Operative repair of 222 cases of vesico-vaginal fistulas

INTRODUCTION AND OBJECTIVES: Vesico-vaginal fistulas remain a significant health care concern in developing countries. Although birth related injuries remain a significant cause of fistula occurrence, iatrogenic injuries are increasing in frequency. The purpose of this study was to review experience with surgical management of fistulas due to numerous etiologies. METHODS: Over a 25 year period, 222 cases of vesico-vaginal fistula were identified. Mean patient age was 45.2 years (range 18 - 64). Etiology of fistula included: hysterectomy -187, prolonged or traumatic birth -10, post radiation for cervical malignancy with no tumor -9, active cervical tumor -7, anterior colporrapy -5, pelvic fracture -2, and cystolithotomy -2. Seven cases were managed initially with catheter drainage and 8 cases were treated with fulguration of small fistulous tract. All other cases were treated with either transvesical, retrovesical, or transvaginal repair dictated by location of fistula. RESULTS: Method Patients Results (cured) Catheter drainage 7 (3%) 7/7 Fulguration 8 (3.5%) 5/8 Transvesical 168 (75%) 32/168 Retrovesical 30 (13%) 28/30 Transvaginal 12 (5%) 12/12 Of 38 failures, 15 had received radiation alone or in combination with radical hysterectomy. All seven cases with tumor present failed, as did the two cases of radical hysterectomy who did not have radiation. The remaining failures (14) occured in patients who had undergone more than one prior attempt at repair. CONCLUSION: The majority of vesico-vaginal fistulas can be successfully managed with the appropriate choice of surgical approach. Fistulas arising in radiated fields or in the presence of active pelvic malignancy are more likely to fail. Diminished bladder capacity after radiation or radical hysterectomy contributes to the higher failure rates in that subset of patients.