Interposition Of Omentum Research Articles

Robot-assisted repair of rectovesical fistula

A 76-year-old man developed a rectovesical fistula after rectal resection for adenocarcinoma complicated by peritonitis with the necessity of the creation of a colostomy. The patient was undergone a rectosigmoidoscopy with the placement of clip-type Ovesco to close the fistula, but this technique resulted ineffective. A robot- assisted closure of the rectovesical fistula was performed using Xi Da Vinci System. The surgical procedure will be divided into 3 parts: longitudinal median cystotomy, excision of the fistula tract, and the closure of the anterior rectal wall and bladder with interposition of omentum, between the suture lines of the rectum and bladder, to prevent fistula recurrence. The patient removed the catheter after 4 weeks of surgery and the patient remained free of urinary leakage from the anus. In February 2021, the surgery for intestinal re-anastomosis was performed. Robotic surgery is a good approach for the treatment of rectovesical fistula when the endoscopic treatment was unresolving

When the bowel meets the bladder: Optimal management of colorectal pathology with urological involvement.

Fistulae between the gastrointestinal and urinary systems are rare but becoming increasingly more common in current surgical practice. They are a heterogeneous group of pathological entities that are uncommon complications of both benign and malignant processes. As the incidence of complicated diverticular disease and colorectal malignancy increases, so too does the extent of fistulous connections between the gastrointestinal and urinary systems. These complex problems will be more common as a factor of an aging population with increased life expectancy. Diverticular disease is the most commonly encountered aetiology, accounting for up to 80% of cases, followed by colorectal malignancy in up to 20%. A high index of suspicion is required in order to make the diagnosis, with ever improving imaging techniques playing an important role in the diagnostic algorithm. Management strategies vary, with most surgeons now advocating for a single-stage approach to enterovesical fistulae, particularly in the elective setting. Concomitant bladder management techniques are also disputed. Traditionally, open techniques were the standard; however, increased experience and advances in surgical technology have contributed to refined and improved laparoscopic management. Unfortunately, due to the relative rarity of these entities, no randomised studies have been performed to ascertain the most appropriate management strategy. Rectourinary fistulae have dramatically increased in incidence with advances in the non-operative management of prostate cancer. With radiotherapy being a major contributing factor in the development of these complex fistulae, optimum surgical approach and exposure has changed accordingly to optimise their management. Conservative management in the form of diversion therapy is effective in temporising the situation and allowing for the diversion of faecal contents if there is associated soiling, macerated tissues or associated co-morbidities. One may plan for definitive surgical intervention at a later stage. Less contaminated cases with no fibrosis may proceed directly to definitive surgery if the appropriate expertise is available. An abdominal approach with direct repair and omentum interposition between the repaired tissues has been well described. In low lying fistulae, a transperineal approach with the patient in a prone-jack knife position provides optimum exposure and allows for the use of interposition muscle grafts. According to recent literature, it offers a high success rate in complex cases.

Neobladder-Vaginal fistula: The University of Southern California experience.

The use of orthotropic neobladder (ONB) construction in women has increased in popularity. With increasing numbers so have complications distinct to this procedure. Neobladder vaginal fistula (NVF) is a rare but challenging complication. We present our experience correcting this problem. An IRB approved database of female patients with an ONB was retrospectively reviewed. Patients with a history of NVF were identified and charts reviewed. Our standard technique of radical cystectomy and orthotopic diversion in female patients includes interposition of omentum between the neobladder and anterior vaginal wall and sacrocolpopexy. Two hundred and forty-nine female patients underwent cystectomy and ONB construction between 1995 and 2015. Fourteen patients were diagnosed with a NVF (5.6% incidence). The average age and follow-up was 67 years and 33.7 months, respectively. Surgery for fistula closure was attempted in 13 patients. One repair was combined abdominal and transvaginal; the remaining 12 were performed transvaginally. Location of NVF was categorized as at the urethra-neobladder anastomosis (UNA, nine patients) and anterior vaginal wall (AVW, four patients). Eight patients had a successful fistula repair (61.5%) but only five patients ultimately retained their ONB (39%). Patients with a NVF pose a surgical challenge. Successful fistula repair does not necessarily result in adequate continence due to an incompetent outlet. NVF location at the UNA is the more common location and is more challenging in regard to successful resolution of the NVF as well as possible urinary incontinence post-NVF repair.

Mesh repair of a large ventral hernia with interposition of omentum in a calf: a case report

A one-month-old, Piedmontese female calf was admitted to the Department of Veterinary Sciences, University of Turin, for repair of a large ventral hernia. A large ventral hernia, approximately 20 cm long and 15 cm large was noticed extending from 3 cm caudal to the umbilicus down to the pubis. At ultrasonography the hernia content was represented by small intestine and omentum and no adhesions to the hernial sac could be detected. The hernial sac was composed by skin only. Because of the large dimensions of the defect and the economic value of the animal, surgical correction was recommended to the owner. A prosthetic implant with a polypropylene mesh was elected due to the dimension of the abdominal defect. The implant was placed intra-abdominally with the interposition of the omentum between the mesh and the underlying viscera. Two and six months after surgery follow-ups were performed and a positive outcome was confirmed. This is the first report of ventral hernia repair in large animals that combines the use of a tension-free polypropylene mesh with the interposition of the omentum between the viscera and the mesh. This procedure is safe, cost-effective and not associated with major complications.

A rare case of vaginolith, vesical calculus with vesicovaginal fistula in adolescent female

A case of large dumbbell shaped stone involving both vagina and urinary bladder secondary to vesicovaginal fistulae is presented. Vagina is a rare site for urinary stone formation. Clinical presentation is variable like difficulty in micturation and dyspareunia. Proper vaginal examination can be helpful to make the diagnosis. Attention is paid especially in young gynecologists for the importance of 1 st doing pelvic examination before carrying certain investigations and have a possibility of VVF with vaginal stone. We present a neglected case of vesicovaginal fistula with vaginolith and vesical calculus formation in a 15 year old girl with continuous dribbling of urine per vagina. Diagnosis was confirmed on ultrasonography CT IVU demonstrating exact site and size of vesical calculus. Vesical calculus was removed by combined suprapubic approach and repair of fistula was done after interval of 6 months by suturing urinary bladder and vagina defect and omentum interposition in between them.

Laparoscopic transperitoneal approach for vesicovaginal repair : The first experience in Hasan Sadikin Hospital

Introduction : Obstetric fistula is a severe and debilitating condition occurring throughout the developing world. Although there are no accurate data on the incidence and prevalence of the condition, the majority of vesicovaginal fistulas develop after gynaecologic surgery, with transperitoneal hysterectomy accounting for 90% of cases. Several techniques are available for repairing the fistulas. Transperitoneal approaches give good results even for difficult posterior located fistulas, but are associated with increased morbidity compared with the transvaginal approach. We performed a laparoscopic repair and omentum interposition. Objective : To report our first experience in transperitoneal laparoscopic repair of vesicovaginal fistula in Hasan Sadikin Hospital. Patient and Method : A 31-year-old female presented with vesicovaginal fistula after sectio caersaeran. After a failed trial of conservative treatment with catheter drainage, a transperitoneal laparoscopic repair was performed. Cystoscopy was performed initially to confirm the fistula location and for bilateral ureteric catheterization. A 4-port technique was performed with the patient in the position with her legs in lithotomy position. Without opening the bladder, the fistula tract was excised with separation of the bladder from the anterior vagina wall. Both the bladder and vagina walls were then closed separately using intracorporeal suturing with an interpositional omentum. Result : Total operative time was 270 min. Normal diet was resumed on day 1, drain was removed on post operatif day 1 and patient was discharged on the second day with an indwelling catheter. Good cosmetic result on wound operation and no leakage under cystogram after 2 weeks. The catheter was removed after 2 weeks. Conclusion : Laparoscopic transperitoneal repair of vesicovaginal fistula with omentum inteposition is feasible in Hasan Sadikin Hospital with good outcomes, short hospital days, and good cosmetics result. Keywords : Fistula vesico vaginal, laparoscopic.

Laparoscopic Transperitoneal Approach for Vesicovaginal Repair : The First Experience in Hasan Sadikin Hospital


 
 
 Background. Obstetric fistula is a severe and debilitating condition occurring throughout the developing world. Although there are no accurate data on the incidence and prevalence of the condition, the majority of vesicovaginal fistulas develop after obstetric procedure, with delayed labour accounting for 90% of cases. Several techniques are available for repairing the fistulas. Transperitoneal approaches give good results even for difficult posterior located fistulas, but are associated with increased morbidity compared with the transvaginal approach. We performed a laparoscopic repair and omentum interposition. The objective of this article is to report our first experience in transperitoneal laparoscopic repair of vesicovaginal fistula in Hasan Sadikin Hospital.
 Method. A 31–year–old female presented with vesicovaginal fistula after sectio caersaeran because of de- layed labour. After a failed trial of conservative treatment with catheter drainage, a transperitoneal laparoscopic repair was performed. Cystoscopy was performed initially to confirm the fistula location and for bilat- eral ureteric catheterization. A 4–port technique was performed with the patient in the position with her legs in lithotomy position. Without opening the bladder, the fistula tract was excised with separation of the bladder from the anterior vagina wall. Both the bladder and vagina walls were then closed separately using intracorporeal suturing with an interpositional omentum.
 Results. Total operative time was 270 min. Normal diet was resumed on day 1, drain was removed on post operative day 1 and patient was discharged on the second day with an indwelling catheter. Food cosmetic result on wound operation and no leakage under cystogram after 2 weeks. The catheter was removed after 2 weeks.
 Conclusion. Laparoscopic transperitoneal repair of vesicovaginal fistula with omentum inteposition is feasible in Hasan Sadikin Hospital with good outcomes, short hospital days, and good cosmetics result. Still need more same cases before a final conclusion
 
 

Diagnosis, treatment and need for hysterectomy in management of postcaesarean section vesicouterine fistula

Objective.The aims of this study were to report the diagnosis, treatment and functional consequences of postcaesarean section vesicouterine fistula (VUF), and to investigate the need for hysterectomy. Material and methods. The study included 22 cases with VUF after caesarean section (mean age 30.5 years) between 1999 and September 2012. Total urinary incontinence was found in seven women, occasional incontinence in 15 and cyclic haematuria in 17. VUF was diagnosed by ascending cystography in 14 patients and by computed tomography/magnetic resonance imaging in six. Cystoscopy revealed VUF in all women. VUF repair was conducted by a transabdominal approach. The bladder was opened, the fistula was defined, a circumferential bladder incision was made around the fistula and the fistulous tract was excised. The uterine rent and bladder were closed with omentum interposition. Results.Mean follow-up was 2.8 years (range 0.5–7 years). The repair was successful in all women. Hysterectomy was needed in only one case with dysfunctional uterine bleeding and an enlarged uterus. The incontinence disappeared in all cases. The menstrual cycle became regular after a mean of 5 months in all women who retained their uterus. Five women became pregnant and had a successful delivery after 2–3 years. All women were able to have sexual intercourse after 2 weeks. Conclusions.Cystoscopy was the mainstay of diagnosis of VUF in the current study. Imaging was not able to show very small fistulae. Unless otherwise indicated, there is no need to remove the uterus even if the fistula is large. Although the repair is challenging, it was successful in all cases and pregnancy is possible after repair.

V858 ROBOTIC VESICOVAGINA FISTULA REPAIR

You have accessJournal of UrologyReconstruction, Transitional Cell Carcinoma & Adrenal1 Apr 2011V858 ROBOTIC VESICOVAGINA FISTULA REPAIR Aqsa Khan, Claudia Sevilla, and Jennifer Anger Aqsa KhanAqsa Khan Los Angeles, CA More articles by this author , Claudia SevillaClaudia Sevilla Los Angeles, CA More articles by this author , and Jennifer AngerJennifer Anger Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.680AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic technology provides a minimally invasive abdominal approach to reconstructive pelvic surgery that can be performed by many pelvic surgeons, not just expert laparoscopists. Some might argue that the improved dexterity of the robot, precision of instruments, and the three-dimensional imaging of the robotic camera provides a technical advantage over open abdominal and vaginal approaches. The post-hysterectomy vesico-vaginal fistula (VVF) repair is an example of an operation that, in many instances, may benefit from robotic technology. METHODS This video describes the surgical techniques of robotic-assisted VVF repair. RESULTS To reduce inflammation after surgical injury, waiting up to three months before repair is optimal. Intra-operative ureteral stenting with open-ended stents can aid in intra-operative visualization of the ureteral orifices. Identification of planes is aided by manipulation of a vaginal stent and intra-operative filling of the bladder. Robotic assistance greatly aids in developing and extending the plane between the vagina and the bladder. The vagina and bladder are each closed in two layers. Interposition of omentum or bladder peritoneum is ideal, though other biologic material can be used when endogenous tissue is not available. Generally a foley catheter or suprapubic tube is left for three weeks, at which time a cystogram is performed and the catheter is removed. CONCLUSIONS In proximal VVFs, particularly those where vaginal access is difficult, robotic-assisted VVF repair provides a durable result through a minimally invasive abdominal approach. Larger series are needed to compare outcomes to open abdominal and vaginal approaches. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e344 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aqsa Khan Los Angeles, CA More articles by this author Claudia Sevilla Los Angeles, CA More articles by this author Jennifer Anger Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Laparoscopic transperitoneal extravesical repair of vesicovaginal fistula

Laparoscopic repair of vesicovaginal fistula (VVF) has been recently reported. We present our experience of laparoscopic transperitoneal extravesical repair of VVF. Fifteen females with supratrigonal VVF were included. Patients with malignant radiation and recurrent fistulas were excluded. Laparoscopic transperitoneal extravesical repair was done using four to five ports. The bladder was closed longitudinally, while the vagina was closed transversally with interposition of omentum in between. Bladder was drained by a urethral catheter for 3 weeks. Mean operative time was 171.6 ± 19.5 min. There was no conversion to open in all patients. Mean blood loss was 110 ± 17 cc. No intraoperative or postoperative complications. Mean hospital stay was 3 ± 1 days. At a mean follow-up of 18.9 ± 8.6 months all patients were cured. Laparoscopic transperitoneal extravesical repair of VVF is a safe and effective minimally invasive procedure for treatment of VVF.

V1547 TECHNIQUE OF ROBOTIC VESICOVAGINAL FISTULA REPAIR

You have accessJournal of UrologyReconstruction1 Apr 2010V1547 TECHNIQUE OF ROBOTIC VESICOVAGINAL FISTULA REPAIR Hany Atalah, Li Ming Su, and Linda Morgan Hany AtalahHany Atalah More articles by this author , Li Ming SuLi Ming Su More articles by this author , and Linda MorganLinda Morgan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1299AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Post-hysterectomy vesicovaginal fistula is a rare event that is associated with significant quality of life consequences. Minimally invasive approaches for vesicovaginal fistula repair have been described. As robotic surgery has expanded to address both upper and lower urinary tract pathology, herein we describe our step-by-step technique of robot assisted vesicovaginal fistula repair. METHODS This instructional video is of a 64 year old female who suffered a vesicovaginal fistula following a prior robotic hysterectomy. Vaginal approach to the fistula was deemed impossible due to the proximal location of the fistula as well as the patient's extremely narrow introitus. The procedure was performed in the dorsal lithotomy position using a 4-armed technique with the da Vinci S system. Ureteral stents were placed intraoperatively to identify the location of the ureters in proximity to the fistula. The vesicovaginal fistula was defined by endoscopic placement of a guidewire through the fistulous tract. The vesicovaginal fistula was excised repaired in multiple layers including interposition of omentum. RESULTS The total operative time was 3.5 hours with minimal blood loss. The patient was discharged on postoperative day #1 and returned for a cystogram study after two weeks of catheter drainage. The patient experienced no complications and has complete continence at this time. CONCLUSIONS Robotic surgery has expanded to address complex reconstructive urologic surgery including vesicovaginal fistula repair. Robot assisted repair may be utilized for proximally located fistulas and is an alternative to open or laparoscopic surgical repair with low morbidity and minimal blood loss Gainesville, FL© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e596 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hany Atalah More articles by this author Li Ming Su More articles by this author Linda Morgan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Sternal Closure Reinforced with Rib Heads: A Novel Technique for Prevention and Treatment of Sternal Dehiscence

When a sternotomy cannot be performed at the midline and/or there is infection at the operation site, sternotomy revision can cause problems that increase the mortality and morbidity of the patients. There is no agreement on the best treatment method. In this paper we present a modified wiring technique. This technique consisted of wrapping wires twice around each rib head and placing standard circumferential wire sutures, thus providing full stability by decreasing the load on the sternum using only steel wires. The study group included 23 patients with sternal dehiscence because of inappropriate sternotomy (n = 10) and/or mediastinitis (n = 13). Two mediastinal tubes were placed for irrigation in 13 patients with mediastinitis and/or wound infection, and mobilization and interposition of omentum as an axial graft was performed in 2 patients. Irrigation and antibiotherapy were continued for 4 to 6 weeks. Complete wound healing was obtained in all patients. Twenty-two patients treated with this technique survived. One patient died on postoperative 42nd day because of renal insufficiency and multi-organ failure. Early and aggressive debridement of infected and necrotic tissue, irrigation, and antibiotics are necessary for successful treatment, but we believe that the most important factor is full stabilization of the sternal tissue with minimal use of foreign stabilization material. Despite the limited number of cases, we suggest that our stabilization technique seems to be successful in achieving full stabilization even in infected and fragile sternal bony tissue in patients with sternal dehiscence and/or inappropriate sternotomy.

Laparoscopic Ureterolysis: Technical Alternatives

We describe our technique for laparoscopic ureterolysis for idiopathic retroperitoneal fibrosis. Various options for tissue interposition are discussed, including management of bilateral disease. Patients found to have retroperitoneal fibrosis were offered laparoscopic ureterolysis with the option of treatment with anti-inflammatory medications preoperatively. The obstructed renal collecting system was decompressed preopeatively with a nephrostomy tube or Double-J stent to stabilize renal function. A four-port transperitoneal approach was used. Patients with bilateral obstruction were offered bilateral ureterolysis in the same operative session. Case 1 was a 57-year-old man with right-ureteral obstruction in a solitary kidney, the left kidney having been lost to retroperitoneal fibrosis. The patient had right laparoscopic ureterolysis with omental interposition. Case 2 was a 45-year-old man with left-flank pain and left-sided hydronephrosis. He underwent laparoscopic ureterolysis with an omental wrap through a mesenteric window. Case 3 was a 56-year-old woman with a retroperitoneal mass causing bilateral hydronephrosis. The patient had left laparoscopic ureterolysis with omental interposition through a mesenteric window. In the same sitting, the patient was repositioned for right laparoscopic ureterolysis with interposition of a peritoneal flap. The treatment of retroperitoneal fibrosis can be performed in a safe and effective manner through the laparoscopic approach. Interposition of omentum or peritoneum can be accomplished laparoscopically. Moreover, bilateral disease can be managed in a single session using this approach.

Laparoscopic Rectovesical Fistula Repair

Rectovesical fistula (RVF) is a rare complication of radical prostatectomy. A 62- year-old man with clinically localized prostate cancer underwent open radical prostatectomy that was complicated by rectal injury and subsequent RVF development. Conservative management failed, and the patient was referred for surgical correction. The operative steps consisted of (1) cystoscopy, (2) RVF catheterization, (3) ureteral catheterization, (4) five-port transperitoneal laparoscopic approach, (5) cystotomy, (6) opening of the fistulous tract, (7) dissection between the bladder and the rectum, (8) closure of the rectum, (9) interposition of omentum, (10) suprapubic cystostomy placement, (11) bladder closure, and (12) colostomy creation. The operative time was 240 minutes. The hospital stay was 3 days. The urethral catheter was kept indwelling for 4 days. At 8 weeks postoperatively, the suprapubic tube was removed and the colostomy reversed. At 1-month follow-up, the patient remains free of fistula recurrence. Laparoscopic rectovesical fistula repair is feasible and represents an attractive alternative to the standard approaches.

Hemoptysis Following Left Ventricular Aneurysm Repair: A Misleading Clinical Sign

We report on a 66-year-old man with severe hemoptysis following coronary artery bypass grafting and repair of a left ventricular septal defect after acute myocardial infarction. Initial diagnosis was delayed by misleading clinical symptoms and radiologic studies. Due to subfebrile temperature and sputum culture positive for Pseudomonas aeruginosa, he had been treated with antibiotics before reoperation. At reoperation, replacement of all foreign material and reconstruction of the ventricular repair with bovine pericardium resulted in reinfection with the same organism despite prolonged antibiotic therapy after 6 months. Removal of the pericardial tissue with direct suture closure of the ventricles and interposition of omentum led to complete healing of the infection without reoccurrence after 2 years.

Urologic complications after implantation of aortofemoral blood vessel prosthesis

After implantation of aorto-femoral grafts, primary ureteral lesions and secondary ureteral obstructions are the most important urological complications. Surgical repair carried out as quickly as possible, including reanastomosis without tension and covering with a peritoneal patch or omentum interposition, seems the best means of preventing secondary complications. In the case of secondary obstructions, the interval between implantation of the graft and the diagnosis of obstruction has to be considered. A wait-and-see strategy is justified in the case of early obstruction without symptoms during the 1st year because of the high rate of spontaneous remission. Obstructions that appear more than 1 year after operation or symptomatic obstructions have to be treated immediately (i.e. duodenojejunal stent, percutaneous nephrostomy). If repeated obstructions after removal of stents or nephrostomies are noted, surgical repair seems to be indicated. Stents or nephrostomies as definitive procedures are appropriate only in patients in whom surgical revision is not possible or desirable.

Polypropylene mesh closure after emergency laparotomy: morbidity and outcome.

Alternative methods for abdominal wall closure may be necessary after emergency laparotomy. The purpose of this study was to determine the morbidity and outcome of emergency fascial closure with polypropylene mesh. A retrospective review was performed of all patients undergoing emergency fascial closure with polypropylene mesh from January 1990 to March 1994. Seventy patients were identified. Indications for mesh placement included visceral edema (40), infected/necrotic fascia (21), and planned reexploration (7). Enteric fistulas developed in five patients (7.1%). When omentum was interposed between intestine and mesh, the incidence of fistula was significantly reduced (0 of 51 vs 5 of 19, p < 0.01). Forty-two patients (60%) survived with wound closure, accomplished by skin flaps in 19 (45%), skin grafting in 11 (26%), and secondary healing in 6 (14%). The mesh was removed in six patients (14%). Complications of mesh extrusion and hernia occurred less often after skin flap closure compared with skin grafting or secondary healing (1 of 19 vs 9 of 17, p < 0.01). No mesh infection occurred. Polypropylene mesh placement is an effective alternative for abdominal closure after emergency laparotomy, even when intraabdominal sepsis is present. Fistulas associated with its use may be effectively eliminated by the interposition of omentum between bowel and mesh. Wound closure with full-thickness skin flaps is the preferred method for soft tissue coverage when mesh is used.

Youssef’s Syndrome: An Appraisal of Hormonal Treatment

Two cases of vesicouterine fistula, caused by lower-segment cesarean section, are presented. Both cases had classical symptoms of Youssef's syndrome, i.e. cyclic hematuria, absence of vaginal bleeding and complete urinary continence. These patients were treated by the continuous administration of an estrogen-progestogen combination for 6 months. However, it failed in 1 case requiring transabdominal transperitoneal closure of the fistula with an interposition of omentum. We feel that hormonal treatment may be tried as first modality in the treatment of Youssef's syndrome, before resorting to surgery.

Urethrovaginal and vesicovaginal fistula. A review of 29 patients.

During an 11-year period 29 women were treated for 6 urethrovaginal and 24 vesicovaginal fistulae. In all patients the urethrovaginal fistula was preceded by an operation for a benign lesion. Of the 24 patients with vesicovaginal fistulae 11 had a benign and 13 a malignant primary disease. Endoscopy, vaginal examination and IVP provided in most cases sufficient information with which to establish a diagnosis. The urethrovaginal fistulae were operated on either by a vaginal approach (3 patients); two recurrences occurred but healed after reoperation. Of the 24 patients with vesicovaginal fistulae, 14 underwent a combined operation usually including omentum interposition, while 10 underwent primary diversion. Primary cure ensued after 9 of 14 combined operations; recurrences were operated on by a combined approach in 2 patients, vaginal in one and with fibrin occlusion in one. Eight of the 10 patients who underwent urinary diversion had a malignant disease. A vaginal approach in recommended at the primary reconstruction of urethrovaginal fistulae, whereas a combined suprapubic and vaginal approach is recommended in vesicovaginal fistulae as well as in recurrent urethrovaginal fistulae.