Role of Day Care Vesicovaginal Fistula Fulguration in Small Vesicovaginal Fistula

Abstract

Objectives:

Vesicovaginal fistula (VVF) is a common condition that physically and mentally debilitates the patient. In the developing countries such as India, it results mainly due to neglected obstetric care. Options for surgical repair of VVF consist of transvaginal, transvesical, laparoscopic repair. Endoscopic management of VVF on day care basis by fulgurating the fistulous tract is a minimally invasive method for small fistula involving the lower genitourinary tract. We evaluated the efficacy of fulguration for the conservative treatment of urinary fistula of different etiologies by using endoscopic approach.

Materials and Methods:

From September 2008 to July 2009, five patients with VVF of <0.7 cm underwent VVF fulguration under cystoscopic guidance on day care basis. Perurethral catheter was kept for 3 weeks postoperatively and was removed when cystogram showed healing of the fistula. All the patients were on anticholinergic medications postoperatively.

Results:

Of the five patients who underwent endoscopic fulguration, four patients had positive outcome and one patient showed persistent VVF on follow-up cystogram. This patient underwent repair of the fistula by vaginal route.

Conclusions:

Endoscopic transvesical vesicovaginal fistula fulguration appears to be a safe and effective procedure for small VVF on day care basis, with decreasing morbidity, improving cosmesis, and decreased hospital stay.

Introduction

V esicovaginal fistula (VVF) has been a social and surgical problem for centuries. In the developed world, 90% of cases are caused by inadvertent injury to the bladder during surgery. Obstetric VVF related to prolonged labor remains a major medical problem in many underdeveloped countries with a low standard of obstetric care. In 1852, Sims reported a repair of VVF in female slaves;¹ since then, many surgical techniques have been developed to correct this abnormality, including transabdominal, transvaginal, and laparoscopic approaches. The selected route of repair depends mostly on the training and experience of the surgeon. The best approach is probably the one with which the surgeon feels most experienced and comfortable. For women who have a VVF during or after recovery from a gynecological procedure, the prospect of undergoing further surgery and recovery can also be stressful, especially if laparotomy is required. For small VVF, endoscopic conservative treatments have become increasingly popular, reducing the invasiveness of treatment and shortening the period of convalescence. The main advantage of this procedure is that it can be done on a day care basis and is minimally invasive with minimum morbidity. We evaluated the efficacy of fulguration for the conservative treatment of urinary fistula of different etiologies by using endoscopic approach.

Methods

This is a prospective study of five patients undergoing endoscopic electrofulguration of VVF of <0.7 cm due to various gynecological causes, from September 2008 to July 2009. Table 1 shows the details of the treatment.

Table 1.

Etiology and Success Rate in Our Series

S. no.	Etiology	Fistula (cm)	Duration of catheter usage	Remark
1	Postabdominal hysterectomy	0.5	3 weeks	Success
2	Postabdominal hysterectomy	0.7	6 weeks	Failed
3	Postvaginal hysterectomy	0.5	3 weeks	Success
4	Postvaginal hysterectomy	0.6	3 weeks	Success
5	Postabdominal hysterectomy	0.5	3 weeks	Success

Procedure

Fistulous tract is electrocoagulated by putting bugbee electrode inside the fistulous tract as far as possible endoscopically. The electrode is slowly withdrawn from the track with electrode on coagulation, till the edges of the fistula track blanch. Care is taken not to overcoagulate as this can cause widespread tissue necrosis, sloughing, and enlargement of the fistula. The patient is discharged on the same day evening with a catheter to drain the urine.² All the patients were drained for a minimum period of 3 weeks and were put on anticholergenics to relax the bladder. At 3 weeks, cystogram antero-posterior (AP) and oblique view was done and the catheter was removed when no persistent leakage was observed.

Results

Of the five patients operated endoscopically, four had positive outcome, showing absence of leakage on follow-up. One patient had persistent fistula on follow-up cystogram at 6 weeks; this patient was having a fistula of 0.7 cm. Catheter was kept for another 3 weeks as the patient had complains of persistent leakage at the end of 3 weeks. These patients underwent pervaginal repair. The median age was 40 years (range, 32–45), with three patients having a history of three abdominal hysterectomies, two for fibroids and one for menorrhagia. Two patients had a history of vaginal hysterectomy, one for menorrhagia and the other for fibroid. The average hospital stay was 16 hours. All the patients were discharged once they recovered from the effect of spinal anesthesia.

Discussion

An abdominal hysterectomy is the most common cause of VVFs in developed countries, occurring in 1 per 1800 hysterectomies. In most cases, a definitive cure of a VVF requires surgery, and large VVFs never resolve with conservative management. A 3- to 6-month waiting period between the development of a postoperative VVF and an attempt at surgical closure has been recommended to allow the inflammation to subside. An endoscopic electrofulguration approach may provide a minimally invasive option with less postoperative morbidity, better cosmesis, and decreased hospital stay. Curettage of fistula track with screw followed by prolonged catheterization has been reported to be successful in a small series of patients by Aycinena (1977).³ As early as 1938, O'Conor applied electrocoagulation for small highly situated fistula.^4
–6 Stovsky and colleagues (1994) reported success in 11 of 15 patients by electrocoagulation of small fistula of <3.5 mm.⁷ It was suggested that disruption of the epithelial component with subsequent fibrosis with scarring and closure of the track is the mechanism by which electrocoagulation exerts its effect. Falk and Orkin (1957) treated eight patients with <3-mm fistula with electrocoagulation and catheter drainage for 10 days.⁸

Conclusion

Endoscopic VVF electrocoagulation appears to be a safe and effective procedure for small fistula of <0.7 cm on a day care basis, with decreasing morbidity, improving cosmesis, and decreased hospital stay. In general, this conservative approach is useful for small oblique fistula of <0.7 cm in diameter, with all the advantages of a minimally invasive surgery.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviation Used

References

Sims

. On the treatment of vesico-vaginal fistula. 1852. Int Urogynecol J Pelvic Floor Dysfunct, 1998; 9:236–248.

Falk

, Tancer

. Vesicovaginal fistula: an historical survey. Obstet Gynecol, 1954; 3:337–341.

Aycinena

. Small vesicovaginal fistula. Urology, 1977; 9:543–545.

O'Conor

, Sokol

. Vesicovaginal fistula from the standpoint of the urologist. J Urol, 1951; 66:579–585.

O'Conor

Jr. , Sokol

, Bulkley

, Nanninga

. Suprapubic closure of vesicovaginal fistula. J Urol, 1973; 109:51–54.

O'Conor

Jr . Review of experience with vesicovaginal fistula repair. J Urol, 1980; 123:367–369.

Stovsky

, Ignatoff

, Blum

. Use of electrocoagulation in the treatment of vesicovaginal fistulas. J Urol, 1994; 152,5 Pt 1:1443–1444.

Falk

, Orkin

. Nonsurgical closure of vesicovaginal fistulas. Obstet Gynecol, 1957; 9:538–541.