Modified Laparoscopic Abdominal Vesico-Vaginal Fistula Repair—“Mini-O'Conor” Vesicotomy

Introduction

Vesico-vaginal fistula (VVF) is a major cause of morbidity and social disability. In the developed world, the most common cause has been iatrogenic injury to the bladder during gynecologic surgery, with malignancy, radiation, and inflammation being other causes. In large parts of the developing world, with inadequate obstetric care, prolonged labor remains an important cause. A plethora of approaches and techniques have been described to treat VVF. O'Conor's suprapubic approach was described in 1951 and is accepted as the gold standard of care for supratrigonal fistulas. ¹ Other methods include the transvaginal and endoscopic approach, using local tissues and a variety of interposition flaps to minimize recurrences. The choice of operation depends on the location and size of the fistula, vaginal capacity, availability of local tissues, and often on the preference of the surgeon, with urologists preferring an abdominal approach and gynecologists a vaginal one (editorial comment by Raz). ² With the development of laparoscopic surgery, these modalities have been adopted in the transabdominal management of VVF repair. In this article, we hereby report our experience with laparoscopic repair of supratrigonal VVFs from using the O'Conor operation and describe a modification in the technique by using a limited cystotomy, which we describe as a “Mini-O'Conor” operation.

Patients and Methods

We retrospectively analyzed the charts of 8 patients who underwent laparoscopic VVF repair in our unit from 2004 to 2008. All patients had developed VVF secondary to either hysterectomy or caesarean section. Two patients had previously undergone failed attempts at repair. One patient had been operated on twice, once by the vaginal and once by the abdominal route for a posthysterectomy fistula. Another patient had undergone open VVF repair and left ureteric reimplantation with psoas hitch for a posthysterectomy VVF and uretero-vaginal fistula with recurrence of the VVF. Demographic and clinical data are provided in Table 1. The workup of patients included a thorough history and physical examination, micturating cystourethrogram, intravenous urography, and cystoscopy prior to surgical repair. These examinations ruled out coexisting ureteric fistulae while confirming and characterizing the fistula between the vagina and bladder. All patients had a supratrigonal fistula, with size ranging from 4 to 12 mm (mean, 7).

Results

The operation was successfully completed in all cases without the need for a conversion. There were no major intraoperative complications. Three of eight patients had cystoscopic placement of ureteric catheters. Operative times were 110–160 minutes (mean, 145). Estimated blood loss ranged from 40 to 100 mL (mean, 60), and no patient required a blood transfusion. All patients accepted oral fluids on the evening of the operation, except 1 patient who developed ileus, and all patients were ambulatory on the morning after surgery. No patients developed symptomatic bladder spasms. In all cases, the catheter was removed on postoperative day 14. All patients were continent after catheter removal and remained so at a mean follow-up of 29 months (range, 5–50).

Discussion

Vesico-vaginal fistuale may be repaired by a vaginal or abdominal approach. Advantages of the vaginal approach include avoidance of the morbidity of laparotomy and the possibility of outpatient surgery. However, as stressed by Eilber et al., ⁴ the approach chosen should be the one the surgeon is most comfortable with. Most urologists are familiar with the suprapubic route. In addition, with the advent of laparoscopy, the morbidity of access—which was one of the arguments against the suprapubic approach—has reduced significantly.

The suprapubic transvesical approach is well established for the repair of primary or recurrent vesico-vaginal fistulae. Success rates described in the literature have varied from 65 ⁵ to 100%. ¹ Success rate is related to the etiology of the fistula and surgeon experience. Surgical principles for this operation were described by Turner-Warwick and include meticulous preoperative evaluation to exclude multiple fistulae, separation of the bladder and vaginal walls, excision of devitalized tissue, and closure without tension. ⁶ Tissue interposition is also an important adjunct. Evans et al., in a large series of abdominal VVF repair, reported a 100% success rate where interposition flaps were used versus 65% success where no flaps were used, irrespective of etiology. ⁷ Similarly, tissue interposition has been advocated for vaginal repair of VVF. ⁴

Laparoscopy has now been applied to most ablative and reconstructive urologic operations. The first laparoscopic repair of VVF was described in 1994 by Nezhat et al. ⁸ Since then, it has become the standard of care for repair of VVF requiring an abdominal approach, with good success rates described in several series.^9–11 A summary of these reports is shown in Table 2. In addition to the generic advantages of laparoscopy, which include rapid convalescence, shorter hospital stay, and improved cosmesis, laparoscopy offers excellent visualization of pelvic structures due to good illumination and magnification and quick, direct access to the fistula. However, it can be a difficult operation and requires prior experience with pelvic laparoscopic surgery and freehand suturing.

Our operative technique differs from that of Sotelo et al. ⁹ in a few steps. We did not catheterize the fistula, and ureteric catheterization was only employed when the orifices were found to be within 1 cm of the fistula, Additionally, cystoscopic guidance was not employed during closure of the cystotomy. We have modified the standard technique of laparoscopic VVF repair by minimizing the extent of cystotomy. Classically, the technique describes a large cystotomy starting at the dome of the bladder and extending down the posterior wall to the site of the fistula, bivalving the bladder. While this allows for excellent visualization, a large cystotomy has the disadvantages of increasing operative time and blood loss and, possibly, of increased bladder irritability postoperatively. We hypothesized that a smaller cystotomy would minimize these problems, while still allowing an accurate dissection and repair. In our experience, the smaller size of the bladder opening helped to reduce the operative time required for creation as well as repair of the cystotomy while allowing adequate exposure. A small cystotomy may easily be extended as required, although we did not find this necessary. We did not excise the edges of the fistula in any of the cases. Although this step has been debated in discussions on VVF repair, we believe that there is a theoretic risk of enlarging the fistula in case of failure of the repair.

Although most reported series have not discussed bladder irritability in the postoperative period, Blaivas et al. reported persistent urge incontinence in 2 of 24 patients. ² Similarly, Chibber et al. gave anticholinergic drugs to all their patients in the postoperative period to prevent bladder spasm. ¹⁰ In our group of patients, anticholinergic drugs were given empirically for 48 hours and then discontinued. Early discontinuation helps to limit the side effects of anticholinergic drugs, notably constipation. Despite early discontinuation of anticholinergic drugs, no patient had symptomatic bladder spasms.

Conclusion

Laparoscopic repair of VVF is effective and has minimal morbidity. It is easily accomplished with a small vesicotomy.

Disclosure Statement

No competing financial interests exist.