Iatrogenic vesicovaginal multioperated fistula in a 6 year old girl. What is the best approach?

Abstract

Purpose Vesicovaginal fistula is an uncommon clinical entity in pediatric urology practice. We present the video of a 6 year old girl who underwent elsewhere at the age of 3 months a nephroureterectomy due to nonfunctional ureterohydronephrotic right system. The patient developed a vesicovaginal fistula and since then she had undergone one open and another endoscopic unsatisfactory attempt to treat the fistula, before she was referred to our institution. Material and methods We performed a cystogram that confirmed the fistula and showed left vesicoureteral reflux. The cystoscopy showed an infratrigonal fistula close to the previous right ureteral orifice. We decided to do a transvesical approach and were able to identify the defect. With cautious dissection of the bladder wall, we managed to isolate it from the vaginal wall. The fibrotic tissue was excised and the vagina was closed in two layers through the bladder. We used fibrin glue and prepared an omentus flap that was mobilized laterally to the bladder up to the trigonal area that was used to cover the vaginal suture. At last, we closed the posterior wall of the bladder that was previously attached to the fistula and a cystostomy tube was left for 4 weeks leaving the contralateral ureter untouched. Results The patient had a satisfactory result and after cystostomy tube removal the fistula was indeed closed. Conclusions Infratrigonal vesicovaginal fistulas in children, differently from adults should be better treated through the abdomen, observing the general principles of fistula closure: complete isolation of the organs involved, removal of fibrotic tissue, closure in various layers, use of fibrin glue and interposition of well-vascularized flaps.