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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

Transposition of Island Skin Flap for Repair of Vesicovaginal Fistula

Vesicovaginal fistulae that have occurred secondary to irradiation and/or have recurred after repeated attempts to close them must be treated with procedures beyond the ordinary. In such cases, an island skin flap based on the bulbocavernosus muscle can be transposed to aid in the closure. This myocutaneous tissue, which in most patients with gynecologic malignancy is usually spared from heavy radiation, brings a nonirradiated blood supply to aid in wound healing.

Physiologic Changes. The vesicovaginal fistula is closed. The vulva is spared excoriation from constant urine leakage.

Points of Caution.  The surgeon must ensure that the blood supply of the bulbocavernosus muscle is intact. If the patient has received radiation that has covered the vulva, the blood supply muscle and fat pad may be insufficient for proper nutrition to the island skin flap. In addition, the margins of the vesicovaginal fistula must be examined and found free of necrosis and cellulitis before a closure is attempted.


A vesicovaginal fistula is depicted slightly behind the trigone of the bladder. The surgeon has debrided the vesicovaginal fistula of all scarring and unhealthy tissue. Previous cystoscopy has shown that the ureteral orifices and ureters at the trigone are intact and not involved with the fistulae. If this is in doubt, however, catheters should be placed up the ureter to the kidney and left in for the entire operation.

A longitudinal incision is made from the top of the labia majora down to the point of the island myocutaneous flap. After measuring the diameter of the vesicovaginal fistula in the vagina, this island skin flap can be marked off and cut to appropriate size. It is always wise to cut the island skin flap a little larger than needed.

The island skin flap has been dissected out with its bulbocavernosus muscle and associated fat pad that ensures the blood supply to the skin flap through its small perforated vessels. A Kelly clamp is used to open a tunnel underneath the labia minora. The labia minora are retracted away from this area with Allis clamps.

The bulbocavernosus myocutaneous flap has been tunneled underneath the labia minora. It is placed into the defect of the vesicovaginal fistula.

The bulbocavernosus myocutaneous flap is sutured to the margins of the vaginal mucosa with interrupted 3-0 monofilament delayed synthetic absorbable suture. The bladder can be tested at this point by placing a catheter in the bladder and filling the bladder with a milk solution to note any leaks around the fistula. A cystoscope can be placed to ensure that the ureteral orifices are intact and not compromised by the surgical procedure or the sutures used to place the flap.

The vesicovaginal fistula repair has been completed. The donor site incision is closed with interrupted monofilament synthetic absorbable suture.

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