There are distinct differences between a vaginal and abdominal approach to fistula repair. All things being equal, the vaginal approach is far preferable for a number of reasons. Firstly, the surgery is done completely through the vagina so there is no visible scar. Secondly, the post-operative recovery is much easier and less painful without an abdominal incision and there is much less chance of wound infection and other complications. Further, blood loss is less and there is less chance that you will require a blood transfusion.
It’s not quite that simple. In the hands of all but the most expert of fistula surgeons, the abdominal approach probably has a considerably higher success rate. Further, the vaginal approach can result in more vaginal scarring; it can shorten the vagina and cause painful intercourse (dyspaerunia). And in some women, the vagina is simply too small or the fistula is up too high for the surgeon to be able to adequately expose it. In these instances, an abdominal approach should be used. In addition, if there has been an injury to the ureter or the intestine, an abdominal approach is needed so that both surgeries can be accomplished. Further, many urologists are not familiar with the vaginal approach and many gynecologists are not familiar with the abdominal approach. In some instances, at the discretion of your surgeon, it may be better to perform the surgery with a combined approach, through both the vagina and abdomen in order to insure a successful outcome.
No matter which approach is used, it is often advisable to bring in a new blood supply to the damaged area to insure that enough oxygen reaches the tissues to allow proper healing. The two most common ways of doing this are with Martius labial fat pad and an omental flap. The Martius flap is used in vaginal repairs. An incision is made over the labia, adjacent to the vaginal opening and a longitudinal strip of fat, about the width of an index finger is isolated, being careful to preserve the blood vessels feeding the fatty tissue. The flap is then tunneled underneath the vaginal wall and placed over the site of the fistula repair. In time, new blood vessels will emerge and help nourish the fistula repair.
An omental flap is used in abdominal repairs. The omentum is an apron like mass of fatty tissue, rich in blood vessels, which hangs down from part of the large intestine called the transverse colon. The omentum has been called “the watchdog of the abdomen because whenever there is damage or infection to part of the abdomen, the omentum covers it, bringing in a rich blood supply and nourishment to the damaged area and helping it heal.
There is one more approach we don’t really approve of, and have never tried. Therefore, we can’t say with certainty that it’s unwise to try. It’s called fulguration of the fistula tract. This is a very simple technique that’s done with a cystoscope. The fistula is visualized and its edges fulgurated. Fulguration is heating the tissue to very high temperatures which cause the tissue to actually undergo necrosis. The theory is that this will set up an inflammatory reaction to which the body will respond by trying to heal it and that this will cause the fistula to heal. This doesn’t make any sense to us, particularly because it was ischemic necrosis that caused the fistula in the first place. Nevertheless, a few doctors have reported success with this technique.
Whenever a fistula is diagnosed, one must have a high index of suspicion that there might be other injuries as well which require surgical repair at the same time as the fistula repair. To overlook these would be a travesty, because another surgery would be necessary. There could be a fistula from the ureter to the vagina (a ureterovaginal fistula) an obstruction to the ureter by a suture from the original surgery or there could be sphincteric incontinence. A careful evaluation to exclude each of these potential conditions should be undertaken prior to surgery so that they may be diagnosed beforehand and repaired at surgery. In order to diagnose these conditions, kidney X-rays (IVP and retrograde pyelography) should be performed in all patients whenever possible. Cystoscopy and pelvic examination are also essential.
Further, women with these injuries have usually undergone one or more prior vaginal operations and have urinary incontinence which is very difficult to manage. The vaginal tissues are often very scarred and the blood supply may be deficient. Prior to surgery careful examination of the vagina is necessary to determine the actual extent of tissue loss and to assess the availability of local tissue for use in the reconstruction. In most instances there is sufficient tissue in the vagina itself to use for the repair, but if the vaginal tissue is extensively scarred and there is not enough tissue for the repair, other areas such as the labia, the abdomen and the inner thigh should be evaluated for possible use for tissue grafts.
For practical purposes, the only treatments for fistulas are surgical. Some doctors recommend that an indwelling catheter be left in place for a prolonged period of time (weeks or months), to give the fistula a chance to heal on its own. Although there have been a few reports of success using this method, most of the time it is unsuccessful and only delays the otherwise inevitable surgery. Further, it is very frustrating for a woman to spend weeks or months with a catheter in place, especially because it usually is ineffective in controlling the leakage and, aside from the liberal use of absorbent pads, there is no good way of keeping her dry.
There are two main types of surgical repair of vesicovaginal fistula – an abdominal repair and a vaginal repair. In general, although there are distinct advantages and disadvantages to each method, the decision to use one or the other is based mostly on the experience and skills of the surgeon. This type of surgery requires a great deal of experience on the part of the surgeon, and, for this reason, it is particularly important to choose a surgeon who has such experience. It really doesn’t matter whether he is a urologist or gynecologist as long as he or she has done plenty of these operations and has a good success rate. In the hands of a skilled surgeon, the chances of success ought to be in the range of 90% or more unless the fistula has been caused by radiation or cancer. Then the success rate is lower, about 60-80%.
Finding an experienced surgeon to repair the fistula is not an easy task because fistulas are not very common in industrialized countries and, therefore, there are not many experienced surgeons. There are probably experienced surgeons in most large cities and towns, but you really have to check for yourself. If you chose your surgeon carefully in the first place, the chances are that he is highly skilled. If he or she diagnosed your fistula in a timely fashion (within a few days or a week or two) and exhibited care and concern, the best place to start is to discuss the problem with him or her. It may well be that he or she is experienced at performing fistula surgery. If your surgeon is not so experienced, he or she will probably be able to refer you to an experienced surgeon.
In general, the more fistula operations a surgeon has performed, the better he or she is, but that’s not an infallible rule. You should ask your doctor directly if he or she is experienced, about how many fistula operations he or she has done and what their success rate has been. There’s no way to grade the success of the surgeon and there’s no easy way to be sure that you’ve chosen the right one, but there are common sense guidelines. Because fistulas are so rare, you’re unlikely to find a doctor whose operated on more than a dozen or so. A real expert in industrialized countries may have done a hundred; in Africa a real expert might do thousands of fistula operations. If your doctor has done a dozen and all were successful, that’s pretty good; if all failed, stay away from that doctor. If his success is over about 80% that’s OK, but you’d do better to find a surgeon whose success is well over 90%. If he or she says that the success rate is 50% or less, look for another. The surgeon really should have a pretty idea of what his or her own success rate is because, not only are fistulas rare, but when the surgery is unsuccessful, it’s almost always apparent within the first 2 – 4 weeks.
In the past, much controversy surrounded the timing of surgical repair. For decades it had been taught that surgery should be delayed for 3-6 months or longer to allow adequate time for the tissue to heal and for inflammation and swelling (edema) to subside. Most experts now agree that surgery can be safely performed as soon as the vaginal wound is free of infection and inflammation and the tissues are reasonably pliable (soft). It is almost always possible to perform the surgery within a few weeks after the original surgery.
Management of incontinence while waiting for healing of the vaginal tissue is sometimes a difficult problem. In women with small fistulas, bladder catheter drainage is usually sufficient. If significant leakage occurs with a Foley catheter in place, it is usually best to remove the catheter and manage the incontinence with absorbent pads until the fistula can be surgically repaired.
Most fistula surgeons recommend that a catheter be left in place for a few weeks after surgery until the fistula has had a chance to heal, but a few surgeons only leave a catheter in overnight. It’s advisable for the surgeon to check that the fistula has healed before the catheter is removed. This is done by examining the vagina at the site of the fistula repair to be sure that it appears healthy and also by filling the bladder with saline or water or dye and checking that it doesn’t leak through the vagina. If healing appears incomplete or if there is still leakage, the catheter should be left in another few weeks, then checked again. For practical purposes, the wounds should be well enough healed by a maximum of four weeks. If there is still leakage at that time, the operation has failed.
For women with urethrovaginal fistulas the situation is even more complicated because, in addition to repairing the fistula, it is usually necessary to do an anti-incontinence operation at the same time. One word of caution, though. Not all urethrovaginal fistulas cause a problem and not all have to be surgically repaired. If a urethrovaginal fistula is discovered on examination by your doctor, but you experience no symptoms and have no incontinence, there is no need to repair it at all. However, if there is incontinence, it usually means that the fistula involves not only the urethra, but the sphincter and bladder neck as well.
Surgeries to repair these kinds of injuries are much more complicated than the repair of a vesicovaginal fistula and require a very experienced surgeon. First, the surgeon has to repair the urethra, and then he has to repair the incontinence. Because he or she is doing so much surgery in such a small place, it is usually advisable to bring in a new blood supply to insure the best chance for healing. This may be accomplished by a Martius labial fat pad graft as described in the previous section. Despite the complexity of this surgery, in experienced hands, the overall success rate is over 90% with respect to continence and a successful fistula repair.
Historically, there are three different approaches to repairing these injuries:
Although these techniques appear to be comparable with respect repair of the fistula, incontinence persists in about half of the women unless it is repaired at the same time. In our judgment, there is almost never a need to do anything but a vaginal repair combined with pubovaginal sling and Martius flap. We believe that vaginal reconstruction is considerably easier and faster, is much more amenable to concomitant anti-incontinence surgery and has a much easier recovery with much less complications and less blood loss.
Vesico-vaginal and urethro-vaginal fistulas (holes in the vagina connected to the bladder and urethra) are rare in industrialized countries, but are common in the third world because of inadequate obstetric care. The only treatment is surgical and in the hands of experienced surgeons the success rate is very high. Even if the surgery should fail, a second operation or even a third will almost always be successful in expert hands. Whenever a fistula is diagnosed, a careful search for associated injuries to the ureter should be undertaken and, if found, these injuries should be repaired at the same time.
Women with urethrovaginal fistulas have an even more complicated problem because, in addition to the fistula, there is usually an injury to the sphincter as well. In the hands of experts, after a single operation to repair both the fistula and the incontinence, a successful outcome can be achieved in over 90% of women.
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