Vesicovaginal fistula (VVF) is a devastating complication after hysterectomy. VVF can be repaired vaginally, abdominally and laparoscopically. Interposition flaps increase the success rate of VVF repair and reduce the risk of failure. Classically, Martius labial fat pad graft was used for the development of the interposition flap in cases of VVF. This approach, however, can be difficult and result in pain, disfiguring and scarring of the area where the labial fat pad is harvested. Peritoneal flap developed via the vaginal route can provide an alternative option, which is effective as an interposition flap between the bladder and the vagina (1). The aim of this study is to evaluate the outcomes of vaginal repair of VVF with peritoneal interposition flap harvested vaginally. The aim of this video is to demonstrate the technique of vaginal repair of VVF with peritoneal flap development and interposition between the bladder and the vagina.
.

Prospective study of all women who presented with post abdominal hysterectomy vesicovaginal fistulae from January 2019 to July 2020. All women presented within three weeks of the surgery. All women underwent repair of the fistulae three months post hysterectomy or the attempted repair if repair was attempted previously. All VVF repairs were performed through the vaginal route. The repair was performed after developing tension free bladder flaps that were closed in two layers vaginally. This was followed by creating a peritoneal flap that was sutured as an interposition flap between the bladder and the vagina. All women had an indwelling catheter after surgery for two to four weeks and were treated with prophylactic anticholinergic treatment, and had a cytogram prior to catheter removal. This video demonstrates the technique of VVF dissection and repair followed by peritoneal flap development.

Twelve women underwent the vaginal repair of the fistulae (VVF) with peritoneal interposition flap. In ten women, the VVF was recurrent following previous failed attempted repair. Ten of the women had attempt at previous repair. In nine cases, the previous attempted repair was done via the abdominal route. All VVF's were at the level of the vaginal vault. The vaginal repair was successful in curing the VVF in all women. The cystogram in all women showed complete healing of the fistulae and had a successful trial without catheter, with normal voiding. None of the women developed new onset lower urinary tract symptoms following the successful VVF repair. In this video we demonstrate the vaginal approach to VVF repair with peritoneal flap development.

Vaginal repair of post hysterectomy VVF (including recurrent VVF) with peritoneal interposition flap is feasible, safe and effective option that avoids laparotomy. Peritoneal interposition flap is a successful alternative to Martius fat pad in post hysterectomy VVF repair and does increase the success rate of the repair without the complication of Martius labial fat pad.

Raz S, Bregg K, Nitti V, Sussman E. Transvaginal repair of vesicovaginal fistula using a peritoneal flap. J Urol . 1993 Jul;150(1):56-9.