Management
The operative techniques are described as Abdominal or vaginal approaches
The timings of repair of Vesico-Vaginal Fistula
- Obstretic fistula - 3 to 6 months delay before definitive repair
- Post radiation Fistula - 6 to 12 months delayed repair
- Post abdominal surgery - abdominal approach - 3 months preferable while vaginal approach 2 to 3 weeks after initial surgery.
Abdominal Approach (O'Connor's Technique)
Vaginal approach
- Martius interposition flap - In 1928 Martius described a labial flap of bulbocavernosus muscle for urethrovaginal fistula repair, which was later modified multiple times, and in modern usage generally refers to a labium majora fat pad flap without muscle. The Labia Majora incision is given on most prominent part and labial fat pad dissected (which is brigh yellow fibrofatty tissue). There is a natural tissue plane around the fibrofatty fatpad. Care has to be taken that the poserior lateral attachment through which blood supply from a branch of internal pudendal is present is not damaged. Posterior dissection is then performed and fibrofatty fat pad freed from the proximal attachment. A length of 8 to 15 cm can be easily mobilized in this fibro-fatty fat pad, the length should be adequate and there should be no tension in the repair. Care should be taken to stay lateral to the bulbocavernosus and ischiocavernosus muscles. Too medial a dissection includes these structures and results in significant bleeding. Too superficial a dissection risks scar deformity.
Conservative management
Surgical Therapy
Surgical objectives or principles
Tips
- for Martius flap - put foley's catheter plastic sheath over the Martius Flap and the flap slides very easily into the tunnel
- Trans-labial ultrasound for decent of bladder and angle of bladder for stress incontinence
- TVT vs TOT
- Overactive bladder inject botulinium toxin in trigone of bladder (Trans-vaginal) or trans-vesical
- Overactive bladder - sacral biomodulation / Sacral neuromodulation
- Bladder pressure - 40 mm Hg of water is cut off after which damage to kidneys start occurring
Post-operative care
References:
- Wilson A, Pillay S, Greenwell T. How and why to take a Martius labial interposition flap in female urology. Transl Androl Urol. 2017 Jul;6(Suppl 2):S81-S87. doi: 10.21037/tau.2017.04.38. PMID: 28791226; PMCID: PMC5522801.
