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Vagina and Urethra

Anterior Repair and Kelly Plication
Site Specific Posterior Repair
Sacrospinous Ligament Suspension of the Vagina
Vaginal Repair of Enterocele
Vaginal Evisceration
Excision of Transverse Vaginal Septum
Correction of Double-Barreled Vagina
Incision and Drainage of Pelvic Abscess via the Vaginal Route
Sacral Colpoplexy
Le Fort Operation
Vesicovaginal Fistula Repair
Transposition of Island Skin Flap for Repair of Vesicovaginal Fistula
McIndoe Vaginoplasty for Neovagina
Rectovaginal Fistula Repair
Reconstruction of the Urethra
Marsupialization of a Suburethral Diverticulum by the Spence Operation
Suburethral Diverticulum via the Double-Breasted Closure Technique           
Urethrovaginal Fistula Repair via the Double-Breasted Closure Technique
Goebell-Stoeckel Fascia Lata Sling Operation for Urinary Incontinence
Transection of Goebell-Stoeckel Fascia Strap
Rectovaginal Fistula Repair via Musset-Poitout-Noble Perineotomy

Sigmoid Neovagina

Watkins Interposition Operation

Vesicovaginal Fistula Repair

Vesicovaginal fistulae are usually secondary to obstetrical trauma, pelvic surgery, advanced pelvic cancer, or radiation therapy for treatment of pelvic cancer.

The basic principles for treatment of vesicovaginal fistulae have changed little since the mid-19th century work of Marion Sims. The principles are (1) to ensure that there is no cellulitis, edema, or infection at the fistula site prior to closing the fistula and (2) to excise avascular scar tissue and approximate the various layers of tissue broadside to broadside without tension. A 20th century addition to these principles is that of using transplanted blood supply from the vestibular fat pad, bulbocavernosus muscle, gracilis muscle, or the omentum.

The type of suture used appears less significant when the above principles are followed. In general, we have used the glycolic acid sutures such as Dexon or Vicryl because of their reabsorption and reduced tissue reaction. Many surgeons prefer, however, to use a non-absorbable monofilament suture of nylon or Prolene on the vaginal mucosa. These sutures should not be placed into the bladder mucosa. If they are left in the bladder for long periods of time, urinary stone formation will occur.

The purpose of the operation is to close the vesicovaginal fistula permanently without encroaching on the ureter or the urethral orifices.

Physiologic Changes. The fistula is closed, and resumption of micturition via the urethra resumes.

Points of Caution. Adequate blood supply to the tissue surrounding the fistula must be provided. Excision of scar tissue is vital to closure. Recently, tissue transplants have been used to bring in external blood supply to the fistula site. This is a vital point when the fistula is secondary to radiation therapy. In addition, when the fistula is secondary to radiation therapy, we have performed a temporary urinary diversion by ileal loop. This has dramatically improved our ability to permanently close radiation fistulae. At a subsequent operation, the ileal loop can be reimplanted in the dome of the bladder after the fistula has been closed and bladder function is adequate.

In all fistulae, the principle of dual drainage is vital for proper closure. A transurethral as well as suprapubic Foley catheter is left in place until the fistula has closed. Generally, the transurethral catheter is removed after 2 weeks, but the suprapubic catheter is left in place for at least 3 weeks. Acidification of the urine with ascorbic acid or cranberry juice is helpful in reducing urinary tract infection. Frequent urine culture and appropriate antibiotic therapy are indicated, however.

If an alkaline urine is present with a vesicovaginal fistula, the urine will precipitate triple-sulfate crystals and deposit them on the opening of the vagina.

These are quite painful and must be completely removed prior to closure.


For vesicovaginal fistula closure the patient is placed in the dorsal lithotomy position. The vulva and vagina are prepped and draped.

Adequate exposure of the fistula must be made. Many unsuccessful fistula closures have resulted from the failure to achieve adequate exposure of the fistula site, poor placement of the sutures, and closure of the fistula under tension. A large mediolateral episiotomy is frequently required and should be carried up to the area of the fistula.

With adequate exposure the fistula tract can be excised with a scalpel. The incision is carried around the circumference of the fistula.

The margin of the fistula tract is elevated with thumb forceps and excised with Metzenbaum scissors. The entire tract is dissected. Frequently, when dense scar tissue has been released, the fistula will be 2-3 time larger than noted preoperatively.

The layers of the bladder wall and vagina should be adequately delineated, and each of these layers should be mobilized to allow the layers to be drawn together with fine sutures without tension.

The bladder mucosa is identified and closed with interrupted 4-0 synthetic absorbable suture. An attempt should be made to keep the suture in the submucosal layer. We do not perform running locking sutures or continuous suture, since we feel this reduces the blood supply that is vital to proper closure.

A second layer, the bladder muscle, is closed with 2-0 synthetic absorbable suture.

The bladder muscle is completely closed over the fistula area with interrupted 2-0 synthetic absorbable suture.

At this point, it is necessary in high-risk cases to seek an external blood supply for the fistula site. This can be the bulbocavernosus muscle from beneath the labia majora, or in cases where a large fistula exists or where the fistula is high in the vaginal canal, the gracilis muscle from the leg or the rectus abdominis muscle can be brought in to cover the fistula site.

If the bulbocavernosus is selected, two incision sites are acceptable. One is on the inside of the labia minora as seen in Figure 9. The other is down the body of the labia majora. If the latter incision is selected, the bulbocavernosus muscle must be tunneled under the labia minora into the episiotomy wound.

Allis clamps are used for retraction of the labia, and a scalpel is used for dissection down to the bulbocavernosus muscle. It is important to enlarge the incision so that the entire muscle can be visualized.

The bulbocavernosus muscle is identified and mobilized. Frequently, at the level indicated here, the branches of the pudendal artery and vein enter the muscle and may have to be clamped and ligated for hemostasis. The bulbocavernosus muscle should be mobilized by blunt and sharp dissection up to the level of the clitoris and transected at its insertion in the perineal body.

If the initial incision has been made on the inside of the labia minora, no tunneling of the bulbocavernosus muscle is needed, and the muscle is swung into position, covering the fistula site. It is sutured to the perivesical tissue with interrupted 3-0 synthetic absorbable sutures. If the initial incision has been carried over the labia majora, a tunnel is created with a Kelly clamp under the labia minora into the episiotomy incision. The bulbocavernosus muscle is pulled through this tunnel, applied to the fistula site, and sutured into place with interrupted 3-0 synthetic absorbable suture.

The vaginal mucosa must be mobilized for closure without tension. Generally, the wound is closed with interrupted 0 synthetic absorbable suture.

The vaginal incision, the episiotomy incision, and the incision for the bulbocavernosus muscle transplant are closed.

A Foley catheter is inserted through the urethra. The bladder is generally filled with approximately 200 mL of methylene blue or sterile milk solution to ascertain if the fistula is completely closed. We frequently perform this same procedure after Steps 7 and 8 to demonstrate complete closure of the fistula site.

In addition to the transurethral Foley catheter, a suprapubic Foley catheter is placed as demonstrated in Bladder and Ureter. Dual drainage for the fistula closure is vital.



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