Introduction

Vesicovaginal fistula (VVF) is a fistulous tract between the bladder and the vagina, leading to continuous involuntary leakage of urine into the vagina. VVF has profound emotional and physical effects on the patient's well-being as not being dry is a social stigma. The treatment of VVF is a surgical challenge, and therefore, a large number of treatment options starting from minimal to maximally invasive have evolved over the past two centuries and are still evolving. It is extremely difficult to prove the superiority of one over the other due to lack of randomized trials, varied aetiologies’ and differences in clinical expertise. We are working in a tertiary care centre and treating more than 50 cases of VVFs in a year. The small VVFs, which occur following failure of conservative management and secondary to failure of primary repair, are a formidable challenge to the treating surgeon. We reported the first case of laser welding of VVF previously with neodymium yttrium aluminium garnet laser (Nd-YAG) laser [1]. We hereby present our long-term experience of treating this subset of patients with our minimally invasive approach of laser welding and our results.

Material and methods

Between January 1, 2001 and January 3, 2010, eight patients underwent laser welding of vesicovaginal fistula. The mean age was 44 years (35–55). The VVFs were primary (failing to heal following conservative management) in five and secondary (recurring following primary repair) in three cases (Table 1). All patients underwent urine routine, microscopic and culture sensitivity, hemogram, renal function tests, excretory urography with post voids films (for delineation of the upper tracts) preoperatively. All patients underwent per speculum examination, three swab tests and cystopanendoscopy with vaginoscopy to confirm VVF. Cystopanendoscopy revealed small supratrigonal VVF of 3 mm (2–4) in size in all the eight cases, and these cases were then taken up for laser welding. Laser welding was done after at least 6 weeks of the initial surgery in secondary cases and immediately after diagnosis in primary cases after a trial of initial catheterisation failed. One surgeon (PND) did all the procedures. After regional anaesthesia, the patient was placed in low lithotomy. Rigid cystoscopy was performed using 22 French sheath and 30° lens. After visualisation of the fistula, a 4 French ureteric catheter/guide wire is passed through the fistula into the vagina or in cases of difficulty in identifying the fistula, betadine is instilled in the bladder, vaginoscopy is performed to delineate the fistula site and ureteric catheter/guide wire is passed into the bladder through the vagina (Fig. 1). Circumferential welding of the fistula is performed on the bladder as well as vaginal side (Fig. 2). We employed Nd-YAG in the first case and holmium YAG laser (5–15 W, frequency 10 Hz/s) in the remaining seven cases. Following the procedure, an indwelling per urethral catheter is kept for 3 weeks. Patients were discharge after 1 day with advice regarding maintenance of urethral catheter patency, which is paramount for a successful outcome. All patients received postoperative antibiotics, vitamin C and anticholinergics. Patients were also advised to refrain from sexual activity for 6–8 weeks following the procedure.

Table 1 Patients’ presentation, clinical findings and results
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Fig. 1
figure 1

Fistula with a guide wire across it and the laser beam shown as red glow

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Fig. 2
figure 2

Final appearance of fistula following laser welding on both bladder and vaginal site

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Results

Eight patients underwent laser welding of VVF. The mean age was 44 years (range, 35–55). All patients have history of abdominal hysterectomy. The VVF was primary (failing to heal following conservative management) in five and secondary (recurring following primary repair) in three cases. Three patients had failed surgeries: open abdominal approach in two and vaginal approach in one. One of these patients underwent two failed procedures. In all of the cases, the location of the fistula was supratrigonal. The mean fistula size was 3 mm (2–4). Mean operative time was 12.5 min (range, 10 to 20). Average length of hospital stay was 1 day (range, 1 to 2; Table 1). The urethral catheter remained indwelling for 3 weeks postoperatively. In seven patients, convalescence was uneventful. In one patient, there was failure to proceed due to bleeding and poor vision, and the procedure was abandoned. All of the patients are dry after catheter removal, and on subsequent follow-up had no complaints of leakage. Our mean follow-up is 47 months (2–110), and all patients are doing well with no voiding complaints.

Discussion

VVF diagnosed within the first few days of surgery should be treated conservatively by placing a transurethral or suprapubic catheter for up to 30 days. Zimmern et al. concluded that a small fistula, which stops leaking following Foley placement, has a high chance of healing spontaneously with a 3-week trial of Foley catheterisation [2]. Elkins and Thompson noted 12–80% success with continuous bladder drainage. Successful cases were the ones in which VVFs were less than 1 cm, not associated with carcinoma or radiation and diagnosed and treated within 7 days of index surgery [3].

VVF following failure of conservative management (primary) and secondary VVF (due to recurrent/residual VVF following surgical repair) are two entities which pose a treatment dilemma in front of the treating surgeon on whether to treat them conservatively using minimally invasive approaches (endoscopy, laparoscopy, robot-assisted) or through conventional open surgery (abdominal/vaginal approach).

Pettersson et al. first described fibrin occlusion of a VVF in 1979 [4]. They successfully treated a VVF that developed following surgery and radiotherapy. Hedelin et al. performed the fibrin occlusion technique in nine patients with chronic recurrent fistulas in patients with prior failed surgical repair and demonstrated a 50% success rate [5]. Falk H et al. used electrocoagulation successfully for the first time in 1957 for nonsurgical closure of VVF [6]. Stovsky et al. reported a 73% cure rate with electrocoagulation in 15 highly selected patient group. Eleven fistulas, which were managed successfully with electrocautery as the sole treatment modality, were either pinhole openings or bladder mucosal dimples. Only four fistulas were large enough to be seen cystoscopically. They used Bugbee electrode for fulguration (at low-current settings) with placement of a large Foley catheter for a minimum of 2–3 weeks [7]. In the opposing view, Margolis and Mercer contradicted use of electrocoagulation as it entails destruction of viable tissue with its usage [8].

The electrocoagulation destroys the epithelium, leaving a scar, which in turn is covered by vaginal and bladder epithelium, thus sealing the communication between vagina and bladder. The success of electrocoagulation depends on confining the current to the epithelium without destroying the surrounding area and ensuring continuous catheter bladder drainage.

Lasers have been used to weld tissue and have established their effectiveness in the laboratory setting when compared with more conventional methods of tissue approximation. The technique is based on the fact that tissue when heated undergoes macromolecular structural changes in electrostatic and covalent bonding between structural proteins, which form a weld on cooling [9–11]. The commonly employed lasers used for urologic laser-assisted welding are the CO2, Nd:YAG, argon and holmium:YAG [12].We described laser welding for the first time successfully in the repair of a 3-mm VVF in the supratrigonal area of the bladder employing Nd-YAG laser to fulgurate the fistula opening [1]. The Nd-YAG laser has the advantage over electrocoagulation because of its precise and accurate destruction of the areas involved. Ho-YAG laser is a further refinement of the Nd-YAG laser as it penetrates the tissue only superficially while providing proficient sealing of tissue. Laser fulguration in contrast to electrocoagulation offers accuracy and precision. Lasers by being confined to the epithelium leads to optimal destruction using thin contact fibre under good vision. We believe that the laser welding of VVF is a feasible and efficacious approach with a successful outcome in our properly selected subset of patients. Nevertheless, a word of caution: the factors, which lead to our success in these patients, are primarily patient selection. This procedure is efficacious only in small fistulas (<4 mm) with no underlying pathologies like malignancy and radiation cystitis. In laser welding, there is no direct contact of the surfaces of a fistula, and healing seems unlikely to involve significant detrusor muscle in growth, so the procedure is entirely dependent on vaginal and bladder epithelial growth and prolonged bladder drainage. Therefore, though majority of fistula with conventional repair recur within first year of repair, the laser welding group of patients can recur theoretically years after a repair because of lack of detrusor backing and inadvertent bladder distension. In our experience, the procedure has been successful as in the cumulative follow-up of 47 months (2–110), there was no recurrence of fistula seen in any of the patients. We generally do not treat fistulas of more than 5 mm in size with laser as they are bound to fail. Majority of our patients are having large fistulas, and therefore, only a much selected few are taken up for the laser welding. Laser welding should therefore be performed for a highly selected group by surgeons who are apt in using lasers; nonetheless, the results will not be fruitful. Preoperative optimisation includes the following: sterile urine culture, if culture is positive, culture-specific antibiotics, vaginal douching with antibiotics, local tissue health, and acidification of urine to diminish risks of cystitis (Vitamin C at 500 mg orally three times per day). Postoperatively, uninterrupted continuous catheter drainage of urine and anticholinergics to prevent bladder spasms are paramount for a successful outcome. We are routinely using antibiotics postoperatively because our patients are coming from remote areas where there is no access to medical facilities and we don’t want the repair to be jeopardized because of infection. Bladder spasms are important to prevent especially with laser welding so that the healing area is left unaffected by spasm because of Foley catheter in situ.

Conclusion

Laser welding of VVF is a simple, safe, successful and efficacious minimally invasive procedure in a select group of patients.