Laparoscopic Repair of Vesicovaginal Fistula

Abstract

Open transabdominal and transvaginal approaches for repair of vesicovaginal fistula (VVF) are well described [1, 2]. Currently laparoscopic approach is widely practised in the repair of vesicovaginal fistula [5–9]. Transvesical transurethral repair has been described by Mc Kay et al. [3, 4], wherein he used a transurethral port for suturing. The repair continues to be a challenge even by open technique as recurrence results in about 5–10 %. VVF due to obstetric causes are repaired 3 months after the onset of vaginal urinary leak. However iatrogenic VVF following pelvic surgery can be managed earlier as there is no ischemia to tissues.

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

1 Introduction

Open transabdominal and transvaginal approaches for repair of vesicovaginal fistula (VVF) are well described [1, 2]. Currently laparoscopic approach is widely practised in the repair of vesicovaginal fistula [5–9]. Transvesical transurethral repair has been described by Mc Kay et al. [3, 4], wherein he used a transurethral port for suturing. The repair continues to be a challenge even by open technique as recurrence results in about 5–10 %. VVF due to obstetric causes are repaired 3 months after the onset of vaginal urinary leak. However iatrogenic VVF following pelvic surgery can be managed earlier as there is no ischemia to tissues.

2 Surgical Technique

Preliminary evaluation includes IVU/CT urogram and cystoscopy to know the location and relation of VVF to the ureteric orifice and to rule out an associated ureterovaginal fistula.

2.1 Transperitoneal Approach ( O’ Connor’s Technique)

Cystoscopy and ureteric stenting is done for protection of ureteric orifice and ureters. Patient is placed in lithotomy position. Optimum sized three way urethral catheter is left in and kept sterile and accessible for subsequent bladder filling. Four ports (a 10 mm supra umbilical camera port, two 5 mm ports in each midclavicular line for hand instruments and one 5 mm suprapubic port for suction and irrigation) are used. Cystotomy is done in the midline using electrocautery or ultracision till the edge of the fistula. Subsequently adequate mobilization of bladder wall from vaginal wall is done. The fistula is excised with cold scissors. The bladder defect and vaginal defect are trimmed. Initially the vaginal defect is closed horizontally using interrupted 3–0 absorbable monofilament sutures. Whenever possible omentum is mobilized and sutured over the anterior wall of vagina below the sutureline. Then the bladder defect is closed in two layers (inner layer with 3–0 continuous vicryl sutures and outer layer with 2–0 interrupted vicryl sutures) bringing in trimmed, healthy bladder wall over the previously fistulous area. 14 size transabdominal drain is left through one of the pararectus ports.

2.2 Transvesical Approach ( Cystorrhaphy)

After preliminary cystoscopy and colposcopy to assess the defect, vagina is packed with large pad to prevent leak of water or air. Using cystoscopic view and irrigation, two 5 mm transvesical suprapubic ports are inserted for hand instruments. Usually some of the irrigating fluid escapes and the transvesical ports tend to slip out of the bladder. It is also important to keep the bladder distended to have some working space. Hence a trocar with self retaining mechanism needs to be used. Subsequently the pneumovesico insufflation is done. Urethra can be used as a third port for transurethral suturing. The edges of the fistula are trimmed (any suture material of previous surgery that is seen can be removed). Transurethral suturing of vesical defect is carried out using 3–0 interrupted vicryl.

If the vaginal defect is small it can be left alone. Otherwise the vaginal defect can be closed with continuous 2-0 vicryl suture by vaginal route as in open surgery. Urethral foley catheter is left in for about 10 days.

3 Follow-Up

The tube drain can be removed on the eighth postoperative day if there is less drainage. The urethral foley catheter can be removed on the tenth postoperative day following a cystogram.

4 Comment

Laparoscopic repair of vesicovaginal fistula is feasible by minimally invasive technique. This is certainly more acceptable for the distressed patient than open repair. Transvesical cystorrhaphy appears to be the least morbid procedure.

5 Laparoscopic VVF Repair ( O’ Connor’s Technique)

Fig. 29.1

CT image showing vesico vaginal fistula

Fig. 29.2

Cystoscopic view showing a supra trigonal VVF

Fig. 29.3

Port position

Fig. 29.4

Adhesiolysis in progress

Fig. 29.5

Vertical cystotomy being done

Fig. 29.6

Cystotomy extended around fistula (Note preplaced ureteric catheter in fistula)

Fig. 29.7

Bladder mucosal incision around fistula

Fig. 29.8

Plane developed between posterior wall of bladder and anterior vaginal wall

Fig. 29.9

Fistula completely excised

Fig. 29.10

Vaginal rent closure with 3-0 PDS suture in progress

Fig. 29.11

Vaginal closure in progress

Fig. 29.12

Vaginal closure completed

Fig. 29.13

Omental interposition anterior to vagina

Fig. 29.14

Bladder closure started

Fig. 29.15

Bladder closure with 3-0 V Lock suture in continuous fashion

Fig. 29.16

Bladder closure in progress

6 Modification;1. Cystorrhaphy

Fig. 29.17

Bladder distended to look for any leak

Fig. 29.18

CT cystogram done 3 months later does not show any leak

Fig. 29.19

Cystoscopy showing the VVF in supratrigonal area following hysterectomy 1 week back

Fig. 29.20

Left ureteric catheterisation done to safeguard left ureter as it is close to VVF

Fig. 29.21

Transvesical port insertion under cystoscopic guidance

Fig. 29.22

External view of ports position for transvesical approach. Note cystoscope through urethra as camera port

Fig. 29.23

Trimming the edges of the bladder defect

Fig. 29.24

View after trimming the edges

Fig. 29.25

Common difficulty in transvesical approach is escape of air through VVF preventing bladder distention

Fig. 29.26

Closing the bladder defect transvesically using 3–0 interrupted vicryl sutures

Fig. 29.27

Closure of the defect in progress

Fig. 29.28

Defect nearly closed

Fig. 29.29

If closure of defect is difficult urethra can be used as a port for the needle holder (as seen by transvesical 5 mm camera port)

Fig. 29.30

Tube drain (a suprapubic catheter) introduced through transvesical port

7 Technical Modification 2. Transverse Cystotomy Approach

Fig. 29.31

Cystoscopic view 3 months later shows well healed scar (at the previous site of fistula)

Fig. 29.32

Transverse cystotomy started

Fig. 29.33

Transverse cystotomy in progress – yellow ureteric catheter seen in the fistula

Fig. 29.34

Cystotomy extended to encircle the fistula

Fig. 29.35

Plane created between the bladder and vagina

Fig. 29.36

Plane between bladder and vagina created

Fig. 29.37

Fistula margin excised

Fig. 29.38

Freshened fistula margin

Fig. 29.39

Vaginal opening of the fistula

Fig. 29.40

Vaginal closure started

Fig. 29.41

Vagina transversely closed

Fig. 29.42

Vaginal closure complete

Fig. 29.43

Bladder closure started with barbed sutures

Fig. 29.44

Bladder closure in progress with 3-0 V loc suture

Fig. 29.45

Bladder closure complete

Fig. 29.46

Omental or colonic epiploica interposition