Clinical
Female Lower Urinary Tract Symptoms (LUTS) / Voiding Dysfunction
Mehul Mehul Agarwal
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Abstract Centre
Vesicovaginal fistulas have been seen after caesarean sections done for obstructed labor and prolonged second stage of labor. Simple fistulas include supratrigonal, away from ureteric orifices, less than 3 cm in size, with no history of prior repair. Based on the site of fistulas, the general rule has been to opt for abdominal approach for supratrigonal fistulas and vaginal approach for infratrigonal fistulas.(1) Here, we discuss a patient with complex fistula (3cm size, recurrent, infratrigonal location) operated abdominally achieving favourable results.
A 29 year lady presented with urinary leak per vaginum since eight months. She had history of laparotomy and bladder repair for uterine and bladder rupture 18 months ago, and transvaginal vesicovaginal fistula repair 8 months ago. On evaluation with pelvic assessment, cystovaginoscopy and upper tract imaging, she was diagnosed with complex VVF, 0.5-1cm from bilateral ureteric orifices. Ureteric catheters were placed in both ureters and in the fistulous opening. After docking, port placement, localisation of fistula site, and cystostomy was done. A plane was made between bladder and cervicovaginal layer, and circumferential dissection extended 1 cm distal to the fistula. Closure of cervicovaginal layer, omental tissue interposition, cystotomy closure was done, followed by drain placement.
The postoperative period was uneventful. Patient’s drain was removed on day two and discharged on day three with foley’s catheter. Catheter was removed after three weeks and is doing fine, under regular follow up since four months.
In contrast to the previous notion of vaginal approach for infratrigonal VVF repair, it is the time to consider abdominal approach for complex fistulas, where better results can be achieved with added benefits in terms of accessibility, good tissue interposition especially in patients with intact cervix with lacking vaginal tissue for repair.
Stamatakos M, Sargedi C, Stasinou T, Kontzoglou K. Vesicovaginal fistula: diagnosis and management. Indian J Surg. 2014 Apr;76(2):131-6. doi: 10.1007/s12262-012-0787-y. Epub 2012 Dec 14. PMID: 24891778; PMCID: PMC4039689.
Continence 12S (2024) 101526DOI: 10.1016/j.cont.2024.101526