Laparoscopic Repair of Vesico Vaginal Fistula
There are many causes of the region forming a fistula between the bladder and vagina. In developing countries, the primary etiology is prolonged and obstructed labor, but in developed countries is about 90% of the VVF (VVF) is a surgical trauma after gynecological surgery. Total abdominal hysterectomy for benign disease accounts for most offistulae secondary gynecological surgery. Common nonsurgical causes include locally advanced cancer (cervix, vagina, uterus) and radiotherapy. Risk factors for the formation of VVF include surgery before the uterus, endometriosis, infection, diabetes, arteriosclerosis, inflammatory disease of the pelvis (Imperial), and prior to radiotherapy.
The classic presentation of VVF is continuous throughout the day and loss of urine during the night after pelvic surgery. A patient with a small fistula usually need to cancel a large amount of urine; Special fistulas do not allow proper collection of urine in the bladder, to allow urination. About two thirds of VVF secondary pelvic surgery are clinically evident within 10 days after the initial injury; fistulas caused by radiation can occur within 20 years after treatment.
Physical examination using a mirror, you can specify the source of the leak and may help to distinguish urinary fistula urinary incontinence and other causes. The site of the fistula can be identified if the pelvic exam was negative by placing a Foley catheter, introduce the inking of methylene blue solution in the bladder and the vagina inspection for leaks. If the leak is not visible VVF blue and diagnosis is in doubt, the sensitivity of this test is increased by placing the lining of the vagina and outpatient for a short time.
Indications for surgery
Surgical repair of VVF is indicated if conservative measures fail. About 10% of fistula posthysterectomy closes bladder drainage and antibiotics. The greatest success with this treatment option is included fistula only a few millimeters in diameter. Fistula remains open three weeks after the Foley adequate drainage is unlikely to resolve without surgical intervention.
Cystoscopy with electric shock surface of the bladder fistula is an option for patients with small extensions, lonely, simple fistula. If the device is not without infection or bladder wall is too thin when electric shock, the risk of the surgeon increases the diameter of the fistula with this procedure.
An alternative to vaginal repair the VVF abdominal. The benefits of vaginal repair the VVF include any abdominal incision, reduce morbidity, faster recovery and avoid bladder bivalving. The abdominal approach is used in combination with intra-abdominal pathology as urethral obstruction or fistula or need of increasing cystoplasty (often observed in patients with radiation cystitis).
There are many techniques described in the literature VVF repair. This section covers the technical aspects of our vaginal approach with one simple and complicated VVF changes or radiation-induced fistulas. Also described are various techniques for the insertion of tissue components that may be incorporated into the state.
Fistula tract with a first expanding the metal rings in a small catheter may be inserted which can be used for subsequent withdrawal of the dissection. Then saline is injected in the anterior vaginal wall surrounding the fistula. Inverted J-shaped incision around the fistula tube is made with a long section J extends to the top of the vagina. The asymmetric nature of this cut allows the creation of a flap of the vaginal wall, which can be advanced and turns in fistula repair. This prevents vaginal shortening and overlapping suture lines during the renovation. If the fistula is high in the vaginal incision sleeve must be reversed, placing the base of the distal valve, against the urethral meatus.
Closing the opening of the fistula is completed. Intrafistula catheter is removed and the first repair layer set with the closure of the fistula area with interrupted sutures placed transversely 2-0 polyglycolic acid. These include the wall itself and stitching the bladder fistula from the healthy tissue of about 2 to 3 mm from the edge of the fistula. Inclusion in fistula repair (without resection of fistula) gives firm support for supporting the fabric of the first layer of repair. Advancement and Closure of Vaginal Wall Flap
The final and third layer of closure is done with the vaginal wall flaps that were previously created. The redundant, excess anterior (distal) vaginal flap is excised and the posterior (proximal) vaginal flap is advanced beyond the fistula closure. This covers the fistula site with fresh, healthy vaginal tissue, which helps avoid overlapping of suture lines. The flap is advanced at least 3 cm beyond the fistula closure and the vaginal wall is closed with a running, locking 2-0 polyglycolic acid suture.
An antibiotic-impregnated vaginal packing is placed for 24 hours postoperatively. The urethral Foley and suprapubic catheters are left to drain for 10 to 14 days. Anticholinergics are given to decrease bladder spasms and oral antibiotics are continued until the catheters are removed. A cystogram is done prior to catheter removal to document the integrity of the repair. Sexual intercourse is avoided for 3 months postoperatively.
Adjuvant in the art for the insertion of tissue
Insertion of healthy tissue is the recommended time when repeated fistula repair reconstruction, is high in the vaginal vault, with respect to the previous, ischemic (gynecological), large radiotherapy, associated with the closure difficult and questionable or bad quality when there is a lack of secondary tissue estrogen or atrophic vaginitis. Peritoneal flap or graft Mars can be used during the repair of a VVF complex vaginally; These two techniques are described below. Peritoneal flap is the best method, but we have used it mainly to insert graft in the last five years.
Vaccination Mars or fibro and buccal flap is composed of fatty tissue and the implant has the advantage of fistulae that involve the trigone, the bladder neck and urethra. The blood supply to the graft below the labial subsequent vessel (without internal pudendal), a superior external pudendal artery and the side to close the artery. The supply side of the blood sacrificed during mobilization graft; Transplantation can be divided into either its top or bottom level (relative to the blood flow to the lower or higher, or vascular pedicle), depending on where the transplant will be transferred.
The use of peritoneal flap in the repair of the complex VVF is a simple procedure that does not require additional vaginal graft harvesting as it does in the Martius flap. This technique is used primarily in connection with repairs height VVF. After the formation of the vaginal flap, swinging vaginal dissection posterior (proximal) continues at an impasse. Peritoneum and preperitoneal fat is identified, isolated and mobilized with dissection.
Pathological changes that lead to the formation of FVV after radiation also cause different strategies when repairing radiation induced fistula. Radiation damage leads to endarteritis and results in poorly vascularized tissue along the site of the fistula and the annulment of the surrounding tissue. Thus, the spontaneous healing of this type failure is unlikely. VVF caused by radiation are generally found in the trigone. This area of the bladder is secured and susceptible to the effects of radiation.
Early postoperative complications include vaginal infections, bladder cramps and bleeding. Spasms of the bladder should be treated with anticholinergic vaginal bleeding, and treated with bed rest and packaging vaginally.
Late complications include vaginal shortening or stenosis, urethral injury is not recognized, and repeat fistula. Excessive resection of the vaginal wall causing stenosis or vaginal shortening and treated with vaginoplasty.
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