12 Vesicovaginal fistulae

Abstract

In the past few decades, amidst the revolutionary new advances in the surgical, chemotherapeutic, and radiotherapeutic treatments for cancer, the role of the gynecologic oncologist has diverged from that of the obstetrician–gynecologist and the general surgeon. In the past, the general surgeon was responsible for treating any disease process that was surgically approachable. As new methods of treatment have arisen in the fight against cancer, the field of gynecologic oncology has developed its own identity and exists now as a separate subspecialty. Nevertheless, many of the surgical modalities used by the gynecologic oncologist require understanding of experiences shared by general surgeons, surgical oncologists, urologists, colorectal surgeons, and even vascular surgeons.Intraoperative injuries encountered during gynecologic oncology surgery occur because of the complexity of the involved anatomy and the intimate relationships of these various structures. Most pelvic tumors have the ability to invade and compromise surrounding tissues. With the close proximity of the pelvic organs to those of the abdomen, many pelvic tumors tend to involve a number of adjacent organ systems, including the gastrointestinal tract, the urinary tract, nerves, and blood vessels. The distortion caused by tumor invasion and growth can render normal anatomy difficult to recognize.Gynecologic oncologists normally perform a wide array of procedures, such as staging laparotomy, lymphadenectomy, radical hysterectomy, radical vulvectomy, debulking for ovarian cancer, second-look laparotomy, pelvic exenteration with reconstruction for recurrent cancer, and operations for surgical and radiotherapeutic complications. Unfortunately, even the most expert surgeon in the field encounters situations in which iatrogenic injury cannot be avoided. The pelvic surgeon must be familiar with the most common injuries and be able to solve the problem without hesitating to call for intraoperative consultation when indicated. Often, gynecologic oncologists who work in close contact with gynecologists and obstetricians are the first physicians to be consulted intraoperatively to perform corrective surgery for iatrogenic complications during benign procedures. The management of these various iatrogenic complications should be familiar to the gynecologic oncologist and any pelvic surgeon acting as a consultant. The choice of the reparative technique should be based on the type of injury; the disease and extension; the general condition of the patient; and, just as importantly, the surgeon's personal experience.This article discusses the management of the most common intraoperative injuries encountered during gynecologic cancer surgery. The management of any of these complications can be applied to surgery for benign gynecologic, obstetric, or any surgical procedure in which a pelvic surgeon may be asked to consult intraoperatively. Discussion is dedicated to injuries of the genitourinary tract, gastrointestinal tract, and commonly encountered nerves. The reader is referred to the article by Montz in this issue for a discussion of the management of vascular injuries.