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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 12  |  Issue : 1  |  Page : 75-78

Recurrent vesicovaginal fistula: Our experience


1 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research, JNMC Campus; KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka, India
2 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research, JNMC Campus, Belagavi, Karnataka, India
3 Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka, India
4 Department of Biochemistry, Kuvempu University, Shimoga, Karnataka, India
5 Department of Biotechnology and Microbiology, Karnatak University, Dharwad, Karnataka, India

Date of Web Publication18-Jan-2019

Correspondence Address:
Dr. R B Nerli
Department of Urology, JN Medical College, KLE Academy of Higher Education and Research, JNMC Campus, Belagavi - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_161_18

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  Abstract 


INTRODUCTION: One of the major complications of vesicovaginal fistula (VVF) surgery is recurrent fistula formation. A repeat repair is undertaken after resolution of the inflammatory response to the initial procedure. We report our experience with recurrent VVF managed at our center.
MATERIALS AND METHODS: We retrospectively reviewed the inpatient/outpatient case records of all women who underwent repair of recurrent VVF at our center. The age of the patient at initial presentation of VVF, cause of VVF, and site, size, position, and type of repair were noted.
RESULTS: During the study period from January 2000 to December 2016, a total of nine women with a mean age of 38 years underwent repair for a recurrent VVF at our center. All patients were assessed in detail 12 months after the repair. All patients were continent and were voiding well.
CONCLUSIONS: It is important to strictly adhere to the basic surgical principles so as to achieve a successful VVF repair. The bladder closure is much more important in achieving a successful repair than vaginal closure. Recurrent VVFs should always be treated with interposition of a tissue graft between the bladder and the vagina.

Keywords: Prognostic factor, recurrent vesicovaginal fistula, surgical repair


How to cite this article:
Nerli R B, Musale A, Ghagane SC, Deole S, Neelagund SE, Hiremath MB, Dixit NS. Recurrent vesicovaginal fistula: Our experience. Indian J Health Sci Biomed Res 2019;12:75-8

How to cite this URL:
Nerli R B, Musale A, Ghagane SC, Deole S, Neelagund SE, Hiremath MB, Dixit NS. Recurrent vesicovaginal fistula: Our experience. Indian J Health Sci Biomed Res [serial online] 2019 [cited 2019 Feb 17];12:75-8. Available from: http://www.ijournalhs.org/text.asp?2019/12/1/75/250389




  Introduction Top


Vesicovaginal fistula (VVF) has been known since ancient times and is the most common acquired fistula of the urinary tract.[1] In the developing world, VVF commonly occurs following obstetric complications,[2],[3] whereas in the industrialized world, VVF commonly occurs due to injury to the bladder at the time of gynecologic, urologic, or other pelvic surgery.[4],[5] It is well known that the first opportunity is the best opportunity to achieve successful repair of VVF.[6] Previous failed attempts at repair produce scarring and anatomic distortion and may compromise potential reconstructive flaps. Therefore, careful preoperative planning is essential to maximize the chances for a successful result. There is no “best” approach for all patients with VVF.

One of the major complications of VVF surgery is recurrent fistula formation and it is difficult to prognosticate factors responsible for recurrence. Marshall wrote in his editorial “Imagination and versatility of the most skillful surgeon cannot close all fistulas.”[7] It is important to strictly adhere to the basic surgical principles, including careful preoperative evaluation, wide exposure of the fistula and surrounding tissues, tension-free closure, excision of all fibrosed tissue, and initial maintenance of an uninfected and dry suture line, so as to achieve a successful VVF repair.[8] The bladder closure is much more important in achieving a successful repair than vaginal closure.

Recurrent fistulae are initially managed conservatively with bladder catheterization and observation. A repeat repair is undertaken after resolution of the inflammatory response to the initial procedure. In most cases, a vaginal approach would be adequate; however, if necessary, an abdominal approach could also be used. We report our experience with recurrent VVF managed at our center.


  Materials and Methods Top


We retrospectively reviewed the inpatient/outpatient case records of all women who underwent repair of recurrent VVF at our center. This study was approved by the institutional/university ethical committee. The age of the patient at initial presentation of VVF, cause of VVF, and site, size, position, and type of repair were noted. The imaging records were also similarly noted and analyzed [Figure 1] and [Figure 2].
Figure 1: (a) Computed tomography showing communication between bladder and vagina. (b) Computed tomography in lateral showing distinct communication between bladder and vagina

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Figure 2: (a) Three-dimensional reconstruction of the bladder and vagina. (b) Communication between bladder and vagina noted. (c) Supratrigonal fistula seen clearly between the bladder and the vagina

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Similarly, the age at second repair, type of repair, interposition of tissue, and postoperative care and complications were also noted. Success was defined as the absence of urinary leak through the vagina.


  Results Top


During the study period from January 2000 to December 2016, a total of nine women with a mean age of 38 years underwent repair for a recurrent VVF at our center. The mean age, cause of VVF, and other patient demographics are summarized in [Table 1].
Table 1: Patients demographic

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All the patients undergoing recurrent VVF repair underwent the repair through the open abdominal route. The bladder was bivalved and the repair was done in two layers. The bladder was closed vertically, whereas the vagina was closed horizontally [Figure 3]. Omentum was used to interpose between the two organs. The uterus was preserved in all the three women who had uterus. Postoperatively, the catheter was removed on the 10th day as per the departmental protocol.
Figure 3: (a) The bladder is bivalved which shows the fistula communication. (b) The tip of suction is introduced into the vesicovaginal fistula. (c) The bladder is closed vertically and omentum is interposed between bladder and vagina

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All patients were assessed in detail 12 months after the repair. All patients were continent and were voiding well. Two women had frequency, with the functional capacity of the bladder as assessed by the voiding diary being about 150 cc. These women were advised a low dose of tablet solifenacin succinate. The vagina was contracted in seven of the nine women and they were not engaged in sexual activity. The other two women had resumed sexual activity 6 months after the repair. Dryness of vagina was the complaint in these two women.


  Discussion Top


VVF is uncommon in modern urological practice. In most of the western/developed world, nearly 90% of cases are caused by an inadvertent injury to the bladder during surgery.[4] Gynecological surgeries are the most common cause, with hysterectomy (abdominal or vaginal) accounting for 75% of fistulae.[4],[9] Urological or gastrointestinal pelvic surgery could also be responsible and the reported incidence of iatrogenic VVF after pelvic surgery is 0.5%–2%.[7],[10] History of previous uterine surgery, pelvic irradiation, or endometriosis is known to increase the risk.[10] Anatomical distortion by fibroids or an ovarian mass also increases the risk, which is also greater in those with compromised healing, e.g., patients who are anemic, malnourished, or using steroids.[10] Other less common causes of VVF include pelvic malignancy, pelvic irradiation, obstetric trauma, and infection, including tuberculosis.[10],[11] VVFs can follow an erosion of a foreign body such as a pessary or following vigorous intercourse.[10] This usually occurs in those who have married at a very young age or those who have been raped.

In many developing countries, prolonged and obstructed labor is responsible for an overwhelming majority of VVFs. It has been estimated that a VVF occurs in 1–3 per 1000 deliveries in West Africa.[6] The lack of modern obstetric care in these nations is the reason for the high incidence of VVF. The prevalence is particularly high in areas where early marriage is practiced. Mothers may experience labor before reaching full physical maturity. Other obstetric causes of VVF include accidental injury at the time of cesarean section, forceps delivery, and traditional surgical practices.

Over 85% of VVFs are repaired successfully at the first attempt.[12] Closure rates are similar for both transvaginal and transabdominal techniques. Recurrent fistula formation, ureteric injury or obstruction, and vaginal stenosis remain the major complications following VVF repairs. Ayed et al.[8] evaluated the prognostic factors for recurrence of VVF in 73 patients undergoing 97 procedures with a mean rate of 1.38 procedures/patient. Multivariate analysis demonstrated that recurrence was statistically significant for multiple fistulas (single vs. two or more), fistula size (>10 mm), fistula type (Type I vs. Type II), fistula etiology (obstetrical vs. nonobstetrical), and presence of urinary tract infection before the repair. Recurrence risk was fivefold higher for both the size and type of the fistula, threefold higher for obstetrical etiology, and 4.5-fold higher for multiple fistula. The interposition of flaps was a protective factor for recurrent cases.

Recurrent VVFs should always be treated with interposition of a tissue graft between the bladder and the vagina. The tissue graft could be harvested from the surrounding tissues, with stalk (flap), or it could be a free graft from a distant tissue or an organ. In transvaginal procedures, various local flaps could be used: labial fat tissue flap (Martius flap), labial skin flap, vaginal flap, bulbocavernosus muscle flap, and tubular gluteal skin graft.[13],[14],[15],[16] In transabdominal approach, the flaps can be used from the visceral peritoneum, posterior wall of the uterus, rectus abdominis flap, rotational bladder flap, urachal flap, and perisigmoid fat flap.[17],[18],[19],[20] The most commonly used free grafts are free bladder mucosal autograft and small intestinal submucosa graft.[21]

Hadzi-Djokic et al.[22] reported on the use of autologous buccal mucosal graft in two women with recurrent VVF. Both women underwent suturing of the VVF with the interposition of BMG and both women were cured.


  Conclusion Top


It is important to strictly adhere to the basic surgical principles so as to achieve a successful VVF repair. The bladder closure is much more important in achieving a successful repair than vaginal closure. Recurrent VVFs should always be treated with interposition of a tissue graft between the bladder and the vagina.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gerber GS, Schoenberg HW. Female urinary tract fistulas. J Urol 1993;149:229-36.  Back to cited text no. 1
    
2.
Tebeu PM, Fomulu JN, Khaddaj S, de Bernis L, Delvaux T, Rochat CH, et al. Risk factors for obstetric fistula: A clinical review. Int Urogynecol J 2012;23:387-94.  Back to cited text no. 2
    
3.
Reddy M, Devaraju S, Hiremath M. Laparoscopic approach to vesicovaginal fistula: Our experience. Recent Res Sci Technol 2010;19:2.  Back to cited text no. 3
    
4.
Tancer ML. Observations on prevention and management of vesicovaginal fistula after total hysterectomy. Surg Gynecol Obstet 1992;175:501-6.  Back to cited text no. 4
    
5.
Nerli RB, Reddy M. Transvesicoscopic repair of vesicovaginal fistula. Diagn Ther Endosc 2010;2010:760348.  Back to cited text no. 5
    
6.
Elkins TE. Surgery for the obstetric vesicovaginal fistula: A review of 100 operations in 82 patients. Am J Obstet Gynecol 1994;170:1108-18.  Back to cited text no. 6
    
7.
Marshall VF. Editorial comment. J Urol 1980;123:369.  Back to cited text no. 7
    
8.
Ayed M, El Atat R, Hassine LB, Sfaxi M, Chebil M, Zmerli S, et al. Prognostic factors of recurrence after vesicovaginal fistula repair. Int J Urol 2006;13:345-9.  Back to cited text no. 8
    
9.
Goodwin WE, Scardino PT. Vesicovaginal and ureterovaginal fistulas: A summary of 25 years of experience. J Urol 1980;123:370-4.  Back to cited text no. 9
    
10.
Smith GL, Williams G. Vesicovaginal fistula. BJU Int 1999;83:564-9.  Back to cited text no. 10
    
11.
Ba-Thike K, Aye T, Oo N. Tuberculous vesicovaginal fistula. Int J Gynecol Obstet 1992;37:127-30.  Back to cited text no. 11
    
12.
Nerli RB, Patne PB, Joshi K, Dixit NS, Hiremath MB. Vesicouterine fistula: A case report. J Sci Soc 2015;42:48.  Back to cited text no. 12
  [Full text]  
13.
Stanojević D, Djordjević M, Martins F, Rudić J, Stanojević M, Bizić M, et al. Repair of vesicovaginal fistula caused by radiation therapy with labia maiora skin flap. Srp Arh Celok Lek 2010;138:356-61.  Back to cited text no. 13
    
14.
Shoukry MS, Hassouna ME, El-Salmy S, Abdel-Karim AM. Vaginal flap re-enforcement of vesico-vaginal fistula repair. Int Urogynecol J 2010;21:829-33.  Back to cited text no. 14
    
15.
Fu Q, Bian W, Lv J. Bulbocavernosus muscle flap for the repair of vesicovaginal fistula. Anatomic study and clinical results. Urol Int 2009;82:416-9.  Back to cited text no. 15
    
16.
Choudhrie AV, Thomas AJ, Gopalakrishnan G. Vesicovaginal fistula repair using tunneled gluteal cutaneous fat-pad flap. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:121-2.  Back to cited text no. 16
    
17.
Lentz SS. Transvaginal repair of the posthysterectomy vesicovaginal fistula using a peritoneal flap: The gold standard. J Reprod Med 2005;50:41-4.  Back to cited text no. 17
    
18.
Reynolds WS, Gottlieb LJ, Lucioni A, Rapp DE, Song DH, Bales GT, et al. Vesicovaginal fistula repair with rectus abdominus myofascial interposition flap. Urology 2008;71:1119-23.  Back to cited text no. 18
    
19.
Sharifiaghdas F, Taheri M. The use of a rotational bladder flap for the repair of recurrent mixed trigonal-supratrigonal vesicovaginal fistulas. Int J Gynaecol Obstet 2012;119:18-20.  Back to cited text no. 19
    
20.
James MH, Tisdale BE, Davies TO, McCammon KA. The urachal flap: A previously unreported tissue flap in vesicovaginal fistula repair. Female Pelvic Med Reconstr Surg 2013;19:148-51.  Back to cited text no. 20
    
21.
Sharifi-Aghdas F, Ghaderian N, Payvand A. Free bladder mucosal autograft in the treatment of complicated vesicovaginal fistula. BJU Int 2002;89 Suppl 1:54-6.  Back to cited text no. 21
    
22.
Hadzi-Djokic J, Pejcic T, Stamenkovic V, Petrovic M, Acimovic M. Buccal mucosal graft interposition in the treatment of recurrent vesicovaginal fistula: A report on two cases. Taiwan J Obstet Gynecol 2015;54:773-5.  Back to cited text no. 22
    


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