2-16. VESICOVAGINAL FISTULA REPAIR
(1) Through the vaginal outlet, the mucosal tissue of the anterior vaginal
wall is dissected free, the opening from the bladder into the vagina is closed, the fascial
attachments between the bladder and vagina are repaired, and temporary drainage is
(2) The fistulas vary in size from a small opening that permits only slight
leakage of urine into the vagina to a large opening that permits all urine to pass into the
(3) Vesicovaginal fistulas may result from radical surgery in the
management of pelvic cancer, from radium therapy without surgery, from chronic
ulceration of the vaginal structures, from penetrating wounds, or from childbirth.
(4) A urethrovaginal fistula usually causes constant incontinence or difficulty
in retaining urine. This condition occurs after damage to the anterior wall and bladder or
following radiation, surgery, or parturation. A ureterovaginal fistula develops as a result
of injury to the ureter. In some cases, reimplantation of the ureter in the bladder or
ureterostomy may be done.
b. Operative Procedure--Vaginal Approach.
(1) Traction sutures are placed about the fistulous tract; tissues are grasped
with Adair forceps and plain tissue forceps.
(2) The scar tissue about the fistula is excised, cleavage between bladder
and vagina is located, and clean flaps are mobilized, using scissors, forceps, and
(3) The bladder mucosa is inverted toward the interior of the bladder with
interrupted sutures of chromic gut number 4-0 swaged to fine curved needles held with
a Mayo needle holder and tissue forceps. The suture is passed through the muscularis
of the bladder down to the mucosa.
(4) A second layer of inverting sutures is placed in the bladder and tied,
thereby completely inverting the bladder mucosa toward the interior.
The vesicovaginal fascia is repaired with interrupted number 2-0 chromic
(6) The vaginal wall is closed with interrupted chromic gut sutures in the
direction opposite to the closure of the bladder wall.