This video will demonstrate the techniques used to facilitate the transvaginal closure of simple and complex or recurrent vesicovaginal fistulas. Numerous video clips will be utilized to demonstrate these techniques. Key surgical steps that should be considered are as follows. Identify the location of the fistula in the bladder and determine its proximity to the orifices. If there is any concern that the dissection will in any way come in proximity with the ureters, we recommend routine placement of double J stents. Next, identify the site of the fistula in the vagina. If necessary, dilate that tract to allow for the placement of a Foley catheter transvaginally. Circumscribe and sharply mobilize the underlying tissues away from the fistula's tract and ideally we like to enter the peritoneum as this assists in the mobilization of the posterior part of the fistula and allows access for mobilization of a vascularized pedicle. One should determine if the fistula's tract should be excised based on the state of the tissue whether it's vascularized, inflamed, or felt to be unhealthy. Once adequate mobilization has occurred, the fistula can be closed in two layers. Once the fistula is closed, a watertight seal is tested and repeat cystoscopy is then performed to ensure absence of ureteral compromise. Based on the availability of mobilized tissue, a third layer can sometimes be approximated. The first part of this video will demonstrate closure of simple vesicovaginal fistulas. On this cystoscopic view, one can notice that the tract is small and it's away from the ureteral orifices. When looking vaginally, we identify that the tract is tortuous and sometimes these tracts need to be dilated to allow for the passage of a Foley catheter. The placement of the Foley catheter through the tract is crucial as this allows for the downward mobilization of the fistula's tract and facilitates dissection. Once the catheter is in place, downward traction is utilized to facilitate the dissection of the fistula's tract. Here, you can see the tract is circumscribed with a scalpel. It can also be circumscribed with unipolar cautery. The goal is to initiate a dissection between the vaginal wall and the wall of the bladder. Here you can see us sharply dissecting between these two structures to completely mobilize the fistula's tract. Ideally, we prefer to enter into the peritoneum at the level of the vaginal cuff as this facilitates the dissection of the posterior part of the fistula and at times allows the utilization of a vascular pedicle. Here, you can see that the fistula has been nicely mobilized. Next we will address the fistula's tract. In this particular case, the tract seems to be devascularized. Accordingly, it needs to be excised. Once the tract is excised, a layered closure is undertaken with 3-O chromic catgut sutures. These sutures are placed in an interrupted fashion. A minimum of a two-layered closure is required. While performing the initial closure, a Foley catheter or a dilator may be kept in place until the edges of the fistula have been approximated. Then, they may be removed and the closure is completed. Once the two layers are placed, the area is irrigated and we proceed with cystoscopy to ensure the presence of a watertight closure. Now, we will demonstrate two cases of complex fistulas. The first case is a patient who had an unsuccessful LATSCO procedure that occurred after a laparoscopic hysterectomy. In reality, this is two fistulas. You can see that one tract has a catheter in place and the other a probe. The fistula is in close proximity to the right ureteral orifice. When looking vaginally, one can visualize the catheter and the probe. Again, a similar dissection is undertaken utilizing the same principles of complete mobilization of tissue. We can see a large area of scar tissue and granulation just posterior to the fistula tract. This appears to be unhealthy and will be excised. Here, we have entered the peritoneum. We will utilize a small flap, an omental flap, to act as a vascular pedicle after the fistula is closed. Here, you can see that the omental flap has been mobilized. The fistula is closed in two layers as previously described and the omental flap is sutured in place over the suture line of the fistula's closure. Repeat cystoscopy notes a watertight closure with minimal distortion of the trigone. Again, one can see the close proximity of the fistula repair to the right ureteral orifice. The second complex case is a patient who underwent anterior colporaphy with biologic mesh augmentation, specifically pelvicole. This resulted in a fistula in the trigone, most likely an outright injury to the bladder. The complexity in this case is that pelvicole is just underneath the bladder mucosa and this required extensive dissection for removal of the pelvicole that can be seen here. Once all the pelvicole was removed, the fistula's opening in the bladder was closed in two layers with interrupted chromic cat-cut sutures. Double J stands had been previously placed in the bladder. This shows the completed repair and again, the importance here is to note the minimal distortion of the trigone of the bladder. One can see that the incision line required to remove the pelvicole comes close proximity to the right ureteral orifice. In conclusion, most vesicovaginal fistulas can be successfully repaired via the transvaginal route. One must always be prepared to perform extensive mobilization and we feel that the entry into the peritoneum tremendously facilitates the success of such a repair and allows access to the placement of an intervening pedicle, whether it be peritoneum or omentum. It's also important to excise unhealthy tissue prior to performing the multilayered closure. And when a foreign body is involved in a fistula, it's best to have as much of the foreign material excised prior to the closure of the fistula to prevent recurrence.

transvaginal closure techniques

vesicovaginal fistulas

bladder and vagina

mobilizing tissues

fistula closure