Special Surgical Procedures II
LESSON 2: Procedures in Gynecological and Obstetrical Surgery
Section Ii:
2-16
2-16. VESICOVAGINAL FISTULA REPAIR
a. General.
(1) Through the vaginal outlet, the mucosal tissue of the anterior vaginal wall is dissected free, the opening from the bladder into the vagina is closed, the fascial attachments between the bladder and vagina are repaired, and temporary drainage is established.
(2) The fistulas vary in size from a small opening that permits only slight leakage of urine into the vagina to a large opening that permits all urine to pass into the vagina.
(3) Vesicovaginal fistulas may result from radical surgery in the management of pelvic cancer, from radium therapy without surgery, from chronic ulceration of the vaginal structures, from penetrating wounds, or from childbirth.
(4) A urethrovaginal fistula usually causes constant incontinence or difficulty in retaining urine. This condition occurs after damage to the anterior wall and bladder or following radiation, surgery, or parturation. A ureterovaginal fistula develops as a result of injury to the ureter. In some cases, reimplantation of the ureter in the bladder or ureterostomy may be done.
b. Operative Procedure--Vaginal Approach.
(1) Traction sutures are placed about the fistulous tract; tissues are grasped with Adair forceps and plain tissue forceps.
(2) The scar tissue about the fistula is excised, cleavage between bladder and vagina is located, and clean flaps are mobilized, using scissors, forceps, and sponges.
(3) The bladder mucosa is inverted toward the interior of the bladder with interrupted sutures of chromic gut number 4-0 swaged to fine curved needles held with a Mayo needle holder and tissue forceps. The suture is passed through the muscularis of the bladder down to the mucosa.
(4) A second layer of inverting sutures is placed in the bladder and tied, thereby completely inverting the bladder mucosa toward the interior.
(5) The vesicovaginal fascia is repaired with interrupted number 2-0 chromic gut sutures.
(6) The vaginal wall is closed with interrupted chromic gut sutures in the direction opposite to the closure of the bladder wall.
(7) The bladder is distended with distilled sterile water to determine any leaks. A catheter is left in the bladder; dressing are applied and held in place with a nonirritating plastic tape and a binder.
c. Operative Procedure--Trans-peritoneal Approach.
(1) With the patient in a slight Trendelenburg position, a median abdominal incision is made, as for laparotomy.
(2) The fistulous tract is identified; the vaginal vault and the adjacent adherent bladder are separated with scissors, forceps, and sponges.
(3) The vesicovaginal septum is dissected down to the healthy tissue beyond the site of the fistula.
(4) The fistulous tract is mobilized. The bladder site of the fistula is inverted into the interior of the bladder with two rows of inverting sutures of chromic gut number4-0. The muscularis and mucosa layers of the vagina are inverted into the vaginal vault by means of two rows of sutures.
(5) The flaps of peritoneum are mobilized both from the bladder and from the adjacent vaginal vault, and are closed to form a new vesicovaginal reflection of peritoneum below the site of the old fistulous tract.
(6) The wound is closed in layers, as for laparotomy. Dressings are applied and held in place with adhesive or plastic tape, and an indwelling catheter is left in the bladder.
