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A chronic tuboovarian abscess with vaginal fistula occurring after vaginal hysterectomy was removed laparoscopically. The fistula was closed by a combined laparoscopic-vaginal procedure. A complete cure was achieved without complications.
PURPOSE: Vaginal fistulas are rare but can cause extremely distressing symptoms for patients and prove difficult to define anatomically. Barium studies have been reported as having a maximum sensitivity of only 34 percent for detection of vaginal fistulas. Vaginography is an alternative method for diagnosis and evaluation of suspected vaginal fistulas, which has been reported to have a sensitivity of 100 percent. We reviewed our total experience of vaginography to fully assess its capabilities. METHODS: Twenty-seven patients with clinically suspected vaginal fistulas were investigated with vaginography during a six-year period. Results of vaginograms were compared with final operative or clinical diagnosis and with results of other radiologic investigations. RESULTS: Vaginography successfully identified 19 of 24 fistulas, giving a sensitivity of 79 percent. In our series, barium enema was only able to identify 9 percent of fistulas arising from the colon. CONCLUSIONS: In this, the largest series of vaginograms, apparent reduction in sensitivity from the 100 percent quoted in earlier series to 79 percent probably represents a more accurate assessment of vaginography as a diagnostic investigation. Even allowing for this reduction, vaginography is still the most sensitive, economic, and informative investigation for identification and delineation of vaginal fistulas. We recommend that vaginography be the initial investigation of choice in patients with clinically suspected vaginal fistulas.
Bladder injury with subsequent development of a Vesico-Vaginal Fistula following a Laparoscopic Assisted Vaginal Hysterectomy is reported. The injury was not recognised intra--operatively or in the immediate post-operative period. On the third post-operative day, the patient complained of abdominal distention, and a reduced urine output was noted. There was no haematuria. Conservative management by continuous bladder drainage was not successful. A low-pressure cystogram done on day eight revealed a bladder leakage. On day 21, a repeat low-pressure cystogram showed a vesico-vaginal fistula. A successful transvesical repair by laparotomy was undertaken on day 23. The possible mechanisms of injury, prevention and the principles of management are discussed.
Chronic postoperative pouch-vaginal and vesicovaginal fistulas after hysterectomy and irradiation to treat advanced cervical cancer do not respond to conventional treatment because of the low vascularity in the irradiated area. We present the successful repair of these complications in a female patient, in whom several vaginal and abdominal approaches had been tried and had resulted not only in failure but also in tissue loss and fibrosis and persisting fistulas. First, a synchronous vaginoabdominal approach using a vertical myocutaneous distally based rectus abdominis myocutaneous flap was used successfully to close a pouch-vaginal fistula and simultaneously reconstruct the posterior vaginal wall. In a second approach, the persisting vesicovaginal fistula was closed by a right rectus abdominis myocutaneous flap while simultaneously reconstructing the anterior vaginal wall, closing the enterocutaneous stoma and performing an appendicovesicostomy as a continence channel for catheterization. Despite unfavorable local wound situations, including an enterocutaneous stoma through the rectus abdominis and various previous incision lines, the transfer of axially well-vascularized tissue can solve these problem wounds. Consecutive bilateral use of the rectus abdominis flap may be necessary to deal with extensive pelvic wounds. This technique should be considered as one repair modality in irradiated pelvic wounds with fistulas. Previous enterostomy is not a contraindication to the use of this flap.
We describe a case of a vesico-vaginal fistula in a 32-year-old lady presenting with true urinary incontinence. There was a 1.5 x 1.5 cm deficit in the bladder wall and the left ureteric orifice was very close to the edge of the defect. For a successful transvaginal repair, we used a mobilized vaginal flap to bridge the defect in the bladder wall. This avoided the mobilization of the bladder wall and also prevented the left ureteric orifice from getting entrapped in the suture line. Adjacent wall of vagina was mobilized and stitched over the first layer to achieve water tight repair. Her post operative period was uneventful. The repair healed well and she was discharged in a good condition.
BACKGROUND: Urinary-vaginal fistula is one of the most common and dreaded complications of obstetric trauma in developing countries. Management of these fistulas is complicated by the presence of substantial urethral loss and the tendency of the repair to break down. STUDY DESIGN: We retrospectively studied 46 patients with urinary-vaginal fistulas operated on in our institution over 5 years. Most of the patients had obstetric trauma as the causative factor. Twelve patients had urethrovaginal and 34 had vesicovaginal fistulas. Of the 12 patients with urethrovaginal fistulas, 8 underwent a Martius procedure and 4 were treated with simple anatomic repair. Of the 34 patients with vesicovaginal fistulas, 13 underwent a Martius procedure and 21 were treated with anatomic repair. Nineteen patients had recurrent fistulas and 17 had multiple fistulas. RESULTS: Only one patient with a urethrovaginal fistula treated with a Martius procedure had recurrence, compared with three of four of the patients having anatomic repair. None of the patients with vesicovaginal fistulas treated with a Martius flap had recurrence, compared with 4 of 21 in the anatomic-repair group (19.05%). Thirteen patients with single fistulas (7 urethrovaginal and 6 vesicovaginal) treated with a Martius procedure healed well without failure, compared with 1 failure among 16 fistulas (1 urethrovaginal and 15 vesicovaginal) in the anatomic-repair group. In the group of patients with multiple fistulas, the Martius flap also showed a definite advantage. Eight patients with multiple fistulas were offered the Martius flap. The procedures were successful in all but one, compared with six failures out of nine treated with anatomic repair. None of the patients having primary treatment with the Martius flap had postoperative recurrence, compared with 3 of 18 having anatomic repair (16.67%). Only 1 of 12 patients with recurrent fistulas undergoing Martius flap repair had failure (8.33%), compared with 4 of 7 undergoing anatomic repair (57.14%). None of the patients treated with the Martius procedure experienced dyspareunia postoperatively, compared with 33.33% of the patients treated with anatomic repair. CONCLUSIONS: The overall success rate was far better and the complication rate (especially incontinence and dyspareunia) was considerably less with the Martius procedure. We recommend the Martius procedure for urethrovaginal and vesicovaginal fistulas, especially those that are recurrent or multiple.
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OBJECTIVE: Recto-vaginal fistula is a rare complication of ulcerative colitis. There are few reports of restorative proctocolectomy carried out in patients with ulcerative colitis having a rectovaginal fistula. We report our experience with this condition. PATIENTS AND METHODS: Between 1 January 1976 and 31 December 2001, 838 patients underwent restorative proctocolectomy for ulcerative colitis at one hospital. These included 400 women of whom 4 (1%) had an already present rectovaginal fistula. We reviewed all patients who presented with a rectovaginal fistula. These patients were contacted by telephone to establish function and satisfaction. RESULTS: The mean age was 30.0 years (range 19-39 years). The mean age at onset of ulcerative colitis was 21.5 years (range 13-34 years). One patient was asymptomatic, the fistula being discovered at operation. In the other three patients the recto-vaginal fistula had occurred at a mean of 108 months (range 72-192 months) after the onset of ulcerative colitis. Three of four patients had had previous episodes of acute severe disease. Three patients had a narrow rectum with deep ulceration. The mean distance between the anorectal junction and the site of fistulation was 2.7 cm (range 0-7 cm). Three patients had a three-stage and one patient a two-stage procedure. Mean follow-up after closure of the loop ileostomy was 107 months (range 17-276 months). All patients were treated successfully but 2 (50%) had a recurrence at 156 and 40 months after the closure of the loop ileostomy. One patient was diverted and the fistula was closed by a subsequent transanal repair and the other patient was treated with success by temporary loose seton technique. Two patients had excellent functional results whereas two other had some difficulties in continence. Nevertheless all patients were satisfied with the outcome. CONCLUSIONS: Patients with ulcerative colitis and a recto-vaginal fistula can be successfully treated by restorative proctocolectomy, nevertheless they are at risk of late recurrence of the fistula.
Vesico-vaginal fistula repair is feasible both with abdominal and vaginal approach. We report our experience in vaginal repair of 34 vesico vaginal fistulas. Twenty-eight out of 34 fistulas have been treated by vaginal repair (82.3%) (in 2 cases after an attempt of endoscopic repair), 4/34 (11.8%) by abdominal repair and 4/34 (11.8%) by endoscopic repair with good outcome in 2 cases. In 96% of fistulas treated by vaginal repair (27/28) we obtained a complete recovery; in one patient we observed fistula recurrence after 2 months from the operation. Four patients were treated by abdominal approach: in two complex patients with vesico-uretero-vaginal fistula, the repair was associated with entero-cystoplasty and ureteral reimplantation; in one case of huge fistula following cesarean section (7 cm) a vesical flap was used; in one case we repaired a recurrent fistula in orthotopic ileal neobladder: A good outcome was achieved in all cases. Vaginal approach is less aggressive, well accepted by patients and can lead to lower legal issues. Abdominal surgery is mandatory in complex situations, when the fistula is big (> 4 cm) or when ureteral orifices are involved.
Complex vesico-vaginal fistulae (VVFs) continue to complicated prolonged obstructed labour in this country. Recently a young lady presented to us with a huge VVF, associated with loss of the urethra and bladder neck, severe gynaetresia and recto-vaginal fistula. Her VVF was successfully managed by an appendico-vesiscostomy.
Reported series of urinary-vaginal fistulas repaired by a vaginal approach show at least 85% primary closure. However, many patients have had several unsuccessful operations elsewhere prior to the final repair. This means that regularly successful closure is possible, but it demands a certain "know-how" and engagement. In search for the general principles leading to such successful primary closure, different published techniques have been studied. It appears that the essential features are the establishment of a proper distance between the inner vesical and the outer vaginal epithelium and the creation of broad raw surfaces to be ajoined. The operation should not involve any risk of enlarging the existing fistula, and the transfer of normal tissue to the site of the repair and the interposition of tissue between the cavities to be separated are sound reconstructive procedures. A personal technique based on these principles is presented. The gynecologists of to-day most often refer urinary-vaginal fistulas to the urologists, who almost without exception prefer a suprapubic transvesical approach. It is strongly recommended that the large majority of urinary-vaginal fistulas should be repaired by the vaginal approach which is a minor intervention. The plastic surgeon should be engaged in the management of urinary-vaginal fistulas.
The patient, a 73-year-old woman, had undergone hysterectomy and irradiation therapy 26 years ago. On September 4, 1997, the patient was referred to our hospital, and presented with low grade fever and lower abdominal dull pain of a one-month duration. Radiologic and vaginal examinations revealed bilateral hydronephrosis and a giant stone lying down between the bladder and vagina. Vaginal incontinence showed the presence of the vesico-vaginal fistula. She underwent bilateral ureterocutaneostomy and cystolithotomy. A giant vesico-vaginal stone was removed by using a hammer and chisel. It weighed 180 g. The stone was composed of calcium phosphate and magnesium ammonium phosphate. Persistent infection of the bladder and the vagina may have been a possible etiological factor of the vesico-vaginal stone formation. Three weeks after the operation, bilateral hydronephrosis was improved.