Biologic Grafted Repair of Urethral Vaginal Fistula with Concomitant Synthetic Sling Urethral vaginal fistulas are rare but challenging complications of surgical procedures including diverticulectomy, anterior coporaphy, and urethral slings. Preoperative diagnosis of a fistula can be made by a methylene blue dye test, sister urethroscopy, or radiographic imaging. Patients' symptoms of incontinence depend on the size and location of the fistula and multi-channel urodynamics can be useful to evaluate for concomitant stress incontinence. Our patient is a 66-year-old who presented complaining of continuous urine loss since diverticulectomy performed 10 years ago. A .3 millimeter distal fistula was confirmed by cystoscopy and urodynamic testing revealed stress incontinence. At the start of the procedure the location of the fistula is confirmed by sister urethroscopy and use of a lacrimal duct probe placed in the fistula tract. Lidocaine with epinephrine is circumferentially injected in the suburethral tissue surrounding the fistula. Hydrodissection aids to identify the correct plane between the vaginal mucosa and periurethral tissue. The vaginal mucosa is incised vertically, distal and proximal to the fistula tract. Sharp dissection is utilized to separate the underlying periurethral tissue from the overlying vaginal mucosa. Once the correct plane is entered, the dissection is continued bluntly to the level of the vaginal sulcus for placement of the transopterator sling. The dissection is repeated on the contralateral side. It is imperative to have wide mobilization of the periurethral tissue so that the fistula tract may be closed without undue tension. The location of the fistula is again confirmed and the tract is clearly identified in the center of the dissection. We perform a modified LATSCO technique in which the fistula tract is not extensively excised if viable tissue is present. Note that the periurethral tissue has been symmetrically mobilized to allow re-approximation in a tension-free manner. Sequential interrupted sutures of 2 ovicle are placed transversely in the periurethral tissue and tagged with a hemostat. It is important that these sutures do not enter the urethral lumen and instead remain extra-mucosally to over-sew the defect. Adequate bites of tissue are necessary so that tension-free placation can occur without any damage or tearing of the tissue. Historically, a Martius flap had been utilized to cover the repair prior to suburethral sling placement. However, complications such as cellulitis, decreased labial sensation, dyspareunia, and vaginal herniation of the fat pad limit its use. A bovine pericardium graft represents a feasible alternative. The graft is a non-cross-linked matrix of multi-directional collagen fibers that provide excellent strength while allowing for host tissue incorporation. At 15 months after implantation, we can see sufficient tissue ingrowth and neovascularization. The graft is then trimmed to the appropriate size. Interrupted sutures of 2-O-Vicryl are now placed to transfix the graft to the periurethral tissue in a four-point configuration at each corner of the dissection. For this patient's symptomatic stress incontinence, we will now perform a trans-opterator sling. The trans-opterator needle is placed in the skin incision at the lower medial border of the opterator foramen, curved toward the lateral vaginal sulcus, entering the vaginal incision while protecting the bladder and the urethra. The synthetic sling is attached, and the opterator needle withdrawn through the previous path. The procedure is then repeated on the contralateral side. The mesh is then positioned in a tension-free manner, allowing a Kelly clamp to be interposed between the mesh and the graft, protecting the urethra. After placement of the sling, the position of the graft is checked. Additional sutures of 2-O-Vicryl are placed, both distal and proximal to the synthetic sling, to secure the graft, ensuring that it will not migrate and will remain interposed between the mesh and the urethra during the healing phase. At the completion of the procedure, the biologic graft should lay flat between the sling and the suture line of the fistula repair, extending from the bladder neck to the distal urethra, as seen here. The vaginal incision is now closed with 2-O-Vicryl suture, and the procedure is completed. A vaginal pack was placed for 24 hours, and the patient was discharged post-operative day number 1. After 14 days, a voiding cystourethrogram was performed prior to final catheter removal to confirm that the fistula had healed. Thus far, 7 patients have undergone fistula repair with concomitant synthetic sling placement using a biologic graft. At a median follow-up of 88 weeks, all report being cured or greatly improved without any complaints of incontinence. With the utilization of a biologic graft, a successful fistula repair and concomitant synthetic sling can be achieved without increasing patient morbidity.

urethral vaginal fistulas

biologic graft

synthetic sling

diverticulectomy

stress incontinence