes 7-14days to develop Small fistula =leakage in certain postions and can also pass urine normally Large fistula = pt may not void at all but leak Menouria i.e cyclic heamaturia at time of menstruation may be present Recurrent cystitis, perineal skin irritation, vaginal fungal infection

4. History (etiology gynae surgry,pelvic radiation,prolong labour,trauma during labour,attempt of repair,comorbidities ) General & genital examinations Genital/E==full vaginal inspection and include assessment of tissue mobility,accessibility of the fistula to vaginal repair; determination of the degree of tissue inflammation, edema, and infection. CBC and Urine analysis, U.creatinine Urine for culture and sensitivity.

5. 3 swab test intravenous urogram (IVU) is necessary to exclude ureter injury or fistula because 10% of VVFs have associated ureter fistulas. Ascending pyelography to fortify the findings of IVP . Modern imaging technique contarst CT and MRI have limited value. Cystogram Cystoscopy gold standard=size ,shape , number and location of fistulas.

6. Cystoscopic / Cystourethroscopy to assure bilateral ureteral patency and absence of suture placement in the bladder or urethra.

7. CT scan of vesicovaginal fistula. After the intravenous administration of the contrast agent, there is high-density material in both the bladder and the vagina, consistent with a VVF

8. Indications Simple <2cm Dx within 7 days of index surgery Unrelated to carcinoma/radiations Continouse bladder drainage by transurethral or suprapubic catheter Duration upto 30days Small fistula may resolve sponte … If fistula decreases in size=drainage for additional 2-3weeks If no improvement in 30days=surgery conservative

9. Estrogen replacement therapy Local estrogen vaginal cream Antiboitics combination of ( methanamine,methylen blue,phenyl salicylate,benxoic acid) and parasympatholytics (atropine sulphate,hyoscyamine sulfate) Sitz bath Medical management

10. Criteria for succesful repair WHO 2006 Good prognosis Uncertain prognosis

11. Surgical management

12. Time to repair

13. Abdominal approach indications

14. Abdominal Approach for Vesicovaginal Fistula Repair

15. A: A longitudinal incision is placed in the bladder dome. B: The incision is extended around the fistula. The fistulous tract and its vaginal orifice are completely excised. C: Interrupted delayed-absorbable sutures are used to close the vagina in one or two layers.

16. D: Continuous delayed-absorbable suture closes the bladder mucosa longitudinally. E: A suprapubic catheter is placed into the bladder in an extra peritoneal location.

17. F: The bladder muscularis is closed with delayed-absorbable continuous or interrupted sutures. G: An omental flap can be interposed between the bladder closure and the vaginal closure.

18. Vaginal Approach for Vesicovaginal Fistula Repair flap splitting technique

19. A: Ureters have been catheterized. An incision through the vaginal epithelium is made circumferentially around the fistula. B: The vaginal epithelium is widely mobilized from the bladder. The scarred fistula tract should be excised.

20. C: A continuous (or interrupted) delayed-absorbable suture inverts the mucosa into the bladder. D: A second suture line is placed in the musculofascial layer to reinforce the first. Vaginal epithelium is trimmed and approximated

21. Latzko technique for a closure of a simple vesicovaginal fistula. (A)A circumferential incision is made around the fistula. The fistula is not excised. B: The vaginal epithelium is mobilized approximately 2 cm from the fistula.

22. C: Delayed-absorbable interrupted mattress sutures are placed parallel to the edge of the fistula tract to invert it into the bladder. D: One or two additional rows of suture approximate the musculofascial layer of the bladder.

23. The vaginal epithelium is closed transversely with interrupted delayed-absorbable sutures.

24. A: The lateral margin of the labia majora is incised vertically) The fat pad adjacent to the bulbocavernosus muscle is mobilized, leaving a broad pedicle attached at the inferior pole.

25. C: The fat pad is drawn through a tunnel beneath the labia minor and vaginal mucosa and sutured with delayed-absorbable sutures to the fascia of the urethra and bladder. D: The vaginal mucosa is mobilized widely to permit closure over the pedicle without tension. The vulvar incision is closed with interrupted delayed-absorbable sutures.

26. Contraceptive advice i.e spacing for 1-2 years. Abstenence for 3 month. Maintain hygeine . If pregnancy occurs elective C/section is indicated as when fetus attains maturity. Woman who had repair of obstetrical fistula may develop UTIs, DUB and other gynae problems like other population, should go for medical Rx and when pelvic surgery is indicated should be done by experienced surgeon.

27. General factors that increase the risk complications Obesity Smoking Advancing age Poorly controlled diabetes Chronic kidney disease pt Chronic liver disease pt Hypertension Poor nutritional status Bleeding disorders Chronic illness,chronic infections Poor immune system

28. 1. Surgeons involved in VVF repair should have enough training, skills, and experience to select an appropriate procedure for each patient. 2. Attention should be given to skin care, nutrition, rehabilitation, counselling and support prior to and following fistula repair. 3. If a VVF is diagnosed within six weeks of surgery, consider catheterisation for 12 weeks after the causative event.

29. 4. Tailor the timing of fistula repair to the individual pt & surgeon requirements once any oedema , inflammation, tissue necrosis, or infection, are resolved. 5. Where ureteric re-implantation or augmentation cystoplasty are required, the abdominal approach is necessary.

30. 6. Ensure that the bladder is continuously drained following fistula repair until healing is confirmed (10-14 days for simple and/or postsurgical fistulae; 14-21 days for complex and/or post-radiation fistulae). 7. if urinary or faecal diversions are required, avoid using irradiated tissue for repair. 8. Use interposition grafts when repair of radiation associated fistulae is undertaken.