Vesicovaginal Fistula Repair
A vesicovaginal fistula, an abnormal connection (fistula) between the bladder and the nearby vagina, results in continuous leakage of urine from the vagina. A vesicovaginal fistula can be repaired through the vagina or through a large abdominal incision. However, laparoscopic vesicovaginal fistula repair combines the superior access of the abdominal approach with the minimally invasive nature of the vaginal approach. Laparoscopic correction using small “button-hole” size incisions not only reduces the operative risk and recovery time, but also improves the precision of the repair.
Similar to other laparoscopic procedures, the surgeon makes a button-size incision in the center of the abdomen for the insertion of a surgical telescope. After expanding the body cavity with carbon dioxide gas, three or four additional small incisions are made to place narrow tubes used for interchangeable instruments. The surgeon can then visualize the internal organs and the interchangeable instruments on a television monitor.
The abnormal area of the bladder and vagina is exposed. Identification of this area is often facilitated by looking inside the bladder through the normal urinary channel (urethra) with an additional telescope (cystoscopy). An incision is made in the bladder just above the abnormal area. The connecting portion of bladder and vagina is removed and the surrounding healthy portions of these two structures are carefully separated for a short distance. The vaginal opening is closed with dissolvable suture and then reinforced with tissue glue. The edge of the omentum (a neighboring flat organ primarily composed of fat) is secured on top of the vaginal repair in order to further separate the bladder from the vagina. The bladder opening is meticulously repaired with dissolvable suture. The bladder is filled with water to test the closure. A separate small drainage tube is temporarily (usually less than 2 days) left in place. The urinary drainage catheter remains for approximately one week. The skin openings are closed with shower-resistant glue as a substitute for both stitches and bandages.
Results & More
Laparoscopic vesicovaginal fistula repair facilitates quicker recovery, less pain, and a lower complication rate as compared to the typical open-incision abdominal repair. Moreover, this technique provides superior access to this complex anatomy when compared to a vaginal approach. To date, all of Scott D. Miller, MD’s laparoscopic vesicovaginal fistula repairs have been successful. Vast experience and a world-class surgical team help ensure this high level of success.
Most patients are discharged from the hospital the day following surgery. Risk of damage to surrounding organs, blood clots, pneumonia, and wound infection are each under 1%. None of these patients have required transfusion.
Vesicovaginal Fistula Dissection
First, an incision is made in the midline of the bladder just above the vagina. An EEA sizer is used to identify the vagina throughout the dissection. The bladder incision is extended down to the fistula and then around the fistula. Additional sharp dissection is performed between the bladder and the vagina. The upper part of the bladder incision is retracted with the Foley catheter by passing a suture percutaneously with a Carter-Thomason closure device.
Using Vascularized Interposition Peritoneal Flap (VIP-flap)
Fistula formation is a potential complication of urinary reconstruction. Tissue interposition can help prevent this complication. However, suitable omentum and epiploica are not always readily available, and exogenous graft material is not desirable. Rotation of a peritoneal flap (VIP-flap) is usually suitable.
The peritoneal flap is dissected off the anterior abdominal wall with attempted inclusion of ipsilateral medial umbilical ligament, epigastric artery, and properitoneal fat. The base of the flap spans from the pubic arch to the psoas. The video demonstrates vaginal closure, partial bladder closure, and interposition after vesicovaginal fistula dissection. Closure of the remainder of the bladder then follows. Creation of the peritoneal flap (VIP-flap) can be viewed below.
Creation Vascularized Interposition Peritoneal Flap (VIP-flap)
The peritoneal flap is dissected off the anterior abdominal wall with attempted inclusion of ipsilateral medial umbilical ligament, epigastric artery, and properitoneal fat. The base of the flap spans from the pubic arch to the psoas.
Here are schematic renderings of the technique:
Q: How much pain can I expect after the procedure?
A: Pain is typically less with laparoscopic procedures when compared to open-incision surgery. Some abdominal cramps and shoulder discomfort can occur from the carbon dioxide gas used during surgery. This type of pain is best treated with anti-inflammatories rather than narcotics. Although everyone is different, post-operative discomfort is usually easily managed and short-lived.
Q: Is bruising normal after a laparoscopic procedure?
A: When a narrow tube is placed through a button-size skin incision, a small blood vessel just below the skin can break. However, since the snug fit of this tube will compress the blood vessel during surgery, bleeding will often not occur. If this blood vessel were to re-open at a later time, a small amount of blood could track over a large surrounding area (including the genitalia). This is not a true bruise but will have the same appearance. Most important, this finding is not an indication of internal problems.
Q: When can I return to work or other normal activities following my surgical procedure?
A: Dr. Scott Miller recommends at least two weeks away from work. Very few jobs would require more than four weeks of leave. In many cases, a small amount of light work-related duties are acceptable during the first two weeks. All patients should move around frequently from the time of surgery and resume light exercise at one week (gradually increasing to a normal routine by four weeks). Driving a car is often reasonable in approximately one week if reaction time is good. Of course, Dr. Miller will provide guidance for each individual situation.
Q: When can I start having sexual intercourse after surgery?
A: To allow the proper time for healing, nothing should enter the vagina for four weeks following the surgery.
Q: How long does the surgery take Dr. Scott Miller to perform?
A: Although many variables can affect the time necessary for Dr. Scott Miller to meticulously perform the surgery, he usually completes the procedure in one to two hours. However, the time away from family members also includes preparation (30-40 minutes), anesthetic reversal (15-20 minutes), and recovery room stay (2 or more hours). Dr. Scott Miller asks patients to arrive two hours prior to this process, during which time family members can remain present. Occasional updates are given to the family by the operating room nurse. Dr. Scott Miller will come to the waiting area when the patient is ready for transfer to the recovery room.
Q: How long do I stay in the hospital following surgery?
A: Most patients are ready for discharge on the day following surgery.
Q: Should I donate blood prior to my procedure?
A: Since the risk of needing a blood transfusion is less than 1%, blood donation is not necessary.
Q: When can I shower or bathe following my surgery?
A: Since shower-resistant glue was used as a substitute for both stitches and bandages, showering is acceptable once discharged from the hospital. Although water will not harm the surgical areas, mechanical cleansing of the incisions should be avoided for the first week to prevent premature removal of the glue. Complete immersion such as bathing or swimming is allowed at two weeks.
Q: How does the success rate of laparoscopic bladder repair compare to open-incision bladder repair?
A: The success rate of laparoscopic vesicovaginal fistula repair is equal to open-incision vesicovaginal fistula repair?
Q: How will vesicovaginal fistula repair affect my bladder function?
A: Even after removal of a portion of the urinary bladder, most patients will regain all or most of their bladder capacity following this repair.