Treatment

486

Practical Urology: EssEntial PrinciPlEs and PracticE

the most important factor should be surgeon

throughout the case. Ureteral stents are placed

experience and comfort. Surgical mobilization

if the fistula is in close proximity to the ureteral

of well-vascularized flaps, followed by a sepa-

orifices. A urethral catheter is placed, and a

rate water-tight closure of the urinary and

supra-pubic catheter may also be utilized for

genital tracts with nonoverlapping suture lines

bladder drainage. An inverted U-shaped inci-

is the intraoperative goal regardless of the

sion is made which circumscribes the fistula

approach.

site. Anterior and posterior vaginal wall flaps

Transabdominal approaches for fistula repair

are developed after hydro-dissection with ster-

include supravesical or transvesical approaches,

ile saline, and retracted using the ring retractor.

and laparoscopic/robotic techniques. The

Using double-armed SAS, the fistula is closed in

O’Conor transabdominal VVF repair has been

an interrupted fashion. The perivesical tissue is

well described.39 The patient is positioned in a

then closed over the initial suture line in an

low lithotomy position, with access to the vagina

interrupted imbricated fashion, 90° in respect

and abdomen. Ureteral catheters may be placed

to the first layer. A peritoneal flap or a martius

and are recommended if the fistula is near the

flap can be positioned over the imbricated layer

ureteral orifices or the trigone. A lower midline

of peri-vesical tissue. The posterior vaginal wall

incision is performed and the bladder is mobi-

flap is advanced over the suture line anteriorly

lized. The bladder is then bivalved vertically to

to complete the closure.

the level of the fistula, and dissection is contin-

Adjacent tissue flaps can be useful in the

ued distally to open the vesicovaginal space,

setting of complex fistula with compromised

2–3 cm distal to the fistula site. Following mobi-

surrounding tissue, or in patients with prior

lization of the vaginal wall from the bladder wall

failed repairs, radiotherapy, obstetric fistula, or

distal to the fistula tract, the fistula tract is

large fistula tracts. For patients undergoing a

excised, and the vaginal wall is closed with run-

transvaginal approach, a labial fat pad (Martius)

ning synthetic absorbable suture (SAS). The

or peritoneal flaps are most frequently utilized

bladder is closed in multiple layers with running

with success rates of greater than 90%.7 The

SAS. An additional layer of tissue can be placed

Martius graft is harvested from the fibrofatty

between the suture lines utilizing an omental

tissue of the labia majora. It maintains blood

interposition flap or peritoneal flap. It is impor-

supply from the external pudendal artery supe-

tant to secure the interpositional flap distally

riorly and the inferior labial artery inferiorly,

beyond the fistula.

allowing rotation and mobilization from either

In the transvesical approach, the bladder is

pedicle. Once mobilized via a labial incision, this

opened via a midline cystotomy on the anterior

flap can be tunneled into the vaginal dissection

surface of the bladder. The VVF tract is then cir-

for additional layers of fistula closure. In high

cumscribed and excised.Following mobilization

VVF repairs from a transvaginal approach, the

of the vesicovaginal space surrounding the fis-

peritoneum is often encountered during the

tula site, the vaginal and vesical tissues are

course of dissection. The peritoneum can be

closed separately. A flap of adjacent bladder tis-

advanced over the fistula repair as an additional

sue may be advanced to avoid overlapping suture

layer of closure, with success rates of 91–96%.7,41

lines as described by Gil-Vernet.40

As noted previously, omental interposition flaps

The transvaginal approach for fistula repair

are useful adjunctive procedures when perform-

is shown in Fig. 35.3.7,41,42 The patient is placed

ing transabdominal VVF repairs in the manner

in the dorsal lithotomy position, and a rectal

of O’Conor. Interposition flaps or peritoneal

pack is placed. Labial retraction sutures are

flaps can be incorporated into transabdominal

placed as well as a weighted speculum. A self-

fistula repairs between bladder and vaginal wall

retaining ring retractor with hooks is very use-

suture lines. The omental vascular supply is

ful for visualization and retraction. Cystoscopy

based on the right and left gastroepiploic arter-

is performed to localize the fistula tract, and a

ies. In order to provide sufficient length for the

guide wire is placed though the fistula into the

flap to reach the pelvis, the omentum can be

vagina. A 10–12 French foley catheter should be

mobilized along the greater curvature of the

placed though the fistula site, using the previ-

stomach, sacrificing the left gastroepiploic

ously placed guide wire. This catheter provides

artery and allowing larger right gastroepiploic

traction of the fistula toward the introitus

artery to maintain blood supply.