What is the primary treatment for a patient with a vesicovaginal fistula?

Primary Treatment for Vesicovaginal Fistula

The primary treatment for vesicovaginal fistula is surgical repair, which should be performed using either a transvaginal or transabdominal approach depending on fistula characteristics, with appropriate tissue interposition to ensure successful closure. 1, 2

Diagnostic Evaluation

Before proceeding with treatment, proper diagnostic evaluation is essential:

• Comprehensive diagnostic workup is needed to determine fistula characteristics, including size, location, and surrounding tissue quality 2
• Fistulogram is considered the gold standard for evaluating fistulas in patients already on dialysis therapy 3
• For patients not on dialysis, non-nephrotoxic contrast material, carbon dioxide, or ultrasound should be used 3

Surgical Approach Selection

The choice of surgical approach depends on several factors:

• Transvaginal approach: Preferred for distal fistulas with good tissue quality and accessibility 4

  • Success rates of 96-97% have been reported with proper tissue interposition 4
  • Lower morbidity compared to abdominal approaches 5

• Transabdominal approach: Indicated for complex, large, or proximally located fistulas 1, 5

  • Particularly useful when previous repair attempts have failed 5
  • Allows for better exposure of the fistulous tract in complex cases 1

• Minimally invasive approaches: Robot-assisted laparoscopy is gaining popularity 1, 6

  • Demonstrates shorter operative times, decreased blood loss, and improved visibility 1
  • Similar cure rates to open approaches without increased adverse events 1, 6

Key Principles of Surgical Repair

Regardless of approach, successful repair requires adherence to these principles:

• Good exposure of the fistulous tract 1
• Excision of pathological tissue and closure in well-vascularized tissue 5
• Double-layer bladder closure 1
• Tension-free closure of the defect 1
• Retrograde filling of the bladder to ensure water-tight seal 1
• Continuous postoperative bladder drainage 1, 5

Tissue Interposition Techniques

Tissue interposition significantly improves success rates:

• Peritoneal flap: Ideal for proximal fistulas 4

  • Minimal morbidity and 96% success rate 4
  • Easily created during the procedure 4

• Martius flap: Recommended for distal fistulas 4

  • 97% success rate but higher morbidity than peritoneal flap 4
  • Provides reliable results for complex repairs 4

• Omental flap: Often used in transabdominal approaches 5

  • Particularly useful for recurrent or complex fistulas 5
  • 100% success rate reported in some series 5

Timing of Surgery

• Conservative management should be attempted initially for at least 2 months 6
• Surgical repair should be performed after inflammation has subsided 2, 6
• Delayed repair allows for better tissue quality and improved surgical outcomes 6

Success Rates and Recurrence

• Primary repair success rates range from 75-100% depending on approach and complexity 5
• Transvaginal and transabdominal approaches with omental flap interposition show highest success rates (up to 100%) 5
• Recurrence may require secondary repair, with cumulative success rates of approximately 83% 5

Common Pitfalls and Caveats

• Inadequate exposure of the fistulous tract can lead to repair failure 1, 5
• Insufficient tissue interposition increases recurrence risk 4
• Tension on the repair site compromises healing 1
• Inadequate postoperative bladder drainage may result in repair breakdown 1, 5
• Surgical expertise is a critical factor in successful outcomes 2, 5