Surgery for the obstetric vesicovaginal fistula: A review of 100 operations in 82 patients

Abstract

OBJECTIVE: Vesicovaginal fistula resulting from prolonged obstructed labor remains a major problem in developing countries where medical care is limited. For many years surgical closure of the fistula was almost impossible. However, closure rates today range between 65% and 95%. Attention now is being focused on training more surgeons to repair simple fistulas, identifying and preventing complications that occur even with successful vesicovaginal fistula closure, developing new techniques to close the most difficult fistulas to repair, and working to improve obstetric care to prevent future vesicovaginal fistulas. This study reviews contemporary efforts to manage vesicovaginal fistulas with these goals in mind. STUDY DESIGN: One hundred consecutive vesicovaginal fistula repair operations that I performed in 82 patients are reviewed. Specific repair techniques are described for each vesicovaginal fistula type by anatomic vesicovaginal fistula classification. Primary closure rates and complications are examined by vesicovaginal fistula type, location, size, and number of prior repair attempts. RESULTS: After 100 operations, 78 of the 82 patients (95%) had successful vesicovaginal fistula closure. Primary closure rates were noted to be 31 of 33 (94%) for suburethral fistulas, 10 of 14 (71%) for midvaginal fistulas, 9 of 10 (90%) for juxtacervical fistulas, 10 of 12 (83%) for urethral fistulas, 6 of 6 (100%) for uterovesical fistulas, but only 4 of 7 (57%) for combined vesicovaginal and rectovaginal fistulas. Repairs were only 50% successful on second attempts and only 33% successful on third attempts. Even in those patients who had successful closure of the fistula, serious complications occurred in 59% of patients, including other types of urinary incontinence, gynatresia, amenorrhea, and leg weakness. CONCLUSION: Basic principles of fistula surgery remain important in all types of vesicovaginal fistula repairs. Further research is needed into prevention and management of associated complications, into innovative repair of those few patients who do not have successful closure, and into training more surgeons to address the vesicovaginal fistula problem. (AM J OBSTET GYNECOL 1994; 170:1108-20.)