Abdominal closure of a complex vesicovaginal fistula using the O'Connor technique. There are several causes of vesicovaginal fistula. Neglected pessary is an uncommon cause. However, there are several case reports and case series of fistulas that have resulted from pessary use. The case presented is that of a 76-year-old woman referred for a vesicovaginal fistula. She had a two-year history of Gellhorn pessary use, placed for the treatment of pelvic organ prolapse, and managed with pessary self-care with weekly removal. The patient admitted that she had not removed the pessary for several months prior to her presentation. Examination in the office and with cystoscopy revealed a large 4-centimeter vesicovaginal fistula with visible urethelium located adjacent to the cervix. Bilateral ureters were unable to be visualized cystoscopically due to the profuse leakage through the fistula tract and the size of the fistula itself, which distorted the normal anatomy. CT urogram was obtained with evidence of a tract from the urinary bladder to the vagina. On CT, the bladder was not able to be distended given the large size of the defect and the leakage of fluid through the fistula. Fistulas may be repaired through a vaginal or abdominal route. The decision was made to proceed with an abdominal approach to the fistula given the large size of the fistula, involvement of the entire trigone, and suspected ureteral involvement with possible need for reimplantation. The O'Connor technique is a transabdominal transvesical approach originally described in the 1950s. It remains the gold standard in treatment of supratrigonal vesicovaginal fistula repair with success rates quoted as high as 100% in some case series. These are the steps for the O'Connor technique. In our case, a hysterectomy was performed due to the close proximity of the cervix to the fistula and for adequate access to the vesicovaginal space. An interposition graft may be placed during closure. We chose to use an omental flap. Epiploic and peritoneal flaps have been reported. Cystoscopy was performed at the start of the procedure. The anterior and posterior edges of the fistula can be seen tracking down into the vagina. The large fistula occupied the entirety of the bladder trigone. Again, inability to visualize the bilateral ureters was found. After the conclusion of the cystoscopy, a Foley catheter was placed. Step 1, mobilization of the bladder. A vertical midline incision was utilized for abdominal entry and visualization. The round and broad ligaments were opened. The vesicouterine peritoneum was incised and the bladder was dissected off the lower uterine segment, cervix, and upper vagina sharply. Adhesions were encountered, given the underlying fistula and inflammation. The retropubic space was developed using gentle blunt technique for further mobilization of the bladder. Step 2, intentional high cystotomy along the sagittal plane. The outline of the bladder was identified and an anterior cystotomy was performed. This was extended from the dome posteriorly along the midline by evolving the bladder to expose the urothelium towards the fistula. A malleable was placed into the vagina. The radial orifices were identified. The bladder was further mobilized off the anterior cervix. The specimen, consisting of uterus, cervix, bilateral fallopian tubes, and ovaries, was amputated and removed from the field. Vascular sutures were held on traction to assist with visualization later in the case. The previously created dome cystotomy was carried down to the large fistula. Dissection without the use of cautery was utilized in order to preserve the microvasculature close to the fistula. The posterior vesicovaginal plane was developed with sharp dissection for isolation and identification of the bladder and vaginal components of the fistula's tract. Development of the vesicovaginal plane beyond the fistula. The right side of the vagina was further separated from the bladder base. The right ureter was identified as being approximately 1 centimeter distal and lateral to the fistula. A 5 French ureteral catheter was placed over a guide wire under direct visualization. The dissection continued along the left side. Dense scarring was noted throughout this area and the vaginal tissue had suboptimal integrity. During this dissection, the left ureteral orifice was encountered, which confirmed the suspicion that this side was involved in the fistula and would require reimplantation. A sufficient margin of vaginal wall was isolated along the vesicovaginal space to allow for a tension-free closure. Step 5. Multilayer tension-free closure with omental interposition graft. The vagina was closed with 0-vicral figure of 8 sutures in a horizontal orientation. Once the vagina is closed, anchoring 0-vicral sutures were placed at the distal-most aspect of the vesicovaginal dissection to be used for the omental flap between the vagina and bladder later in the case. The most dependent portion of the cystotomy was identified and closed with 3-ovicral in a running fashion. The urothelial and muscular layers were re-approximated in a tension-free closure of the bladder edges in a vertical orientation. At this point, the left ureteral reimplantation was performed. Adequate mobilization was achieved to reach the bladder dome. The ureter was encircled with a vessel loop and large clips were placed across the distal part of the dissected ureter and the ureter was transected. The ureter was somewhat enlarged, consistent with its incorporation in the fistula. A small incision was made in the left bladder dome and the ureter was placed through the bladder wall. The ureter was then spatulated and secured within the wall of the bladder with 6-4-0 PDS sutures, being sure to include the urethelium of the bladder and ureter. Patency was confirmed. A 22-cm-5 French pigtail stent was introduced into the left ureteral orifice. The previously placed right ureteral catheter was removed and replaced with the 24-cm-5 French pigtail stent. The bladder closure was continued. Prior to completely closing the bladder, the omentum was brought into the pelvic field. A small incision was made within the omental body for additional functional length. The omental flap sutures were secured in place and the omental flap occupied the developed vesicovaginal space between and beyond the suture beds of the vaginal cuff and the bladder fistula closures. The remaining bladder closure was performed. A 3-ovicle suture was placed to reinforce the ureteral peritoneum and bladder serosa. The bladder was backfilled with 120cc of sterile saline and no leakage was seen, confirming a watertight closure. A 20 French Foley catheter was placed to allow for clearing of postoperative hematuria. The patient did well postoperatively and cystogram performed at 3 weeks revealed no evidence of a fistula. Cystoscopy with stent removal was performed at 6 weeks postoperatively. The ureteral implant site was visualized, as was the intact suture lines. In conclusion, the O'Connor technique for vesicovaginal fistula may be utilized for large, complex fistulas involving the trigone. Hysterectomy may be required for adequate tissue mobilization and access in order to provide attention-free closure. An omental flap may be utilized as an additional layer to provide neovascularization to surrounding tissues.

O'Connor technique

closure

complex vesicovaginal fistula

neglected pessary use

transabdominal transvesical approach