Lower urinary tract fistulas are often associated with obstetrical trauma or surgery. Urethrovaginal fistulas are rare and their etiologies include surgery, radiation, and pressure necrosis. Management of these fistulas may involve prolonged drainage, vibrant glue placement, or various surgical procedures. Our patient was a 50-year-old female who was referred to our clinic approximately 10 months after a urethral diverticulum repair with a steamy bladder neck suspension. She reported immediate and persistent leakage of urine from the vagina after her suprapubic tube was removed approximately six weeks after surgery. Cystoscopically, the opening of the fistula tract could be clearly appreciated. A No. 4 French Fogarty endarterectomy catheter is depicted here. This was used to cannulate the fistula tract, which was performed with cystoscopic visualization. Hydrodissection of the vaginal epithelium was performed with dilute vasopressin. A circumferential incision was made around the opening of the fistula. We carefully dissected the epithelium off of the underlying fibromuscular layer to mobilize two and a half centimeters of tissue circumferentially. The classic method of genitourinary fistula repair calls for the complete excision of the fistula tract and the edges are cut until fresh vascular tissue is identified. However, the LATSCO technique, as depicted here, stipulates that the tract be left in place with no attempt to excise it or its surrounding tissue. This was followed by a non-overlapping layered closure with delayed absorbable suture. The tension was then turned to the right labia majora where a vertical incision was made. Dissection was then carried down to the level of the boval cavernosus muscle to mobilize the overlying fat pad. Care was taken to avoid compromise to the rich vascular supply at its inferior aspect. A stay suture was placed along the superior aspect of the fat pad graft and used to tunnel the transposition graft to overlie the fistula repair. The fat pad was secured and the overlying epithelium was re-approximated. The labial incision was re-approximated with a series of interrupted suture. At the completion of the procedure, the patient had a Foley catheter and suprapubic tube placed for temporary drainage of the bladder. At three months postoperatively, patient continued to deny any leakage of urine per vagina and on examination was noted to have well-healed vaginal epithelium. The right Martius graft harvest site was also noted to be well-healed with an excellent cosmetic result in symmetry.

case study

urethral diverticulum repair

LATSCO technique

urethrovaginal fistula

fistula repair