The treatment of vescovaginal fistula continues to remain a challenging condition for the urogynecologic surgeon. We at the Atlanta Center of Laparoscopic Urogynecology advocate of laparoscopic repair of the vescovaginal fistula as illustrated in this surgical video. The technique begins with identification and isolation of the fistula tract via cystoscopy. A right angle clamp is inserted through the vagina and into the bladder through the fistula tract. A urethral stent is then inserted into the bladder via cystoscopy and grasped by the right angle clamp and threaded through the entire fistula tract from the bladder into the vagina. This allows for easier identification and location of the fistula tract during the dissection from above laparoscopically. Open laparoscopy is performed and the pelvis is visualized. An EA sizer is placed in the vagina to help facilitate dissection. Initial dissection is begun at the vescovaginal junction and the bladder dissected off the vagina until the fistula tract with threaded stent is clearly visualized. The stent can then be cut and the vaginal portion of the stent removed with the bladder portion elevated superiorly to help continue with the dissection of the bladder off of the vagina. The dissection is carried out beyond the tract to ensure that healthy tissue margins for subsequent closure are present. The fistula tract is excised and the edges of both the bladder defect and the vaginal defect are excised and freshened prior to closing these defects separately. Two separate defects can clearly be visualized independent of each other prior to closure. Healthy tissue edges with good vascularity are ensured prior to closure as well. The vaginal defect is then closed with interrupted 2-O-vicryl sutures. The stent through the bladder defect is maintained to help elevate the bladder up and away from the vaginal defect. Upon closure of the vaginal defect, the bladder can be dissected further down off the vagina to help isolate the two closures if necessary. Prior to closure of the defect in the bladder, the edges of this side of the fistula tract are also excised of any scar tissue to ensure healthy tissue margins with good vascularity for closure. The bladder defect is then closed utilizing a multi-layer closure with absorbable sutures. Microscopic laparoscopic instruments may also be utilized to help facilitate this closure. The first layer of the bladder is closed in an interrupted fashion with 4-O-vicryl suture on an RB1 needle. It is very important to ensure that the mucosa of the bladder is incorporated into this closure. If the fistula tract is in close proximity to either ureter, ureteral stents can also be placed to help identify and protect the ureters during this portion of the closure. The stent placed through the fistula tract can still be isolated and utilized by the assistant to help elevate the tract and facilitate the closure of the defect in the bladder. The previous sutures placed can also be taken up through one of the abdominal ports and this also helps elevate up the tract. The stent is then removed from the tract itself and the lateral margin is closed. We feel that this laparoscopic approach allows for a much more precise repair compared to an open abdominal technique. The field is magnified with laparoscopy, the dissection and ultimate closure of the defects with microscopic instruments is thus more exact. Prior to placing a second layer of closure in the bladder, water tightness is checked by filling the bladder. One can clearly see isolation of the two closures of the bladder and the vagina. A second layer of closure is then utilized to close the bladder defect. This second layer is not completed until we ensure a watertight closure of the first layer. The second layer is completed with a 3-0 vicryl suture, again in an interrupted technique. Care is taken throughout the closure to continue to isolate the two incision lines, meaning the incision line in the bladder and the incision line in the vagina to help reduce the risk of recurrence. An omental flap can be created laparoscopically and imposed between the two suture lines if needed. After the sutures are cut, the watertight closure is confirmed via cystoscopy from below and laparoscopy from above. Following repair, indigo carmine can be given to the patient and a laparoscopic sponge placed to ensure no leakage of blue dye into the pelvis. Via cystoscopy, uretal patency is confirmed bilaterally and the defect in the bladder is inspected closely for adequate closure. Prolonged bladder drainage is maintained postoperatively via suprapubic catheter to facilitate healing and reduce risk of recurrence. At our laparoscopic center in Atlanta, we have had excellent surgical outcomes utilizing this laparoscopic technique for vesicovaginal fissure repair in a 23-hour outpatient setting.

laparoscopic repair technique

vesicovaginal fistula

cystoscopy

bladder and vaginal defects

outpatient setting