ORIGINAL ARTICLE Year : 2022  |  Volume : 33  |  Issue : 4  |  Page : 187-191

Post hysterectomy vesicovaginal fistula repair without vaginal vault closure - A simple laparoscopic extravesical repair approach

Samir Swain, Suresh Kumar Rulaniya, Vishal Kumar Neniwal, Praveen Kumar Yadav, Piyush Agarwal, Shweta Bhalothia, Kishor Maroti Tonge, Zaid Ahmad Khan
Department of Urology and Renal Transplantation, SCB Medical College and Hospital, Cuttack, Odisha, India

Date of Submission22-Jan-2022Date of Decision20-Mar-2022Date of Acceptance23-Mar-2022Date of Web Publication26-Oct-2022

Correspondence Address:
Samir Swain
Department of Urology and Renal Transplant, SCB Medical College and Hospital, Cuttack - 753 007, Odisha
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/UROS.UROS_17_22

Purpose: The purpose of this study is to describe a simple extravesical laparoscopic approach for supratrigonal vesicovaginal fistula (VVF) repair without cystotomy and closer of the vaginal vault. Materials and Methods: This retrospective observational study reviewed data of 36 patients from January 2015 to January 2020. In our technique, the fistula tract was identified without cystotomy with the help of preplaced ureteric catheter in VVF tract. After meticulous extravesical dissection of the fistula tract, the bladder wall was closed in a single layer using polyglactin 2.0 sutures. The omental flap was approximated over the vaginal vault without primary closer of the vault. Results: In most of the patients the fistula opening were located 2 cm away from ureteric orifice while in 4 patients it located within 2 cm of orifice. The mean operative time was 86 min (65–125) and estimated blood loss was 94 ml (40–130). The mean size of fistula was 7.1 mm (5–15 mm). Omental flap was approximate over vaginal opening in most of the patients. The average hospital stay of patients was 5 days. In all patients, Foley catheter was removed on day 14 after cystogram. The mean follow-up of patients was 4.2 months (3–7). All patients remained continent and symptom free during the follow-up periods. Conclusion: Our technique without suturing of the vaginal vault in laparoscopic VVF repair is safe in a simple supratrigonal fistula with good results and avoiding added suturing.

Keywords: Extravesical, hysterectomy, laparoscopic repair, vaginal vault, vesicovaginal fistula

How to cite this article:
Swain S, Rulaniya SK, Neniwal VK, Yadav PK, Agarwal P, Bhalothia S, Tonge KM, Khan ZA. Post hysterectomy vesicovaginal fistula repair without vaginal vault closure - A simple laparoscopic extravesical repair approach. Urol Sci 2022;33:187-91
How to cite this URL:
Swain S, Rulaniya SK, Neniwal VK, Yadav PK, Agarwal P, Bhalothia S, Tonge KM, Khan ZA. Post hysterectomy vesicovaginal fistula repair without vaginal vault closure - A simple laparoscopic extravesical repair approach. Urol Sci [serial online] 2022 [cited 2022 Dec 1];33:187-91. Available from: https://www.e-urol-sci.com/text.asp?2022/33/4/187/359675   Introduction 

Vesicovaginal fistula (VVF) is the most common acquired fistula of the urinary tract. In the developing world, obstetric complication is the main etiology, while in the industrialized world, injury to the bladder at the time of gynecologic, urologic, or other pelvic surgery is the main etiology of VVF. Identification of the urinary bladder wall and meticulous dissection during hysterectomy can prevent this fistula.[1]

The transvaginal and the abdominal routes (open, laparoscopic, or robotic) are the two approaches currently in vogue for the repair of VVF. The selection of route for repair depends mainly on the training and experience of the surgeon. Gynecologists prefer the vaginal and urologists prefer the transabdominal approach. Each type of repair has its own merits and demerits, and the best approach is probably the one with which the surgeon feels most comfortable and in which they are most experienced.[2] Laparoscopic surgery for VVF repair was introduced to duplicate the surgical steps of the transabdominal approach with reduction in morbidity and length of hospital stay. The first reported case of laparoscopic VVF repair was published in 1994. Since then, several groups demonstrated its reproducibility, safety, and efficacy with a good success rate and less morbidity compared with those of open surgery.[3]

Although in standard laparoscopy approach, the bladder and vaginal wall are closed separately and flap interposition is done, in our extravesical technique, cystotomy and vaginal vault suturing were not performed that are novel and not describe in literature.

Objective

The objective of this study was to describe a simple laparoscopic extravesical approach for supratrigonal VVF repair and evaluate the outcome of this technique:

Without cystotomyWithout suturing of the vaginal vault.   Materials and Methods 

Our retrospective observational study reviewed data of patients who managed laparoscopically for posthysterectomy simple supratrigonal VVF from January 2015 to January 2020. The study was conducted in adherence to the ethical guidelines of the Declaration of Helsinki and its amendments. Initially, a total of 42 patients were included in the study, but 6 patients were excluded due to intraoperative inadvertent enlargement in size of vaginal defect while dissection. In those 6 patients urinary bladder wall and vaginal vault were sutured separately with interposition of omental flap in between. The patient profile, investigations, radiological imaging, cystoscopy, intraoperative findings, and postoperative data are collected from medical records departments and departmental electronic data storage systems. On every follow-up, symptoms were evaluated and physical examination was done with data recorded in pro forma.

In our institution, this technique was performed by a single surgeon. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 27.0. (Armonk, NY: IBM Corp). Written consent was taken from all patients for the procedure. This research is approved by the institutional ethical committee with the Registration No. 954/01.12.2021

Evaluations of patients

All suspected patients with VVF after hysterectomy underwent physical, pelvic examination, cystoscopy, and vaginoscopy to locate the site, number, and size of fistula. Size was correlated with scope size and ureteric catheter. Ultrasound of the abdomen and pelvis and functional study in the form of CT urogram were done to look for the status of the upper urinary tract. The size of fistulae ranges from 5 to 15 mm on clinical examination in our study. Ureteral calibration was done in all the cases to rule out associated ureterovaginal fistula.

Inclusion criteria

Patients with posthysterectomy simple supratrigonal VVF.

Exclusion criteria

Vaginal opening >15 mmObstetric VVFMalignant, postradiation VVFComplex fistulae, trigonal fistulae, and multiple fistulae.

Surgical steps

All patients were received general anesthesia and placed in lithotomy position. Cystoscopy was performed and bilateral ureters were calibrated with 5 Fr ureteric catheters. In the fistula tract, ureteric catheter was placed for delineation during dissection [Figure 1]a.

After creating of pneumoperitoneum, the urinary bladder was mildly distended with normal saline and vaginal sponge was pushed in to identify the crease of the urinary bladder and vaginal vault wall. The already placed ureteric catheter in the VVF tract was moved with jerky movement to delineate the exact position of the fistula tract. Then, meticulous extravesical dissection was done to expose the fistulous tract without cystotomy [Figure 2]a. Trimming at the edge of the fistula tract was not done in our study.

In 25 cases where urinary bladder wall defect was more than 1 cm, the defect was closed in a single layer with polyglactin 2-0 suture in a continuous manner followed by reinforcement by perivesical tissue [Figure 2]b. In 11 cases where defect <1 cm, the bladder wall closure was done with polyglactin 2-0 suture in a purse-string manner. After closer of the bladder wall, the ureteric catheter was removed through vagina and approximation of the flap over the vaginal vault opening was done to completely seal it. The omental flap was used in 32 patients and surrounding fatty tissue in 4 patients [Figure 3]. Since it was our initial experience, we exclude large (>15 mm) vaginal opening from this study. In these patients, the urinary bladder wall and vaginal vault were sutured with interposition of the omental flap.

Per operative vaginoscopy showed fistula opening with urinary bladder mucosal protrusion. On follow-up, we have performed vaginoscopy which shows a completely seal of the vaginal vault [Figure 4]a and [Figure 4]b.

Pelvic drain was placed in all patients and was removed on the 3rd–4th day with output <25 ml/day. Both ureteric catheters were removed on the postoperative 7th day. Per-urethral catheter was removed on the 14th postoperative day after confirmation of no leak on cystogram.

Time taken for surgery, intraoperative blood loss, hospital stay, and postoperative vaginal leakage were recorded. Follow-up was scheduled as 14 days, 1 month, and 3 months.

  Results 

The mean age of these 36 patients was 41 ± 2.4 (24–51 years). Out of 36 patients, 19 patients underwent abdominal while 17 patients underwent vaginal hysterectomy. The majority of the patients were having primary type of fistula, only three patients with recurrent type of fistula in our study. In most of the patients the fistula opening were located 2 cm away from ureteric orifice while in 4 patients it located within 2 cm of orifice [Figure 1]b. The mean size of fistula was 7.1 mm (5–15 mm). 3.1 months (2–6 months) was the average time interval between hysterectomy and VVF surgery in our study [Table 1].

The average time taken for laparoscopic repair of VVF without vaginal wall closure was about 86 min (range: 65–125 min). The average intraoperative blood loss was approximately 94 ml (40–130 ml). No major intraoperative complications such as vessel injury and surrounding visceral injury were noted. Approximation of the flap over the vaginal opening was done to completely seal it. Omental flap was used in 32 patients and surrounding fatty tissue in four patients. The average hospital stay was 5 days (range: 4–6 days). Sexual intercourse was allowed after 3 months. The mean time for follow-up was 4.2 months (3–7). On follow-up, no recurrence was observed based on history and physical examination [Table 2].

  Discussion 

VVF is the most common acquired fistula of the urinary tract. Posthysterectomy VVFs are thought to result most commonly from an incidental unrecognized iatrogenic cystotomy near the vaginal cuff.[4]

The goal of treatment of VVF is the rapid cessation of urinary leakage with return of normal urinary and genital function. Favorable outcome with conservative management in the form of catheterization and anticholinergics is noted in VVF of size < 2–3 mm.[5] Laser welding has been tried with success in a small series of women with fistula smaller than 3 mm.[6] It is generally accepted that VVF resulting from obstructed labor should be associated with a 3–6-month delay before definitive repair to allow maximum demarcation of ischemic tissue and resolution of the associated edema and inflammatory reaction.[7] Contemporary reports of early repair of VVF within 6 weeks have shown results equivalent to delayed repair with minimizing patient discomfort. The enthusiasm for delayed management has waned, and in general, uncomplicated postgynecologic urinary fistulae may be repaired as soon as they are identified.[8] In our study, we performed VVF repair after a delay of 2–6 months posthysterectomy. In our study, the main reason of delay in surgery is due to late presentation of the patient to us. Once VVF tract is healthy with well-demarcated margin, surgery can be planned earlier.

Nowadays, laparoscopic repair is a well-established modality in the management of VVF, with a number of studies demonstrating its safety, feasibility, and efficacy with a good success rate and less morbidity compared with those of open surgery.[9],[10],[11] Compared with the O'Connor transabdominal approach, laparoscopic repair is reported to be associated with less surgical trauma, shorter convalescence, and lower morbidity.[12] Laparoscopic VVF repair is most useful in the same scenarios as the transabdominal repair such as in the setting of a high VVF in which a vaginal operation would be anatomically challenging. We have utilized laparoscopic extravesical technique of VVF repair in all our cases. The extravesical technique of VVF repair was first described in the late 1990s, and it focuses on a site-specific dissection and repair technique without cystotomy or bivalving of the bladder. In O'Connor technique bi valuing of bladder was done which theoretically increases chance of fistula repair failure.[13],[14] In complex fistula and patients refused for laparoscopy, we performed open VVF repair with good outcome.

All the present VVF repair techniques involve closure of both the urinary bladder and vaginal defect separately and if required interposition tissue is placed between the two repaired walls.

The basic concepts to not closer of the vaginal vault came from various previous studies. Moustafa et al. compared vaginal hysterectomy with and without vaginal vault closure and found no statistical difference between the two groups except prolapse of the fallopian tube in one case of hysterectomy without vaginal vault closure.[15] Colombo et al. compared open versus closed vault in abdominal hysterectomy and found no difference in outcome between the two groups.[16]

The first case report without closer of the vaginal wall in laparoscopic VVF repair by Von Theobald et al. in 1998, and they used the Endo Hernia stapler to fix an omental flap to the vagina “to enhance blood supply, protect suture line, and close dead space.” On follow-up, the patient was continent and asymptomatic on the day of discharge (8th day). Six months after the procedure, the woman is perfectly continent.[17]

In another case report by Soeroharjo et al., in 2018, they repaired VVF without vaginal wall closure, with cystotomy repair, and concluded that this simplified laparoscopic approach to vesicovaginal fistulae is a viable option for successful repair and that it reduces the size of bladder opening, causes minimal bleeding, and gives successful relief.[18]

In retrospective analysis by Javali et al in 22 patients who underwent laparoscopic VVF repair without vault closure. They used omental patch over vaginal opening in all patients and used 3.0 V-Loc barbed sutures for bladder closure postcystotomy. The mean operative time in their study was 75 min; the mean fistula size was 7 mm with a mean follow-up of 18 months. All patients remained symptom free in follow-up periods in their study.[19] The mean operative time in our study was 86 min which is slightly high as compared to their study; according to us, the reason behind this is we used polyglactin suture for urinary bladder wall closure. The rest data including fistula size, mean hospital stay, follow-up duration, and recurrence are comparable.

We are reporting here repair of VVF without closure of vaginal wall defect. Vaginal wall closure sometimes can be tedious and time-consuming in laparoscopic VVF repair, especially when the defect is low lying on the vaginal wall. We found that the average time taken for laparoscopic repair of VVF without vaginal wall closure was about 86 min which is less than what is observed in another case series reporting VVF repair with vaginal wall closure, i.e., 144.8 min.[20] No significant complications were noted in all patients, and no recurrence was noted during follow-up.

The success rate in our study is 100% for VVF repair, which is similar to the success rate of 98% as described by Miklos and Moore.[20] We describe this success rate to meticulous dissection of tissue while surgery and interposition of tissue in all cases after repair.

Our outcome revealed that avoid suturing of vault can save operative timeline. Limitations of this study are that it is not suitable for large vaginal defects and more prospective, randomized control trial studies are needed in future.

  Conclusion 

Laparoscopic extravesical VVF repair with single-layer urinary bladder closure, without suturing of vaginal vault technique, is safe in a simple supratrigonal fistula with good results and avoiding added suturing.

Acknowledgments

We thank the contribution of our colleagues and our institution.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Kasamba N, Kaye DK, Mbalinda SN. Community awareness about risk factors, presentation and prevention and obstetric fistula in Nabitovu Village, Iganga District, Uganda. BMC Pregnancy Childbirth 2013;13:229.  
    2.Shah SJ. Laparoscopic transabdominal transvesical vesicovaginal fistula repair. J Endourol 2009;23:1135-7.  
    3.Giannakopoulos S, Arif H, Nastos Z, Liapis A, Kalaitzis C, Touloupidis S. Laparoscopic transvesical vesicovaginal fistula repair with the least invasive way: Only three trocars and a limited posterior cystotomy, Asian J Urol 2020;7:351-6.  
    4.Hampel C, Neisius A, Thomas C, Thüroff JW, Roos F. Vesicovaginal fistula. Incidence, etiology and phenomenology in Germany. Urologe A 2015;54:349-58.  
    5.Arrowsmith S, Hamlin EC, Wall LL. Obstructed labor injury complex: Obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world. Obstet Gynecol Surv 1996;51:568-74.  
    6.Drutz HP, Mainprize TC. Unrecognized small vesicovaginal fistula as a cause of persistent urinary incontinence. Am J Obstet Gynecol 1988;158:237-40.  
    7.Goodwin WE, Scardino PT. Vesicovaginal and ureterovaginal fistulas: A summary of 25 years of experience. J Urol 1980;123:370-4.  
    8.De Ridder D, Abrams P, De Vries C, Abrams P, Cardozo L, Khoury S, et al. Incontinence. 5th ed. Paris: EAU-ICUD; 2013. p. 1527-79.  
    9.Dogra PN, Saini AK. Laser welding of vesicovaginal fistula – Outcome analysis and long-term outcome: Single-centre experience. Int Urogynecol J 2011;22:981-4.  
    10.Waaldijk K. The immediate surgical management of fresh obstetric fistulas with catheter and/or early closure. Int J Gynaecol Obstet 1994;45:11-6.  
    11.Kostakopoulos A, Deliveliotis C, Louras G, Giftopoulos A, Skolaricos A. Early repair of injury to the ureter or bladder after hysterectomy. Int Urol Nephrol 1998;30:445-50.  
    12.Bragayrac LA, Azhar RA, Fernandez G, Cabrera M, Saenz E, Machuca V, et al. Robotic repair of vesicovaginal fistulae with the transperitoneal-transvaginal approach: A case series. Int Braz J Urol 2014;40:810-5.  
    13.Miklos JR, Moore RD, Chinthakanan O. Laparoscopic and robotic-assisted vesicovaginal fistula repair: A systematic review of the literature. J Minim Invasive Gynecol 2015;22:727-36.  
    14.Bodner-Adler B, Hanzal E, Pablik E, Koelbl H, Bodner K. Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: A systematic review and meta-analysis. PLoS One 2017;12:e0171554.  
    15.Moustafa M, Elgonaid WE, Massouh H, Beynon WG. Evaluation of closure versus non-closure of vaginal vault after vaginal hysterectomy. J Obstet Gynaecol 2008;28:791-4.  
    16.Colombo M, Maggioni A, Zanini A, Rangoni G, Scalambrino S, Mangioni C. A randomized trial of open versus closed vaginal vault in the prevention of postoperative morbidity after abdominal hysterectomy. Am J Obstet Gynecol 1995;173:1807-11.  
    17.Von Theobald P, Hamel P, Febbraro W. Laparoscopic repair of a vesicovaginal fistula using an omental J flap. Br J Obstet Gynaecol 1998;105:1216-8.  
    18.Soeroharjo I, Khalilullah SA, Danarto R, Yuri P. Laparoscopic repair of vesicovaginal fistulae with a transperitoneal approach at Universitas Gadjah Mada Urological Institute: A case report. J Med Case Rep 2018;12:47.  
    19.Javali TD, Katti A, Nagaraj HK. A simplified laparoscopic approach to repair vesicovaginal fistula: The M.S. Ramaiah technique. Urology 2015;85:544-6.  
    20.Miklos JR, Moore RD. Laparoscopic extravesical vesicovaginal fistula repair: Our technique and 15-year experience. Int Urogynecol J 2015;26:441-6.