In this video, we demonstrate a urethral vaginal fistula repair and a concomitant autologous rectus fascia pubovaginal sling through 3 cm incision. Our patient is a 52-year-old woman with a history of prior urethral diverticulectomy. One year after her procedure, she was referred to our clinic complaining of stress and insensible incontinence. Medical exam revealed leaking from a fistula at the mid urethra as well as the urethral meatus. We started the procedure with harvesting of the rectus fascia. A 3 cm incision is made on the lower abdomen 2 finger breads above the pubic synthesis. The incision is carried down through the subcutaneous fat to the rectus fascia. Next, an extra small Lexus wound protector and retractor by Applied Medical is inserted into the incision. A 10 cm by 2 cm wide strip of the rectus fascia can now be harvested from the anterior abdominal wall transversely. Prior to removing the sling, O-proline sutures are placed in each end of the strip. The sling is removed and placed in saline and the rectus fascia is closed with a running loop of PDS suture. Attention is now turned to the vaginal area for the urethral vaginal fistula repair. Hydrodissection is performed on the anterior vaginal wall with 1% lidocaine with epinephrine. An inverted U incision is made with the apex of the U proximal to the fistula and the arms of the U are carried down towards the bladder neck. Sharp dissection is then used to separate the vaginal wall from the periurethral fascia laterally up to the endopelvic fascia on both sides and then a proximally based vaginal flap is created exposing the bladder neck. A Lone Star retractor is placed at this point to optimize exposure. The fistula is then clearly identified coming from the left side of the urethra using an angiocatheter and indigo carmine. The periurethral fascia is then widely mobilized proximally and distally to the fistula to allow a tension free closure. The fistula is not excised to avoid enlargement of the fistula's tract. The first layer of repair is a full thickness repair of the urethra at the edges of the fistula with interrupted forovicral sutures placed in a vertical manner. The angiocatheter and indigo carmine can again be utilized to ensure a water tight closure. Additional foro interrupted sutures may be placed to ensure a tension free and water tight closure of the fistula's tract. The mobilized periurethral fascial flap is then advanced over the fistula repair and is closed horizontally using interrupted forovicral sutures. This is a critical layer in the repair and is used as a second layer in the closure to cover the initial suture line. Next the pubovaginal sling is performed. This section is carried up to the endopelvic fascia and the endopelvic fascia is perforated on both sides. The retropubic space is then entered. A ras perera ligature carrier is placed over the right pubic tubercle and the inferior border of the rectus fascia is penetrated. Under direct finger guidance to protect the bladder, the carrier is brought through the vaginal incision. Proline sutures on one end of the sling are placed in the carrier and these are then brought up into the abdominal incision. The sling is placed over the prior suture line creating a third layer over the fistula repair. The sling is secured to the perivescal fascia at the level of the bladder neck approximately with two sutures of 3 ovicral. Additionally the sling is secured to the periurethral fascia distally with two sutures of 3 ovicral. The fistula repair is now covered by this additional layer. The pubovaginal sling proline sutures are tied across the midline leaving enough space for two fingers to be placed between the knot and the fascia. The proximally based vaginal flap is then advanced to the vaginal epithelium enclosed with a running 2 ovicral suture. Having previously closed the rectus fascia, the subcutaneous tissue is re-approximated and the skin is closed with a running subcuticular 4 ovicral. Postoperatively a vaginal pack was placed for 24 hours. A Foley catheter was left indwelling for 10 days. In the setting of a urethral vaginal fistula in stress urinary incontinence, a primary closure of the fistula in a concomitant autologous rectus fascial sling is an excellent option to address both conditions. The rectus fascia can be harvested through a 3 cm abdominal incision and the rectus fascia sling acts both as an additional layer for closure and as a treatment for stress urinary incontinence without the need for synthetic material.

urethral vaginal fistula repair

autologous rectus fascia pubovaginal sling

urethral diverticulectomy

stress and insensible incontinence

bladder neck exposure