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| Name | Laparoscopic Vesicovaginal Fistula Repair: Importance of Proper Identification |
| Video Uploader | Video From Boston Urogynecology Associates |
| Upload Date | This Video Uploaded At 18-08-2020 19:30:38 |
| Video Discription | Objective: Achieving complete closure of a vesicovaginal fistula remains a challenge, even to the skilled surgeon. In this video, we demonstrate a novel laparoscopic technique to properly identify and repair a recurrent vesicovaginal fistula. Methods: We present a patient with a recurrent vesicovaginal fistula who had failed three prior repairs including on transvaginal repair and two prior laparoscopic repairs. In this particular case, the small and tortuous fistula tract made identification at the time of surgery a challenge which we feel may have contributed to the prior surgical failures. Therefore, identifying the fistula tract at the onset of the case was of utmost importance.. Due to the sharp angle of the fistula, we were unable to pass a stent through the tract either transvaginal or cystoscopically; therefore, the decision was made to identify the tract transabdominally. After laparoscopic entry using 5mm trocars, the bladder was backfilled with sterile saline to identify superior margin of the bladder. An incision was made with monopolar electrocautery approximately one centimeter cephalad to the bladder edge into the anterior peritoneum between the medial umbilical folds. Dissection was then carried out into the space of Retzius until Coopers ligament was identified. Next, a midline cystotomy was created, and the dimpled area to the left of the midline just above the trigone was probed laparoscopically using a rigid ureteral guidewire. The guidewire passed through the fistula tract and the distal end of the ureteral guidewire was grasped vaginally. The fistula tract was then excised around the guidewire. This laparoscopic technique was not only effective in properly identifying the fistula tract but also ensuring complete excision of the tract using the ureteric wire as a guide. Following excision of the fistula tract, the vagina was closed with a single layer. Next, a double-layer, tension-free bladder closure was performed. The bladder was then backfilled to ensure a water-tight seal. Cystoscopy was then performed which demonstrated well approximated cystotomy without evidence of bleeding. Results: The patient was discharged with a transurethral Foley catheter for 2 weeks at which time she underwent a retrograde cystogram which showed no evidence of a fistula. She reported complete continence at her six-week postoperative visit without recurrence, and we have continued to follow her clinically. Conclusion: In this case, we demonstrate a novel laparoscopic technique for effective identification of recurrent vesicovaginal fistulas using a rigid ureteric guide which allows for proper identification of the fistula tract and facilitates resection of the entire tract. We have found this approach to be simple, inexpensive, and efficient, especially in the difficult cases of recurrent vesicovaginal fistulas. |
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