The purpose of this video is to demonstrate a simplified transvaginal approach to surgical treatment of vesicovaginal fistulas using the LATSCO technique. The case being presented is a patient in her mid-40s who underwent a laparoscopic hysterectomy for the treatment of menorrhagia. Two weeks post-op, she complained of continuous urine loss and was found to have a fistula. Cystoscopic evaluation revealed a fistula track approximately one centimeter cephalad and medial to the right ureteric opening. On vaginal exam, a stitch is found and is thought to be the culprit for the fistula formation. The fistula location is verified by backfilling the bladder with sterile water. Methylene blue dye may also work for this purpose. After identifying the fistula, a rectangular shape approximately one to two centimeters from the location is outlined with a sterile marking pen. The vaginal epithelium is then injected with 1% lidocaine with epinephrine to aid in the dissection and hemostasis. A scalpel blade is then used to incise along the previously outlined vaginal epithelium. Care is taken not to cut too deeply as the bladder is in close proximity. The epithelial edges are grasped with the Alice clamps and carefully dissected off the underlined fibromuscular tissue. The tips of the medicine-bound scissors are ideal for this purpose as they are slightly blunt when compared to tenotomy scissors. Because of this, there may be less of a chance of an inadvertent cystotomy. While performing the dissection, it is important to stay within the previously incised epithelium as removal of a large segment of vaginal tissue can lead to a foreshortened vagina. Here we demonstrate the complete excision of vaginal epithelium surrounding the fistulous tract. The underlined fibromuscular tissue is then imbricated with 2-ovicral suture in an interrupted fashion. The imbrication is typically performed in a horizontal fashion and usually requires four interrupted sutures. After the first row of interrupted sutures are placed, the sutures are then tied. In order to obtain watertight closure, 2-3 layers of imbrication is typically required. To cut down on any chance of infection in this area, the patient is given preoperative antibiotics and lavage is judiciously utilized at every step of the surgery. The vaginal epithelium is now ready to be closed. For this purpose, a 2-ovicral suture is used in a running non-locking fashion. Prior to closure of this area, care is taken to identify all bleeding blood vessels, thereby obtaining appropriate hemostasis. The vaginal caliber has been maintained, resulting in a successful repair. At our institution, we were able to identify 17 patients who had undergone a transvaginal repair of a vesicovaginal fistula from years 2004 to 2012. Median age was 58 and median parity was 2, with a BMI of 26.38. Of the total patients, 14 had a history of a hysterectomy, 10 of which were abdominal, 3 of which were vaginal, and 1 of which was laparoscopic. To aid in the evaluation and management, most patients underwent a vaginal examination in addition to cystoscopic evaluation with image studies and urodynamic testing. The fistula size was most often 0.5 to 1.5 cm in its largest diameter. 47% of the fistulas were located at the apex. The duration of leakage until repair was 67 weeks, with 13 patients undergoing a primary repair. With a median follow-up of 20 weeks, all 17 patients reported being cured. Postoperatively, one patient complained of stress urinary incontinence, while another complained of overactive bladder. In summary, transvaginal repair of vesicovaginal fistulas using the LASCO technique is highly effective and with low morbidity.

LATSCO technique

transvaginal approach

vesicovaginal fistulas

laparoscopic hysterectomy

suturing