Vesicovaginal Fistula:

Vesicovaginal Fistula is an abnormal opening between the urinary bladder and vagina that results in continuous, involuntary dribbling (incontinence) of urine from the vagina.

What causes Vesicovaginal Fistula?

The foremost cause of Vesicovaginal Fistula is difficult and unattended deliveries. Another cause of Vesicovaginal Fistula is injury during gynecologic surgery like hysterectomy where there is extensive dissection between the bladder and the uterus, unrecognized bladder laceration, inappropriate stitch placement, and / or devascularization injury to the tissues. Some factors that increase your risk of developing Vesicovaginal Fistula are history of Pelvic Inflammatory Diseases, pelvic malignancy, endometriosis, infection, diabetes, prior pelvic or vaginal surgery and anatomic distortion of the vaginal vault.

What are the types of Vesicovaginal Fistula?

Depending on the location, cause, complexity, or site of obstruction, Vesicovaginal Fistula can be classified as:

• Simple Vesicovaginal Fistula - In this type of Vesicovaginal Fistula, the length of vagina is normal, fistula is less than 2 cm long and there is no history of radiation or vagina/cervical malignancy. Simple Vesicovaginal Fistula is quite straight forward to repair.
• Complex Vesicovaginal Fistula - In this type, vaginal length is shortened, there is history of pelvic malignancy which may have resulted in radiation therapy and is the fistula is more than 3 cm long. The repair of Complex Vesicovaginal Fistula is quite complicated and can pose a challenge to the surgeon.

How is Vesicovaginal Fistula treated?

The goal of surgical repair of Vesicovaginal Fistula include adequate exposure, good homeostasis, wide mobilization of the bladder and vagina, resection of devascularized tissue and removal of foreign body, tension free closure, non-opposition of suture lines, and confirmation of a water tight seal on bladder closure, and postoperative bladder drainage for 10-14 days with the help of a foley's catheter. Vesicovaginal Fistula can either be treated by vaginal approach or abdominal approach.

• Vaginal approach for the surgical repair of Vesicovaginal Fistula - In transvaginal approach for surgical repair of Vesicovaginal Fistula, the tissues of vaginal wall are dissected and the fistula tract in the bladder mucosa is stitched with absorbable sutures to close. The excessive vaginal tissues are excised and the vaginal mucosa is then closed, completing the repair. Vaginal approach for the surgical repair is employed for simple and small Vesicovaginal Fistula.
• Abdominal approach for the surgical repair of Vesicovaginal Fistula - In transabdominal approach, an infraumbilical incision is made which is carried down into the peritoneal cavity. This method is used for the surgical repair of complex Vesicovaginal Fistula that may be large or small but multiple in number. The abdominal approach may be facilitated by Cystoscopically guided placement of a catheter thru the fistulous tract. The bladder will be exposed, ureteral stents should be placed if the fistula is in close proximity to the ureteral orifice. The vagina and bladder will then be closed with interrupted delayed absorbable suture in a double layer fashion.

How do I prepare for the surgical repair of Vesicovaginal Fistula?

Ask your doctor about any special instructions to prepare for the surgical repair of Vesicovaginal Fistula. Since all medical procedure have a small risk of injury, e.g. injury to ureter or rectum, you will need to sign a consent form before the test. Do not hesitate to ask your doctor about any concerns you might have. You may be asked to give a urine sample before the test to check for infection. Avoid urinating for an hour before this part of the test. Inform your physician about your other health conditions and medications (including all the prescription, non-prescription medications, nutritional supplements i.e. vitamins, minerals and herbal products). Refrain from taking aspirin or Ibuprofen at least 2 weeks before the surgical repair of Vesicovaginal Fistula. Stop smoking a few weeks before the operation to prevent healing problems during recovery period. Do not eat or drink anything for at least 10 hours before the the Vesicovaginal Fistula surgery. You will wear a hospital gown for the examination, and the lower part of your body will be covered with a sterile drape. In most cases, you will lie on your back with your knees raised and apart. The procedure will be performed under general anesthesia and you will be hospitalized for 3 - 4 days (for transabdominal approach) or 1 - 2 days (for transvaginal approach) for the surgical repair of Vesicovaginal Fistula. A nurse or technician will clean the area around your urethral opening and apply a local anesthetic.

What to expect during the recovery period following surgical repair of Vesicovaginal Fistula?

Surgical repair of Vesicovaginal Fistula entails surgery to the bladder as well as the vagina. You will spend the next couple of days in the Intensive Care Unit (ICU) under observation following surgical repair of Vesicovaginal Fistula. Your vital signs, circulation and respiration will be closely monitored. You will also be closely monitored for any immediate post-operative complications like excessive bleeding. You will notice thin tubes (drains) in your pelvic area. These will be removed 7 - 10 days after your operation to repair Vesicovaginal Fistula. There will also be a small plastic drain tube from your abdomen that will stay in place for about 5 - 7 days. You will experience some pain and discomfort which can be alleviated by the use of pain medication. Keep the operation area clean, avoid heavy lifting and sexual activity for 3 - 4 weeks. You will be able to get back to your normal activities in 2 months time following operation to repair Vesicovaginal Fistula. Before going home you will be provided with a follow up regimen that will comprise of Cystoscopy 3 months for at least 2 years.

What is the outcome of surgical repair of Vesicovaginal Fistula?

Surgery to repair Vesicovaginal Fistula is quite successful. The success rate of repairing a Vesicovaginal Fistula is 90 - 95%. For repair of complex Vesicovaginal Fistula, the success rate is less than 90%, but, for experienced surgeons, the outcome remains highly successful.

Benefits of surgical repair of Vesicovaginal Fistula

In addition to the medical benefit from the repair of Vesicovaginal Fistula, you will also experience a profound effect on the your emotional well-being. The offensiveness from incontinence of urine can result in social alienation, ostrasization and immense emotional trauma. Surgical repair of Vesicovaginal Fistula can help you once again become part of the mainstream population.

Risks of surgical repair of Vesicovaginal Fistula

• Transient Vesicoureteral reflux and bladder spasm
• Recurrence of fistula.
• Ureteral stricture
• Infection
• Excessive bleeding
• Injury to other organs
• Thrombo-embolism

Alternatives to surgical repair of Vesicovaginal Fistula

• Medical Treatment
  • Hormone Replacement Therapy / Estrogen Replacement Therapy - This treatment assists with optimizing tissue vascularization and healing.
• Surgical Treatments
  • Electrocautery - This method uses cauterization or burning to repair the Vesicovaginal Fistula
    Fibrin glue - Occlusion therapy using a combination of fibrinogen and thrombin are used as a sealant for the repair of Vesicovaginal Fistula
  • Electrocautery and endoscopic closure using fibrin glue and bovine collagen - After performing Electrocautery of the fistula, a Cystoscope will be inserted into the bladder through your urethra, and 1 mm of bovine collagen will be injected submucosally under direct visualization around the fistula opening. Fibrin glue will be injected transvaginally into the fistula tract. A second application of 1 mm of bovine collagen will then be injected transvaginally into the vaginal mucosal layer around the fistula tract.
  • Laparoscopic repair of Vesicovaginal Fistula
  • Grafts to repair Vesicovaginal Fistula - These can be used as adjunct treatment to enhance formation of granulation tissue following the surgical repair of Vesicovaginal Fistula

Decision to have surgical repair of Vesicovaginal Fistula

With the advent of advanced techniques and equipment, surgical repair of Vesicovaginal Fistula remains standard treatment for optimizing curative potential, minimizing the risk of recurrence and restoring your emotional well being.

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