In the United States, 80% of vesico-vaginal fistulas are secondary to benign gynecologic surgeries. The reported incidence of vesico-vaginal fistula after hysterectomy is 1 in 1,300. Surgical repair could be achieved using a vaginal or an abdominal approach. Options for abdominal repair include high inaccessible fistulas, multiple fistulas, involvement of the uterus or bowel, need for ureteral reimplantation, or failure of vaginal repair. Laparoscopic repair has shown good success rates between 92 and 100%. It can be performed using a transvesical or an extravesical technique. Regardless of the approach, basic principles of surgical repair include wide exposure of the fistula and the surrounding tissue, excision of the fistula's tract, tension-free, water-tight, multi-layered closure of the bladder, interposition of healthy vascularized tissue between the bladder and the vagina, and efficient post-operative bladder drainage. We report on a 50-year-old white female who was referred to our practice for continuous leakage of urine. Her past history is significant for an abdominal hysterectomy six months prior to presentation, complicated by an unrecognized bladder injury, which was repaired three days later. She subsequently developed a vesico-vasinal fistula, and failed vasinal repair with LADSCO procedure five months later. On physical examination, the fistula tract was visualized at the left aspect of the vaginal apex. Office cystoscopy showed a supratragonal fistula, 1-2 cm proximal to the left uterine orifice. Bladder biopsy was benign. The procedure was started by identifying the fistula tract at the vaginal apex after filling the bladder with water and examining the vagina for water leakage. We confirmed the fistula tract 1-2 cm proximal to the left ureteral orifice. A lacrimal duct probe was advanced through the fistula tract to confirm location, and then a 5-french ureteral caster was placed through each ureter to facilitate inter-optive identification. The fistula tract was then dilated with Heng's dilators. A 10-french pediatric polycatheter was advanced through the tract into the bladder, and the balloon was inflated to secure it in place. This will facilitate identification of the fistula during the procedure. Laparoscopically, the bladder and vagina were first identified, and dissection of the vesicovaginal space was started, in an attempt to perform the procedure using an extravesical technique. An incidental vaginotomy was encountered. Dissection was then continued toward the fistula tract. The bladder was further dissected away from the vagina. Due to severe scarring, an incidental cystotomy occurred. We then proceeded by completing the procedure using the transvesical technique. The bladder incision was enlarged, a proper identification of the fistula tract, left ureter, and bladder neck was performed. Further dissection around the fistula tract was carried out using minimal energy to preserve viability of the surrounding tissue. The tract was opened and then excised, and adequate mobilization of the bladder from the vagina was achieved. The bladder incision was enclosed with a figure of eight sutures at the angles, and interrupted simple sutures in the middle, using absorbable 3-O-polygalactin. The interrupted suturing technique facilitates identification of the incision edges, to assure adequate closure, and to avoid inadvertent suturing of the ureters. A second imbricating layer was later done using a similar suture in a continuous running fashion, to assure watertight closure. The bladder was then filled with 100 milliliters of water, and adequate closure was verified. The vagina was enclosed using absorbable 3-O-polygalactin suture. A portion of the omentum with adequate length and mobility was sutured tension-free between the bladder and vaginal incisions, to provide good vascular supply, as well as to act as a physical barrier between the incision lines, in an effort to prevent fistula recurrence. Adequate separation of the bladder and vaginal incisions was verified. Post-optive cystoscopy confirmed good bladder closure without any compromise of the ureters. The patient was discharged home on the following day, with an indwelling bladder catheter. Following cystogram two weeks post-optively, showed an intact bladder without any evidence of fistula recurrence, and the catheter was therefore removed. At two months follow-up, the patient had no complaints, and she expressed great satisfaction with the procedure and the outcome. In conclusion, laparoscopic repair of vesico-vaginal fistulas is associated with high success rates, coupled with decreased post-optive pain, shorter hospital stay, and great patient satisfaction.

vesico-vaginal fistulas

benign gynecologic surgeries

hysterectomy

surgical repair

laparoscopic repair