PL 15. Laparoscopic repair of vesicovaginal fistula (VVF)

Vesicovaginal fistula (VVF) is an abnormal channel between bladder and vagina that results in urinary leakage. It is usually associated with gynecologic procedures such as abdominal hysterectomy. Surgical repair remains the primary method of treatment after a failed attempt with conservative measures. Nowadays, several surgical techniques have been developed for VVF treatment depending on the etiology, location, severity, size of the fistula and experience of the surgeon. Laparoscopic repair of VVF has become the first-line approach because of its safety and effective minimally invasiveness. We describe our experience with laparoscopic VVF repair.

From December 2001 to December 2007, we performed laparoscopic repair operations for 5 patients ranged from 34 to 65 years of age (mean age 48.6 ± 3.2 years) who were diagnosed as VVF. The fistulas of all 5 cases were the results of gynecologic surgical procedures and cystoscopy could reveal their fistulous opening between the bladder and vagina.

First of all, A Foley catheter was placed vaginally through the fistula and pulled out into the bladder guided by cystoscopy. A primary 10 mm port was inserted at the umbilicus, and then established the pneumoperitoneum routinely. Two other ports (5 and 10 mm) were placed in the inferior abdominal wall. Then, the lateral peritoneum was opened with endoscopic scissors and the vesico-vaginal space was precisely developed until the bladder was completely freed posteriorly from the vaginal wall and the catheter could be seen. After the remove of catheter, the fistulous tract and unhealthy tissue margins should be dissected carefully. Subsequently, the openings of the tract both on the bladder and vagina sides were sutured and closed with Vicryl. A suprapubic drain tube was left in place and bladder drainage was accomplished by an urinary indwelling of a Foley catheter.

All 5 operations were successfully completed. There was no conversion to open in all patients. There were no intraoperative or postoperative complications occurred. The mean operative time was 155 min (range 90 to 240 min), which is similar with the open surgical group (155 min:135 min). The mean blood loss ranged from 40-80 mL (mean loss 62 mL), which is less than the open surgical group (62 mL : 151 mL). Compared with the open surgical group, the time of postoperative recovery of intestinal function and postoperative hospitalization also were shortened obviously. After a follow up of 12 months, no recurrence was found.

Based on our clinical practices and experiences, there are two key points to insure the success of operation: the precise location and confirmation of the fistula, the smooth coordination of laparoscopy and cystoscopy. We believe that laparoscopic repair of vesicovaginal fistula is a feasible, effective, and mini-invasive approach for the treatment of vesicovaginal fistula.