Laparoscopic vesicovaginal fistula repairs though inferior of bladder longitudinal incision: summary of surgical experiences over ten years / 中华泌尿外科杂志

ABSTRACT

Objective:To discuss the effect and experience of laparoscopic vesicovaginal fistula repairs though inferior of bladder longitudinal incision.Methods:54 patients were included in this study. Clinical data of patients collected from our hospital since January 2010 to October 2019 who underwent laparoscopic vesicovaginal fistula repair. The median age is 49.5 (8-80) years old. Main complaints were urine flows out through the vagina. 14 cases (25.9%) and 23 cases (42.6%)were post-hysterectomy of benign lesions and gynecological malignant tumors. The symptoms presented at 11 (1-20) days post urinary catheter removal. There were 11 cases (20.4%) of cervical malignant tumors, symptoms presented at 10 (5 to 25) months after radiotherapy. The symptoms of rest of cases 6 (11.1%)presented at 21 (3 to 50) days. One of them had rectal fistula, another had ureteral injury, 6 had bladder contracture, 2 patients had bilateral hydronephrosis. Preoperative CT examination revealed that 4 cases had no obviously hydroureter at upper urinary tract, and 2 cases had mild hydronephrosis in bilateral kidneys. The diameter of the fistula was 0.5-4.0 cm. There were 50 cases of single fistula and 4 cases of multiple fistula. The urine pad test evaluated the degree of urine leakage in patients reveals that 7 and 42 cases with mild and moderate, rest of 5 cases presented with severe result. 37 cases performed with vesico-vaginal fistula repair for the first time; 13 and 2 cases had once and twice vesico-vaginal fistula repair history and there were other two patients had vesico-vaginal fistula repair history for three and four times. All patients underwent general anesthesia under the laparoscopic bladder bottom longitudinal incision bladder vaginal fistula repair, 8 cases performed with Da Vinci robotic assist surgery system. Main steps of the operation include ①search for bladder and vaginal fistula, assessed the size, number, and location of the fistula; ②To set single J stents in the bilateral ureter; ③Fully separated the bladder and vaginal wall, remove scar tissue, and suture the bladder incision with low or no tension way; ④To use great omentum; for patients with low, complex, and mixed bladder vaginal fistulas, recommend to use bladder wall flaps (6 cases), bladder enlargement (3 cases), and ureteral replantation (6 cases). The clinical data of the patients were collected, and a univariate analysis was performed on the cure rate.Results:The mean of blood boss and duration in operation were (33.3±26.5) ml and 85 (60-240) minutes. Mean of hospitalization was (11.3±8.2)days. The postoperative urinary indwelling time were (20.8±8.3)days. 50 cases were completed recovered and 4 cases failed, the curative ratio was 92.6% (50/54). It revealed that the curative ratio of vesicovaginal fistula repair had correlation with history of surgical interventions before operation. The curative effect was reduced ( P=0.00) when the patient had previous laparoscopic vesicovaginal fistula repairs. Patients with multiple fistulas (≥2) had a lower cure rate than single fistulas ( P=0.00). In addition, patients with fistulas above the triangle of the bladder had a higher cure rate than fistulas outside the triangle of the bladder and the urethra ( P=0.00). There was no statistically significant difference in the cure ratio of Age ( P=0.79), operation time ( P=0.06), intraoperative bleeding ( P=0.78), post-operative hospitalization ( P=0.73), indwelling catheterization time ( P=0.30), and size of fistula ( P=0.31). Conclusions:The operation could be effective with fewer complications procedure, which could fix mixed fistula and bladder contracture at the same time.