Clinical Observation On Urinary Vaginal Fistula

Chun, Choong Sung; Lim, Soo Kil

Abstract

A vesicovaginal fistula is a distressing complication which may follow hysterectomy and other extensive pelvic operation. Maligntncies of the uterin cervix or bladder may predispose to erosion and vesicovaginal fistula or such fistulas may occur as a result of extensive radiation therapy. Childbirth, particularly involving prolonged labor with potential necrosis of the vesico vaginal septum or complicated delivery with trauma may also induce a vesicovaginal fistula. In this experience the most common cause of vesicovaginal fistula resulting from surgery was total abdominal hysterectomy. Diagnosis of vesicovaginal fistula is usually made when appearance of methylene blue in the vagina after instillation of the dye into the bladder and further confirmed the presence and definitive localization of the fistula with cystoscopic examination. The operative procedures, the authors utilized were suprapubic transvesical closure in 8 cases, vaginal closure in two cases, and transabdominal approach in one case. The bladder was opened at the dome and then stay sutures were made at 1.0cm from the fistula margin. Then, the fistulous tract was excised making a lateral margin wide enough to leave viable tissue for subsequent closure. Vaginal wall and bladder wall closure were carried out in whole layer using interrupted 2 zero chromic suture. In one case of large fistula with high opening, the patient was underwent transabdominal method interposing a peritoneal flap between vagina and bladder wall. A urethral catheter was placed for 10 to 12 days postoperatively. In 5 cases of ureterovaginal fistula, one patient required the nephrectomy because of pyonephrosis, 2 patients refused further medication, one had ureteral reimplantation and another patient had psoas hitch and Boari operation. The following conclusions were obtained. 1. The most common cause of vesicovaginal fistula was the complication of total hysterectomy. 2. The diameter of fistulous tract was ranging from 1 to 10 mm. 3. For the repair of vesicovaginal fistula transvesical approach were 8 out of in 13 case, vaginal route in 2 cases, intraabdominal approach using a peritonal flap in one case. 4. Urethral catheter had been placed postoperatively was removed on the 12th postoperative day in most cases. Ureteral splint catheter was also placed for 8 to 10 days postoperatively. 5. 12 out of 14 cases, urinary vaginal fistulas were successfully closed on the first surgical attempt and one case healed on the second attempt. One case failed because of infection at the area of closure.