Aira Hospital

The size of a fistula is not of much importance for the repair. The following points however should be considered seriously since they are decisive when analyzing the difficulty of the repair:

·         Is the sphincter mechanism (the urethravesical junction) involved?

·         Is the defect circumferential?

·         Is there much scarring?

 

Based on the first two criteria Dr Kees Waaldjik has made a classification of the fistulas into groups of increasing complexity

VVF Classification ← click here to see Dr Kees Waaldjik’s classification

The principle of surgery is to close the fistula and repair the sphincter mechanism (the UV junction). The closure is done in two or preferably three layers: one or two inverting suture lines in the bladder wall  and one everting suture line in the vaginal mucosa. Interposition of a bulbocavernosus flap can be used as a second layer between the bladder and vagina as reinforcement. The bladder closure has to be watertight (or as near to as possible). Control with installation of dye such as gentian violet or methylene blue - “the dye doesn’t lie”. The vaginal mucosa needs only adaptation, and if difficult to make a closure it can be left open. It will regenerate fast.

With the sphincter function in mind, the bladder closure should be in longitudinal direction if at all possible - aiming at reconstruction the normal UV angle.

The vaginal approach is always preferable.

No sophisticated equipment is needed. Most important are:

·         Operating table which can be set in exaggerated Trendelenburg’s position.

·         Acute angled Thorek’s scissors

·         Auvard’s self retaining vaginal speculum

·         Metal catheter

·         Long and short straight needle holder

·         Long and short forceps

·         Babcock’s or Allis’ forceps

·         Assistant’s suture cutting scissors

·         Mosquitoes – small haemostatic forceps

·         Dye – Gentian violet or Methylene blue

 

This is an example of a very simple fistula repair. The fistula is small, not involving the sphincter mechanism, not circumferential and without any scarring (type I according to Kees’s classification)

Small fistula with prolapsed bladder base	Bladder base reduced with patient in exaggerated Trendelenburg’s position
Bladder wall with fistula mobilized	Two layer closure of the bladder wall with inverting sutures. The second layer is in progress
Dye test	No leakage
Vaginal mucosal closure in progress	Vaginal mucosal closure completed

 

Further readings:

·         For the beginner the book “First steps in vesico-vaginal fistula repair” by Brian Hancock is excellent. ISBN 1-85315-611-6

·         If you aim at becoming seriously involved in fistula surgery the book “Step-by-step surgery of vesicovaginal fistulas” by Kees Waaldjik is an absolute must. It is a veritable gold    mine of information on all aspects of the subject – the “Fistula Bible” so to say. ISBN 1-873732-17-1

Both books can be purchased on line at www.talcuk.org   

      ·    Brian Hancock recently published his second book on fistula surgery ”Practical Obstetric Fistula Surgery”. Also a must for the initiated fistula surgeon with a lot of pictures and references to all available articles, books and teaching materials dealing with  the  subject. 

      Available at the publisher www.rsmpress.co.uk or at www.amazon.com   ISBN 9781853157660