Vol. 115, June
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
SURGICAL REPAIR OF POST-HYSTERECTOMY VESICOVAGINAL FISTULAS RICARDO GONZALEZ*
AND
ELWIN E. FRALEY
From the Department of Urologic Surgery, University of Minnesota College of Health Sciences, Minneapolis, Minnesota
ABSTRACT
Herein we describe in detail the preoperative evaluation, surgical technique and postoperative care used in repairing 13 post-hysterectomy vesicovaginal fistulas by the transabdominal transvesical approach. We were successful in all 13 cases, although 1 required 2 operations. Excellent results can be obtained in these patients if a complete urological diagnostic study is done, a careful technique is used during the operation and specialized postoperative care is given. The transabdominal transvesical approach to this problem is safer and gives better results than the transvaginal operation. Vesicovaginal fistula resulting from obstetrical trauma, cancer, radiation therapy or surgical injury is an extremely disabling condition because of the physical, psychological and social consequences of total urinary incontinence. Fistulas caused by obstetrical trauma are rare in this country, while fistulas from cancer and radiation are somewhat more common. In addition, this last group of fistulas may be difficult to treat and the patient often ends up with a supravesical urinary diversion. By contrast, post-hysterectomy fistulas may be treated by catheter or postural drainage or both, 1· 4 cauterization, 3 , 4 transvaginal operations'· 5 or transabdominal approach. 1-• Drainage appears successful only in a few cases in which the fistulas are small and there are only anecdotal reports of treatment success with cauterization. The transvaginal approach has had a rather high failure rate in the treatment of post-hysterectomy fistulas. 5 • 7 • 8 However, the transabdominal approach to these fistulas has produced excellent results. 6 Our purpose is to reinforce the value of the transabdominal repair for post-hysterectomy vesicovaginal fistula. MATERIALS
Between 1968 and 1974 we treated 13 patients with post-hysterectomy vesicovaginal fistulas using the suprapubic transvesical approach. The 13 women required a total of 14 operations to correct the fistulas, all of which were the result of hysterectomies performed for non-malignant disease. All original procedures were total abdominal hysterectomies except in cases 1 (vaginal hysterectomy) and 6 (subtotal abdominal hysterectomy). Case 3 had 4 fistulas and case 4 had 2; the other patients had only 1. In case 4 there was a recognized complication at the time of operation in that the bladder was entered during the hysterectomy. In case 8 the fistula developed after transvaginal drainage of a pelvic abscess 4 weeks postoperatively. There were no complications other than the fistulas arising from the hysterectomy in the remaining patients. Four patients had undergone attempted repair of the fistulas before they were referred to us (see table).
dye was seen in the vagina; thus, the IVP is an important part of the evaluation in these patients. Bilateral retrograde ureterograms were done in all cases to be certain that there were no associated ureterovaginal fistulas. In addition, cystograms were done in 8 patients and contrast medium could be seen in the vagina in 6. In all cases the communications between the bladder and vagina were visualized by endoscopy. Also, when the patients were endoscoped we instilled 100 cc saline containing 2 ampules of methylene blue into the bladder through a urethral catheter and then determined the exact location of the fistula in the vagina by panendoscopy of the vagina. OPERATIVE TECHNIQUE
The operation is done with the patient under general anesthesia. She is placed supine on the operating table with the legs apart and resting in low stirrups, and the foot of the table is dropped to allow an assistant to stand between the patient's legs. The abdomen, perineum, genitalia and vagina are prepared, the vagina is packed tightly with furacin or vaseline gauze (fig. 1, A) and the patient is draped so that the entire abdomen and perineum are exposed. The abdominal cavity is entered through a low midline incision and an anterior midline cystotomy is performed. The bladder is inspected, the fistula(s) is (are) identified and a
Pt.-Age
PREOPERATIVE EVALUATION
When these patients were first seen by us 11 of the 13 had normal excretory urograms (IVPs). However, 1 patient had distal ureteral stenosis and another had a left renal calculus. In 1 case the fistula could be detected by the IVP in that contrast Accepted for publication September 26, 1975. * Requests for reprints: Department of Urologic Surgery, University of Minnesota Health Sciences Center, Minneapolis, Minnesota 55455. 660
Previous Attempted Repair
Time From Hysterectomyto Repair
1-46
5 mos.
2-43 3-49
6mos. 6mos.
4-43
Suprapubic.
5 mos.
5-22 6-64
Vaginal Bladder neck suspension
3mos. 18 yrs.
7-42 8-35
9-38 10-36 11-40 12-38 13-42
2 mos. 7 wks.
Suprapubic
14 mos. 2mos. 6mos. 4mos.
1 yr.
Other Procedures Done at Time of Repair
Complications
Bilat. salpingooophrectom:,,
Lt. ureterovesical reflux Recurrent or persistent fistula Ileus
Wound infection Lt. ureteroneocystotomy Lt. ureter entered, repaired
F!Go 1 large catheter is passed each ureteral orifice and left indwelling in the renal pelvis throughout the procedure and (figo 1, Next the peritoneum is dissected free from the posterior bladder wall and the dissection is continued caudally until the fistula tract is entered (figo 1, This part of the dissection is facilitated by the vaginal pack, which makes it easy to identify the vagina and the surgical plane between the vagina and the bladder. The assistant at the end of the table helps by pushing on the vaginal packo When the fistula is opened the bladder and vagina are dissected apart for approximately 1 to L5 cmo beyond the lower edge of the fistulao The ureteral catheters simplify identification of the ureters and, thus, help prevent ureteral injury The vaginal pack is removed and all scar tissue surrounding the fistula in the vagina and the bladder is excisedo The bladder mucosa and submucosa are then closed from within the bladder through the anterior midline cystotomy with a continuous suture of 4-zero chromic catgut, making sure both ends of this suture are left outside the bladder (figo 2, A and B) 0
0
0
When suturing is cornpleted the ends of the suture are under traction outside the bladder, muscle defect in the bladder wall and closureo The bladder muscle is "'l-'P""A'""'""u with a continuous suture of 2-zero chromic catgut (figo 2, On occasion it is necessary to perform a ureteroneocystotomy when the fistula is close to one of the ureteral orificeso The vagina is dosed with a transverse running suture of 2-zero chromic catguto A second layer of interrupted inverting suture of the same material is placed (figo 2, D) After the fistula is closed a 24 Foley catheter is placed in the bladder and the cystotomy is closed in 3 layers, using absorbable suture materiaL The position of the ureteral catheters is checked by irrigation and a radiogram, and both are brought out through the urethrao A pedicle flap of omentum, when available, is tailored and interposed between the vagina and the bladder and lightly fixed to the former with absorbable sutureso However, the use of omentum is not necessary if the rest of the procedure has been done as describedo The peritoneum is closed, a rubber drain is placed on the 0
0
662
GONZALEZ AND FRALEY
Fm. 2 retropubic perivesical space and the abdominal incision is closed. The ureteral catheters are sutured to the labia and secured to the indwelling Foley catheter. Postoperatively, the urine output from each catheter is monitored. Ideally, there is no output from the Foley catheter, all urine being diverted through the ureteral catheters. Whenever possible, the ureteral catheters are left indwelling for 10 to 14 days but they are removed when drainage from one or both becomes inadequate. The Foley catheter is always left indwelling for 10 to 14 days. The patient can be ambulated 1 day postoperatively. We routinely have given antispasmodics and antibiotics postoperatively.
patient had multiple fistulas and it is possible that 1 was overlooked. However, the procedure was repeated 10 weeks later and the fistula was cured. Surgical complications are listed in the table. One patient (case 3) had left vesicoureteral reflux but this disappeared spontaneously after 6 months. She has had several voiding cystograms since then that showed no reflux and she has had no urinary tract infections. Another patient had a left ureteral injury during the operation that was repaired at the time and healed without difficulty.
RESULTS
Case 4. A 43-year-old woman underwent total anterior hysterectomy in October 1970. The bladder was entered and repaired during the procedure, and leakage of urine was noted through the vagina in the immediate postoperative period. In January 1971 the patient underwent an abdominal exploration
CASE REPORTS
In 12 of the 13 patients the fistula was corrected completely. The 1 exception was case 4, in which urine leakage was observed shortly after the Foley catheter was removed. In this patient the ureteral catheters never drained properly and this
for
Qr,,Q.,,·,,·.,-~.ci
:repai:r of the fistcla but a sr:1sE bovvel ·.:vas and the v11a.s tern1iL~a.ted. vvhere
were normal on PvP. The underwent suprapubic transvesical repair of the fistulas and a dosed enterocutaneous fistula also was seen and repaired. Catheters were left in both ureters to the bladder dry but they never drained adequately and were removed 10 postoperatively. Two days later leakage of urine was noted through the vagina. The patient was discharged from the hospital and re-evaluated 2 months later. At this time we did a suprapubic transvesical repair of the original recurrent fistula and a left ureteroneocystotomy. The ureteral catheters drained satisfactorily for 14 and the patient was discharged from the hospital without further complications. Case 6. A 64-year-old woman had had persistent urinary incontinence after a subtotal hysterectomy 18 years previously. Nine months before the current hospitalization the remaining cervix uteri was removed and a segmental resection was done on the sigmoid colon for diverticular disease. Examination of the specimen revealed a colovaginal fistula. Because of persistent incontinence the patient underwent suprapubic suspension of the bladder neck 6 months later. When this procedure failed the patient was referred to us. Pelvic examination, cystoscopy and cystography revealed a large vesicovaginal fistula in the midline above the trigone. A left renal calculus was seen on the IVP but otherwise the Were D0fffial. H,t;C>'Uj;Jlctcn; tlVPl
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
SURGICAL REPAIR OF POST-HYSTERECTOMY VESICOVAGINAL FISTULAS RICARDO GONZALEZ*
AND
ELWIN E. FRALEY
From the Department of Urologic Surgery, University of Minnesota College of Health Sciences, Minneapolis, Minnesota
ABSTRACT
Herein we describe in detail the preoperative evaluation, surgical technique and postoperative care used in repairing 13 post-hysterectomy vesicovaginal fistulas by the transabdominal transvesical approach. We were successful in all 13 cases, although 1 required 2 operations. Excellent results can be obtained in these patients if a complete urological diagnostic study is done, a careful technique is used during the operation and specialized postoperative care is given. The transabdominal transvesical approach to this problem is safer and gives better results than the transvaginal operation. Vesicovaginal fistula resulting from obstetrical trauma, cancer, radiation therapy or surgical injury is an extremely disabling condition because of the physical, psychological and social consequences of total urinary incontinence. Fistulas caused by obstetrical trauma are rare in this country, while fistulas from cancer and radiation are somewhat more common. In addition, this last group of fistulas may be difficult to treat and the patient often ends up with a supravesical urinary diversion. By contrast, post-hysterectomy fistulas may be treated by catheter or postural drainage or both, 1· 4 cauterization, 3 , 4 transvaginal operations'· 5 or transabdominal approach. 1-• Drainage appears successful only in a few cases in which the fistulas are small and there are only anecdotal reports of treatment success with cauterization. The transvaginal approach has had a rather high failure rate in the treatment of post-hysterectomy fistulas. 5 • 7 • 8 However, the transabdominal approach to these fistulas has produced excellent results. 6 Our purpose is to reinforce the value of the transabdominal repair for post-hysterectomy vesicovaginal fistula. MATERIALS
Between 1968 and 1974 we treated 13 patients with post-hysterectomy vesicovaginal fistulas using the suprapubic transvesical approach. The 13 women required a total of 14 operations to correct the fistulas, all of which were the result of hysterectomies performed for non-malignant disease. All original procedures were total abdominal hysterectomies except in cases 1 (vaginal hysterectomy) and 6 (subtotal abdominal hysterectomy). Case 3 had 4 fistulas and case 4 had 2; the other patients had only 1. In case 4 there was a recognized complication at the time of operation in that the bladder was entered during the hysterectomy. In case 8 the fistula developed after transvaginal drainage of a pelvic abscess 4 weeks postoperatively. There were no complications other than the fistulas arising from the hysterectomy in the remaining patients. Four patients had undergone attempted repair of the fistulas before they were referred to us (see table).
dye was seen in the vagina; thus, the IVP is an important part of the evaluation in these patients. Bilateral retrograde ureterograms were done in all cases to be certain that there were no associated ureterovaginal fistulas. In addition, cystograms were done in 8 patients and contrast medium could be seen in the vagina in 6. In all cases the communications between the bladder and vagina were visualized by endoscopy. Also, when the patients were endoscoped we instilled 100 cc saline containing 2 ampules of methylene blue into the bladder through a urethral catheter and then determined the exact location of the fistula in the vagina by panendoscopy of the vagina. OPERATIVE TECHNIQUE
The operation is done with the patient under general anesthesia. She is placed supine on the operating table with the legs apart and resting in low stirrups, and the foot of the table is dropped to allow an assistant to stand between the patient's legs. The abdomen, perineum, genitalia and vagina are prepared, the vagina is packed tightly with furacin or vaseline gauze (fig. 1, A) and the patient is draped so that the entire abdomen and perineum are exposed. The abdominal cavity is entered through a low midline incision and an anterior midline cystotomy is performed. The bladder is inspected, the fistula(s) is (are) identified and a
Pt.-Age
PREOPERATIVE EVALUATION
When these patients were first seen by us 11 of the 13 had normal excretory urograms (IVPs). However, 1 patient had distal ureteral stenosis and another had a left renal calculus. In 1 case the fistula could be detected by the IVP in that contrast Accepted for publication September 26, 1975. * Requests for reprints: Department of Urologic Surgery, University of Minnesota Health Sciences Center, Minneapolis, Minnesota 55455. 660
Previous Attempted Repair
Time From Hysterectomyto Repair
1-46
5 mos.
2-43 3-49
6mos. 6mos.
4-43
Suprapubic.
5 mos.
5-22 6-64
Vaginal Bladder neck suspension
3mos. 18 yrs.
7-42 8-35
9-38 10-36 11-40 12-38 13-42
2 mos. 7 wks.
Suprapubic
14 mos. 2mos. 6mos. 4mos.
1 yr.
Other Procedures Done at Time of Repair
Complications
Bilat. salpingooophrectom:,,
Lt. ureterovesical reflux Recurrent or persistent fistula Ileus
Wound infection Lt. ureteroneocystotomy Lt. ureter entered, repaired
F!Go 1 large catheter is passed each ureteral orifice and left indwelling in the renal pelvis throughout the procedure and (figo 1, Next the peritoneum is dissected free from the posterior bladder wall and the dissection is continued caudally until the fistula tract is entered (figo 1, This part of the dissection is facilitated by the vaginal pack, which makes it easy to identify the vagina and the surgical plane between the vagina and the bladder. The assistant at the end of the table helps by pushing on the vaginal packo When the fistula is opened the bladder and vagina are dissected apart for approximately 1 to L5 cmo beyond the lower edge of the fistulao The ureteral catheters simplify identification of the ureters and, thus, help prevent ureteral injury The vaginal pack is removed and all scar tissue surrounding the fistula in the vagina and the bladder is excisedo The bladder mucosa and submucosa are then closed from within the bladder through the anterior midline cystotomy with a continuous suture of 4-zero chromic catgut, making sure both ends of this suture are left outside the bladder (figo 2, A and B) 0
0
0
When suturing is cornpleted the ends of the suture are under traction outside the bladder, muscle defect in the bladder wall and closureo The bladder muscle is "'l-'P""A'""'""u with a continuous suture of 2-zero chromic catgut (figo 2, On occasion it is necessary to perform a ureteroneocystotomy when the fistula is close to one of the ureteral orificeso The vagina is dosed with a transverse running suture of 2-zero chromic catguto A second layer of interrupted inverting suture of the same material is placed (figo 2, D) After the fistula is closed a 24 Foley catheter is placed in the bladder and the cystotomy is closed in 3 layers, using absorbable suture materiaL The position of the ureteral catheters is checked by irrigation and a radiogram, and both are brought out through the urethrao A pedicle flap of omentum, when available, is tailored and interposed between the vagina and the bladder and lightly fixed to the former with absorbable sutureso However, the use of omentum is not necessary if the rest of the procedure has been done as describedo The peritoneum is closed, a rubber drain is placed on the 0
0
662
GONZALEZ AND FRALEY
Fm. 2 retropubic perivesical space and the abdominal incision is closed. The ureteral catheters are sutured to the labia and secured to the indwelling Foley catheter. Postoperatively, the urine output from each catheter is monitored. Ideally, there is no output from the Foley catheter, all urine being diverted through the ureteral catheters. Whenever possible, the ureteral catheters are left indwelling for 10 to 14 days but they are removed when drainage from one or both becomes inadequate. The Foley catheter is always left indwelling for 10 to 14 days. The patient can be ambulated 1 day postoperatively. We routinely have given antispasmodics and antibiotics postoperatively.
patient had multiple fistulas and it is possible that 1 was overlooked. However, the procedure was repeated 10 weeks later and the fistula was cured. Surgical complications are listed in the table. One patient (case 3) had left vesicoureteral reflux but this disappeared spontaneously after 6 months. She has had several voiding cystograms since then that showed no reflux and she has had no urinary tract infections. Another patient had a left ureteral injury during the operation that was repaired at the time and healed without difficulty.
RESULTS
Case 4. A 43-year-old woman underwent total anterior hysterectomy in October 1970. The bladder was entered and repaired during the procedure, and leakage of urine was noted through the vagina in the immediate postoperative period. In January 1971 the patient underwent an abdominal exploration
CASE REPORTS
In 12 of the 13 patients the fistula was corrected completely. The 1 exception was case 4, in which urine leakage was observed shortly after the Foley catheter was removed. In this patient the ureteral catheters never drained properly and this
for
Qr,,Q.,,·,,·.,-~.ci
:repai:r of the fistcla but a sr:1sE bovvel ·.:vas and the v11a.s tern1iL~a.ted. vvhere
were normal on PvP. The underwent suprapubic transvesical repair of the fistulas and a dosed enterocutaneous fistula also was seen and repaired. Catheters were left in both ureters to the bladder dry but they never drained adequately and were removed 10 postoperatively. Two days later leakage of urine was noted through the vagina. The patient was discharged from the hospital and re-evaluated 2 months later. At this time we did a suprapubic transvesical repair of the original recurrent fistula and a left ureteroneocystotomy. The ureteral catheters drained satisfactorily for 14 and the patient was discharged from the hospital without further complications. Case 6. A 64-year-old woman had had persistent urinary incontinence after a subtotal hysterectomy 18 years previously. Nine months before the current hospitalization the remaining cervix uteri was removed and a segmental resection was done on the sigmoid colon for diverticular disease. Examination of the specimen revealed a colovaginal fistula. Because of persistent incontinence the patient underwent suprapubic suspension of the bladder neck 6 months later. When this procedure failed the patient was referred to us. Pelvic examination, cystoscopy and cystography revealed a large vesicovaginal fistula in the midline above the trigone. A left renal calculus was seen on the IVP but otherwise the Were D0fffial. H,t;C>'Uj;Jlctcn; tlVPl
