TREATMENT OF VESICOVAGINAL FISTULA THROUGH TRANSVAGINAL APPROACH
Abstract:
Vesicovaginal fistulas are possible complications of hysterectomy. This paper aims at highlighting the advantages of transvaginal approach in order to solve these fistulas, what are the indications, optimal timing of surgery, surgical technique and causes of failures. We conducted a perspective study on 20 clinical cases of vesicovaginal fistula after hysterectomy via abdominal approach, hospitalized within the Urology Clinic of Sibiu, between 2007 and 2013. Of these, 8 were cases of cervical cancer and 12, cases of uterine fibroids. Diagnosis was based on the local clinical examination, cystoscopy and cystography, which revealed the pathological communication path with a diameter of 0.5-1 cm in the retrotrigonal space (11 patients) and trigonal (9 patients), at a variable distance from the urethral orifices. Fistula was installed shortly after surgery (on average, 5 days), with the total or partial loss of urine vaginally. The results were favourable, one case healed spontaneously after the endoscopic removal of suture synthetic threads and prolonged bladder drainage and per primam healing in 17 patients. The remaining patients were operated vaginally through the technique of clogging the fistulous traject. In 3 cases, it was found the reopening of the fistulous traject, requiring transperitoneal abdominal approach. The following are considered as possible causes of relapse: the large size of vesicovaginal communication orifice, immature fistulous traject with inflammatory reaction maintained by hysterectomy stitches and urinary infection. In conclusion, the high percentage of success rate, of 17/20 patients (85 %), and the simple approach without visceral or bleeding complications, recommend this type of surgery with the observance of the following principles: late intervention at 2-3 months after the installation of fistula, installing urethral probes where the fistulous traject is near the urethral orifice, the separation of the bladder wall from the vaginal one around the fistulous traject, clogging the fistulous treject with purse-string suture, interposition of vascularised tissue flap between the bladder suture line and the vaginal one, where possible.
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