Complex Vesicovaginal Fistula Research Articles

Comparative study between use of Buccal Mucosal Graft and Martius flap as A Second Layer in Vaginal Repair of complex Vesicovaginal Fistula: A prospective randomized trial

Comparative study between use of Buccal Mucosal Graft and Martius flap as A Second Layer in Vaginal Repair of complex Vesicovaginal Fistula: A prospective randomized trial

Transvaginal double-layer parallel in-situ suturing for early complex vesicovaginal fistula repair: Case report.

Complex vesicovaginal fistulas (VVFs) with large defects pose significant surgical challenges. Traditional repair methods often require extensive tissue separation and multilayer suturing, risking local blood supply and healing. This study introduces a novel modified transvaginal repair technique that simplifies the procedure while preserving tissue vascularity. It employs double-layer parallel in situ suturing for early repair of complex VVF. A 50-year-old woman was admitted with continuous vaginal urine leakage for 4 days following trauma. Speculum examination revealed a 3-cm longitudinal oval laceration at the 11 o'clock position in the dorsal lithotomy site, with continuous fluid leakage through the fistula. Self-inflicted complex VVF. The patient underwent prophylactic placement of bilateral double-J stents and continuous catheterization, followed by surgical repair using a modified transvaginal technique involving double-layer parallel in situ suturing. Postoperative evaluations showed successful healing with no urinary leakage. The vaginal sutures were removed on day 24, and follow-up at 1 year confirmed no recurrence of the fistula or lower urinary tract symptoms, significantly improving the patient's quality of life. The modified transvaginal repair technique using double-layer parallel in situ suturing is a simple and effective approach for early repair of complex VVF, highlighting its potential for broader clinical application. Future studies with larger cohorts are needed to validate these findings.

Rectus abdominis muscle flap in complex vesico-vaginal fistula repair: unique situation, uncommon option

BackgroundComplex vesico-vaginal fistulae (VVF) pose unique surgical challenges and necessitate the use of interposition tissue to ensure surgical success. Herein, we describe a case of complex VVF with right uretero-vaginal fistula post radical surgery for locally advanced ovarian cancer and chemotherapy in which the rectus abdominis muscle flap was used as the interposition tissue, as the more routine used options such as omentum and peritoneum were removed in the prior radical surgery.Case presentationWe describe a case report of a vesico-vaginal and right uretero-vaginal fistula in a 34-year-old female post ovarian cancer radical surgery managed surgically with the traditional transvesical technique of repair and ureteric reimplantation with a unique interposition with rectus abdominis muscle considering the absence of the more routine options.ConclusionComplex VVFs pose unique surgical challenges and necessitate the use of interposition tissue to ensure surgical success. The inferior pedicle based rectus abdominis muscle flap is an excellent interposition tissue for repairs via the transabdominal approach especially in scenarios where the more routine options are unavailable.

Prevalent practices and changing trends in the management of vesicovaginal fistula: a cross-sectional study from a nationwide questionnaire-based survey of urologists from a developing country

Vesicovaginal fistula (VVF) management is primarily backed by evidence from retrospective studies and expert opinions and therefore lacks standardization. Newer generations of surgeons are more proactive toward changing clinical practices in domains lacking good-quality evidence. This survey-based cross-sectional study aims to elicit consensus on management practices regarding various domains of VVF management and look for any changes in clinical practice trends. A nationwide survey of urologists was conducted, and responses were grouped into 3 categories (overall response, response from young urologists, and response from experienced urologists) and compared. Based on the level of overall consensus, the responses were categorized as highly preferred, preferred, and somewhat preferred. Consensus was noted in conservative and endoscopic management of VVF, timing of VVF repair, definition of simple/complex VVF, approach for surgical repair for trigonal and supratrigonal VVF, use of interposition tissue for repair, and patient positioning in the postoperative period. A lack of consensus was noted in other domains. Changing trends in clinical practices were noted in attempts at conservative and endoscopic management, investigations considered mandatory for evaluation, surgical approach for complex VVF with bladder neck involvement and radiation-induced fistulas, the use of interposition grafts during surgical repair, the use of cystograms during follow-up, and the definition of a successful repair. There is uniformity in practices regarding many domains of VVF management. Those areas, where discordance in opinions is noted, require further research to bring standardization into practice. Regarding certain aspects of VVF management, there appears to be a change in trends among the younger generation of urologists.

Robotic-Assisted Laparoscopic Repair of Iatrogenic Vesico-Vaginal Fistula

<h3>Study Objective</h3> This video highlights the principles of robotic assisted laparoscopic repair of iatrogenic vesico-vaginal fistula <h3>Design</h3> Surgical video presentation. <h3>Setting</h3> Academic tertiary care center. <h3>Patients or Participants</h3> We present 2 cases of iatrogenic vesico-vaginal fistula repaired robotically. Case 1 is a 49-year-old patient with a vesico-vaginal fistula after an open supracervical hysterectomy with incidental cystotomy and repair. Case 2 is a 61-year-old patient who was referred for management of a supra-trigonal vesico-vaginal fistula as a complication of vaginal hysterectomy. <h3>Interventions</h3> Case 1 started with cystoscopy and placement of ureteral stents. The peritoneum above the vaginal cuff was incised and an anterior colpotomy was created. The bladder was dissected until the fistula was identified and the injured area was 4 cm away from the colpotomy. The fistulous margins where dissected. The bladder mucosa was repaired in 2 layers in a running fashion. The bladder was retrogradely filled, confirming the repair was watertight. The colpotomy was closed in 2 layers. The repair was reinforced with omental interposition. For case 2, a stent was placed through the vaginal fistulous opening. The stent was identified transvesically with cystoscopy. Bilateral ureteral stents were placed. Similar steps from case 1 were carried out. Cystoscopy was performed confirming an adequate repair. Bilateral ureteral stents were removed. A Foley catheter was inserted to remain in place for 3 weeks. <h3>Measurements and Main Results</h3> Both patients were discharged on post-operative day 1. The patient in case 1 had a voiding cystogram showing no evidence of residual or recurrent fistula on post-operative week 3, and urine leakage was resolved. The patient in case 2 is scheduled for follow up on post-operative week 3. <h3>Conclusion</h3> Robotic assisted repair offers optimal surgical exposure and is ideal for supra-trigonal and complex vesico-vaginal fistulas, affording good outcomes for patients.

A novel technique for transurethral vesicovaginal fistula tract resection followed by transvaginal fistula repair: a two-step procedure

Background: The principle of treatment for a vesicovaginal fistula (VVF) tract is complete removal of the fistula tract and surrounding scar tissue, followed by anastomosis without tension from surrounding healthy tissue. We present our novel two-step procedure for VVF repair. Methods: We retrospectively analyzed 12 women, aged 14 to 67 years, who were treated between 2011 and December 2018. Conservative treatments failed, as these patients had complex VVFs. This technique consisted of two steps: first, transurethral resection of the fistula tract and surrounding scar tissue; second, transvaginal repair of the bladder mucosa, bladder muscle, and vaginal mucosa with tensionless anastomosis. If an interposition flap was needed, we used a Martius flap.Results: The mean operation time was 186.3 minutes (range, 145–320 minutes), and the mean urethral catheter indwelling time was 10 days. Ten patients successfully underwent surgery through a transvaginal approach with no intraoperative or postoperative complications. However, one patient developed peritoneal perforation during transurethral resection of the fistula due to severe granulation tissue formation around the fistula, which prompted conversion to an abdominal approach. In two cases, we used a Martius flap because of the poor tissue condition due to previous radiation therapy and an inflammatory reaction. At a mean follow-up of 37 months (range, 16–51 months), no recurrence of VVF was observed in any patients.Conclusions: This novel technique for transurethral VVF tract resection followed by transvaginal fistula repair was very safe and effective technique, and this straightforward technique is expected to reduce surgeons’ burden.

Total pelvic exenteration for pelvic recurrence with complex recto-vaginal and vesicovaginal fistula after surgically treated endometrial cancer

Local recurrences after surgically treated endometrial cancer with associated vesical and rectal fistula represent a particular eventuality in which the only chance for cure is represented by extended pelvic resections. The aim of the current paper is to present the case of a 62 year old patient diagnosed with a local recurrence invading the urinary bladder and the rectum leading to the development of a complex fistula involving both the urinary and digestive tract after surgically treated endometrial cancer. Although initially the patient was not submitted to pelvic radiation therapy, at the time of relapse the presence of this fistula contraindicated any kind of radiation therapy. Therefore the patient was submitted to a total pelvic exenteration with cutaneous ureterostomy and terminal left colostomy. Another particularity of the patient was the fact that she had an ureteral duplication on the right side, both ureters being functional and exteriorized in right ureterostomy. In conclusion, pelvic exenteration might be a good therapeutic alternative for pelvic recurrences with complex fistulas after surgically treated endometrial cancer.

Robotic-assisted vesicovaginal fistula repair using a vaginal cuff flap

Vesicovaginal fistula (VVF) is an abnormal communication between the bladder and the vagina. Complex fistulae include those after failed repair attempts, radiotherapy, measuring ≥ 2 cm, located in the trigone, or with concomitant ureteric strictures or fistulae. We aimed to describe a technique for the robotic repair of a complex VVF using a vaginal cuff flap. A 56-year-old woman with a history of ovarian debulking surgery and radiotherapy underwent repair for VVF and rectovaginal fistula. In lithotomy, cystoscopy was performed for fistulous tract cannulation. Port placement, extensive adhesiolysis, and robot docking followed. The vaginal apex was dissected, the VVF excised, and the bladder closed. The rectum was separated from the posterior vaginal wall, the rectovaginal fistula excised, and the rectum closed. A vaginal cuff flap was harvested and interposed between the bladder and the vagina. Operative time was 9 h, estimated blood loss was 300 cc, and no intraoperative complications occurred. The patient was discharged on postoperative day 8. Further management included 37 sessions in a hyperbaric chamber and a transvesical endoluminal bladder closure 10 months after the initial surgery. Follow-up at 30 months shows no fistula recurrence. Vaginal cuff flaps represent a feasible interposition tissue in patients with hysterectomy for managing complex VVF in the case of omentum unavailability.

Complex vesicovaginal fistula: Analysis of patient characteristics &amp; functional outcome of surgical reconstruction

Complex vesicovaginal fistulas present a unique challenge to surgeons, and surgical reconstruction outcomes may be suboptimal. The aim is to evaluate the patient’s characteristics as well as the factors influencing the functional outcome of complex vesicovaginal fistula surgical reconstruction. From 2016 to 2020, the medical records of 28 patients with complex fistulas were analyzed retrospectively. Means, ranges, and standard deviations were used in descriptive analysis. For categorical data, the Fisher exact probability test was used. The mean (standard deviation) age at presentation was 44.4 (10.04) years, while 85.7% (24) of patients were below 50 years of age. Hysterectomy was the most common aetiology in 21 (75%) patients, followed by radiotherapy in 3 (10.7%). Surgical repair success was seen in 24 (85.7%) patients. Four (14.2%) patients had an unsuccessful repair, one vaginal and three abdominal approach. All the failed abdominal repairs were radiation-induced fistula (p=0.001). Other factors that significantly influenced repair failure include vaginal mucosal atrophy (3 failures out of 8 patients, p=0.013), severe fibrosis around the fistula (4 failures out of 12 patients, p=0.024), non-placement of suprapubic catheter (2 failures out of 3 patients, p=0.006), and non-placement of interposition tissue flap (p=0.005). Hysterectomy and radiotherapy are the common causes of complex vesicovaginal fistula. The outcome of the repair is hampered by vaginal mucosal atrophy and severe scarring. The use of a suprapubic catheter and an interposition tissue flap improves the outcome. Post-irradiation fistula has a significant impact on repair outcome and necessitates special consideration for a comprehensive management strategy.

Multidisciplinary minimally-invasive approach to complex vesicovaginal fistula repair

This video's objectives are to demonstrate the techniques and decision process used in the approach to a complex vesicovaginal fistula resulting from obstetric injury, after previous attempts at repair had failed. Our patient was referred from an outside institution to us. At emergent cesarean delivery at 24 weeks, hemoperitoneum, uterine rupture, and placenta percreta were found. During hysterectomy, the right ureter was ligated and the posterior wall of the bladder sustained large cystotomies. Urology repaired the injury, reimplanted the ureter, and placed a right ureteral stent, but the patient developed a vesicovaginal fistula and left ureteral obstruction. Ten months after diagnosis, it was repaired using a robot-assisted laparoscopic approach. This required bilateral ureteral re-implantation and omental flap. Unfortunately, this repair broke down, and testing was concerning for vesicovaginal and left ureterovaginal fistula, high at the vaginal apex. The patient was referred to our institution for our attending surgeon's expertise in fistula repair. Takeaways from this video presentation include: careful delineation of genito-urinary anatomy, vaginal approach, optimization of visualization, wide mobilization of tissue around the defect, watertight closre, meticulous multilayer closure, and aggressive management of infection.

Robotic Repair of Vesicovaginal Fistula: Step-by-Step Technique for Complex Scenarios

Abstract Introduction: Vesicovaginal fistula is a devastating condition often occurring as a complication of surgery or radiotherapy in women. Complex vesicovaginal fistula represents a challenge f...

V01-01 ROBOTIC-ASSISTED COMPLEX VESICOVAGINAL FISTULA MANAGEMENT WITH A VAGINAL FLAP

You have accessJournal of UrologyIncontinence & Female Pelvic Medicine/Reconstructive Surgery (V01)1 Sep 2021V01-01 ROBOTIC-ASSISTED COMPLEX VESICOVAGINAL FISTULA MANAGEMENT WITH A VAGINAL FLAP Enanyeli Rangel, Laura C. Perez, Anibal La Riva, Aref S. Sayegh, Luis G. Medina, and Rene Sotelo Enanyeli RangelEnanyeli Rangel More articles by this author , Laura C. PerezLaura C. Perez More articles by this author , Anibal La RivaAnibal La Riva More articles by this author , Aref S. SayeghAref S. Sayegh More articles by this author , Luis G. MedinaLuis G. Medina More articles by this author , and Rene SoteloRene Sotelo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001970.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Complex fistulae represent a therapeutic challenge due to their increased recurrence rates. The lack of omentum and history of radiotherapy significantly impacts fistulae management. The aim of this video is to present the robotic management of a complex vesicovaginal fistula (VVF) using a vaginal flap in the case of omentum unavailability. METHODS: A 56-year-old female with previously diagnosed VVF, and rectovaginal fistula presented with persistent urine leakage per vagina despite conservative management with urinary and fecal diversion. Past medical history is positive for metastatic ovarian cancer managed with multiple surgeries and adjuvant chemoradiotherapy. Preoperative cystoscopy demonstrated VVF at the bladder trigone, and vaginoscopy showed a concomitant rectovaginal fistula. Under general endotracheal anesthesia, the patient was positioned in a dorsal lithotomy position. We proceed to identify and cannulate the fistulous tracts and ureters. A 12mm AirSeal® port was inserted in the right upper quadrant under direct vision. Once pneumoperitoneum was established, the rest of the robotic trocars were placed. Initially, extensive adhesiolysis was performed. Once the pelvis was free of adhesions, the vaginal apex was identified and then incised with cautery. We proceed to excise the VVF, and the bladder was closed with 2-0 V-Loc suture. The rectovaginal fistula was identified and excised. The rectum was separated from the vaginal wall. The excess of vaginal tissue was cut, and the vagina was shortened in order not to have overlapping suture lines. The vagina was closed with 2-0 V-Loc suture. Finally, fatty tissue and vaginal flap were mobilized to act as interposition tissues. A Blake drain was left in place. The robot was undocked, and the ports were closed in a standard fashion. RESULTS: Operative time was 11 hours, estimated blood loss was 300mL, and no intraoperative complications occurred. The patient was discharged on postoperative day 8. Posterior management included 37 sessions of hyperbaric oxygen therapy, and a reintervention 1-year after the surgery with a transvesical endoluminal bladder closure for a less than 1mm posterior fistula. Follow-up at 23-month after surgery shows an asymptomatic patient with no leakage. CONCLUSIONS: Vaginal flaps are feasible for managing complex vesicovaginal fistulae in case of omentum unavailability. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e62-e62 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Enanyeli Rangel More articles by this author Laura C. Perez More articles by this author Anibal La Riva More articles by this author Aref S. Sayegh More articles by this author Luis G. Medina More articles by this author Rene Sotelo More articles by this author Expand All Advertisement Loading ...

Robot-assisted Repair of Complex Vesicovaginal Fistulae: Feasibility and Outcomes

OBJECTIVETo share our experience and techniques of robot-assisted repair of complex vesicovaginal fistulae. METHODSProspectively maintained data of patients undergoing robot-assisted repair of complex vesicovaginal fistula (VVF) from December 2014 to October 2019 were analyzed. Patient characteristics, operative data, postoperative events, and follow-up outcomes were noted. All cases underwent preoperative cysto-vaginoscopy and upper tract imaging. The procedure was completed in a standard fashion. Additional procedures included Boari flap reimplantation, Burch-colposuspension, ureteric reimplantation and Vaginal flap incorporation. On follow-up, successful repair was defined as no urine leak after removal of catheter. RESULTSOut of 73 patients undergoing robot-assisted VVF repair at our institute, 33 were classified as complex VVF. Mean age was 42.7 ± 7.2 years. The most common cause of VVF was posthysterectomy (81.8%) with 21 (63.1%) recurrent VVFs. Thirty patients (90.0%) had supratrigonal fistulae; multiple fistulae were present in 3 cases. Two patients underwent Boari flap ureteric reimplantation for concomitant ureteric stricture and ureteric neocystostomy was required in another patient. One patient underwent our novel technique of vaginal flap incorporation and a Burch colposuspension was performed simultaneously in one patient with stress incontinence. The median follow-up was 35 months (interquartile range 8.5months). Successful outcome was noted in 31 (93.9%) patients; recurrence requiring further repair in 2 patients. CONCLUSIONThe current series presents the largest number of complex VVFs repaired by robotic assistance. Robot-assisted repair can be considered as one stop procedure for such complex and vexing problems.

Laparoscopic repair of female genitourinary fistulae: 10-year single-center experience

Laparoscopic repair of different female genitourinary fistulae has been recently reported, including both conventional and laparoendoscopic single-site surgery (LESS). We present our 10-year single-center experience of the laparoscopic repair of different types of female genitourinary fistulae. A retrospective analysis of our records over the last 10years was performed. Type of fistula, etiology, laparoscopic approach, operative data, postoperative outcome, and follow-up were recorded. Overall, 46 patients with laparoscopic repair of genitourinary fistulae were reported: 25 had vesicovaginal fistulae (VVF), 14 had vesicouterine fistulae (VUF), and 7 had ureterovaginal fistulae (UVF). Thirty-three patients had conventional laparoscopic repair, whereas 7 VVF and 6 VUF had LESS repair. In all patients with VVF and VUF, extravesical repair was carried out by excising the fistulous tract and closing both the bladder and the vagina or the uterus with interposing tissue in-between. In patients with UVF, extravesical ureteric re-implantation was performed. Mean operative time was 176 ± 25min. Mean blood loss was 105 ± 25 cc. No intraoperative or postoperative complications occurred. None was converted to open surgery. Mean postoperative hospital stay was 3.2 ± 1.2days. After a mean follow-up of 6.3 ± 3.1years, all patients had undergone successful repair, except for one patient with complex VVF. Laparoscopic repair of VVF, VUF, and UVF is a feasible procedure with a high success rate and low morbidity. LESS repair of VVF and VUF has a comparable success rate to conventional laparoscopy, but with a shorter hospital stay and fewer analgesic requirements.

Comparación de resultados entre abordaje abdominal vs vaginal en el manejo de las fístulas vesico-vaginal

Objective: To compare the results of the surgical approach between the abdominal and vaginal techniques in simple and complex vesicovaginal fistula repair, suggesting the safest surgical approach. Materials and methods: An analytic, cross-sectional, retrospective study with convenience sampling was conducted on females with a history of simple and complex vesicovaginal fistulas that underwent surgical repair with the abdominal or vaginal technique at the Urology Service of the Hospital General de Mexico within the time frame of February 2015 to February 2018. After a thorough review of the medical records, the following study variables were determined: hospital stay, surgery duration, intraoperative blood loss, complications according to the Clavien classification, and the risk for refistulization. The data were analyzed using measures of central tendency and dispersion. Results: Sixty patients that underwent simple or complex vesicovaginal fistula repair were divided into two groups according to the surgical technique employed: 30 patients with the abdominal approach and 30 patients with the vaginal approach. Mean patient age was 42.58 ± 11.3 years and the past histories were hysterectomy due to a benign cause in 37 (62%) patients, hysterectomy due to an oncologic cause in 11 (18%) patients, childbirth in 6 (10%) patients, and infection in 6 (10%) patients. Mean fistula size determined through cystoscopy was 0.73 ± 0.52 cm. The patients that underwent transvaginal surgery had fewer complications, compared with those treated with the abdominal technique (6% vs 33%), p = 0.012. Conclusions: Vesicovaginal fistula repair through the transvaginal approach is recommended for its reduced hospital stay, less intraoperative bleeding, shorter surgery duration, lower recurrence rate, lower complication rate, higher success rate, and faster recovery. It can be performed as a first surgical option.

What is happening with Obstetric Fistula in the West of Nepal?

Aims: Analyzing the changes in the characteristics of patients presenting with fistula in Surkhet. The impact of births after the development of fistula on the grade of fistula and outcome is examined.&#x0D; Methods: This study examines the records of 282 fistula patients identified in Surkhet between 2009 and 2018.&#x0D; Results: There has been reduction in number of women presenting with the most complex vesico-vaginal fistulae and reduction in average number of years women have lived with obstetric fistula before treatment. More women present within one year of injury and better outcome is seen in those with more recent injury. A moderate increase in patients presenting with iatrogenic fistula is seen, (2011 obstetric fistula 77%, iatrogenic 6%, 2018 obstetric fistula 68.5%, iatrogenic 17%).&#x0D; Conclusions: The findings suggest that easier access to maternity care and better fistula awareness is reducing the occurrence of the most severe injuries and improving outcomes.

Diagnosis and treatment of complex vesicovaginal fistulas: a report of 23 cases

目的 探讨复杂性膀胱阴道瘘的诊断与治疗。 方法 对本院2008年1月至2012年12月收治的23例行手术治疗的复杂性膀胱阴道瘘患者的临床资料进行回顾性分析。 结果 初次修补患者5例，二次及以上修补患者18例，13例采用经腹途径修补，6例采用经膀胱途径修补，4例采用经阴道途径修补，其中2例经阴道途径修补术后瘘口未愈，6个月后采用带蒂大网膜移植修补，术后瘘口愈合。 结论 复杂性膀胱阴道瘘手术治疗方式多，应根据患者的具体情况及手术者的经验来决定手术方式。

The surgical treatment for complex vesicovaginal fistula

Objective To discuss the outcomes of transvaginal repair and transabdominal repair for complex vesicovaginal fistula (VVF). Methods The data of complex VVF patients undergoing surgical repair in Peking University First Hospital were retrospectively collected between January 2009 and December 2016. The surgical modalities for complex VVF included transvaginal repair with layered closure and transabdominal repair with full thick vascular peritoneal interposition. The subtype distribution of complex VVF in transabdominal repair group and transvaginal repair group were recorded. The present study included 63 complex VVF patients with the median age of 46 years (range 26 - 60 years). There were 32 cases undergoing transvaginal repair with layered closure and 31 cases undergoing transabdominal repair with full thick vascular peritoneal interposition. The proportion of cases having failed previous repairs was significantly higher in transvagical repair group (30/32 vs. 23/31, P=0.034). Compared with patients with transvaginal repair, patients with transabdominal repair tended to have multiple VVF without statistic significance (18.8% vs. 29.0%, P=0.338). Patients with transabdominal repair had larger VVF than patients with transvaginal repair (median: 1.0cm vs. 0.5cm, P<0.001). Results There were 2 cases suffering from fat liquefaction of surgical incision and 1 case suffering from adhesive intestinal obstruction in patients undergoing transabdominal repair. In the median follow-up duration of 24 months (range 8-102 months) and 29 months (range 8-78 months), the successful rates of transvaginal repair and transabdominal repair were 75% (24/32) and 93.5% (29/31). Severe lower urinary tract symptoms occurred in one patient who had urine leakage after transabdomnal repair. The bladder volume of patients in transabdominal group recovered at postoperative 3-6 months. Conclusions In consideration of surgical invasion and fistula condition, transvaginal repair with layered closure and transabdominal repair with full thick vascular peritoneal interposition should be performed individually for complex VVF. Meanwhile, the surgeons need pay attention to other perioperative management. Key words: Complex vesicovaginal fistula; Transvaginal repair; Transabdominal repair; Treatment effect

Outcome of using a modified surgical technique for the repair of complex vesicovaginal fistulas in Nigeria

The relatively low effectiveness of available surgical repair techniques for complex obstetric fistula has justified the need for continued exploration of more effective repair techniques. Subjects who presented at a vesicovaginal fistula referral centre in Nigeria were randomized into the study group (modified technique) and the control group (conventional technique). Success rates between the two groups were compared. The study comprised 29 patients in each arm of the study. The mean age of patients in the study group was 23.9 ± 9.6 years and 24.4 ± 2.1 years among patients in the control group with the vast majority of the patients in the both groups being married, 75.9% and 86.2% respectively. In both groups, the majority were secundipara, 55.2% in the study group and 44.8% in the control group. The majority (41.4% in the study group and 44.8% in the control group) of the patients in both groups had attained primary level of education. The mean duration of the fistulas among patients in the study population was 1.1 ± 0.3 years with over half (50.0% among patients in the study group and 53.5% of patients in the control group) of the patients had their fistula for less than one year. A highly statistically significant difference in success rate between patients in the study group and patients in the control group was obtained (p=0.0004). The modified repair technique presented by this study has proved to produce superior results when compared to the conventional repair technique in the management of complex obstetric fistulas in Nigeria.

Combined Laparoscopic, Vesicoscopic, and Vaginal Repair of a Vesicovaginal Fistula

Study ObjectiveTo demonstrate a combined laparoscopic, vesicoscopic, and vaginal approach to repair of a complex vesicovaginal fistula. DesignTechnical video demonstrating a combined laparoscopic, vesicoscopic, and vaginal approach for repairing a vesicovaginal fistula (Canadian Task Force classification level III). SettingUrogynecology and Urology Departments of a tertiary referral center for urogynecology. InterventionsA 38-year-old woman presented with a vesicovaginal fistula secondary to a previous total abdominal hysterectomy. An initial attempt to repair the fistula vaginally was unsuccessful owing to infection and comorbidities. After counseling, the patient agreed to a combined laparoscopic, vesicoscopic, and vaginal repair of her vesicovaginal fistula. ConclusionThe incidence of vesicovaginal fistula following a total abdominal hysterectomy for benign causes is 1 in 540 [1]. Management of this complication can be challenging, and success rates vary. Initially, laparoscopy was performed, which allowed mobilization of the omentum to provide an interposition patch between the bladder and vagina after repair of the fistula. The fistula tract was then identified vesicoscopically and excised. Once the tract was closed and the patch secured, a vaginal approach was adopted to excise the remaining fistula tract as well as scar tissue. Interrupted closure of the vagina was performed in multiple layers to reduce the risk of recurrence. We have used vesicoscopy since 2007 for a variety of female urogynecologic problems, including bladder diverticula, ureteric stenosis, vesicoureteric reflux, foreign body removal, and vesicovaginal fistula repair [2]. This combined multidisciplinary approach offers a minimally invasive option for the repair of complex vesicovaginal fistulae, and should be considered in selected complex cases.