Post-hysterectomy vesico-vaginal fistula: outcomes of vaginal cuff excision in transabdominal repair

ABSTRACT

To evaluate the outcome and effectiveness of vaginal cuff excision in transabdominal repair of vesico-vaginal fistulas [VVFs]. Uncontrolled prospective study. Al-Salam Hospital, Sadaah, Republic of Yemen [A tertiary Hospital funded by KSA]. Eleven women suffering from post-hysterectomy VVFs were operated upon during the period from April 2000 to April 2005, at Al-Salam Hospital in Sadaah, Republic of Yemen, using vaginal cuff excision in primary trans-abdominal vesicovaginal fistula repair. During this period, eleven women suffering from posthystrectomy VVFs [non-complex fistulas] for benign conditions [5 after hysterectomy, 3 after supravaginal hysterectomy for ruptured uterus and 3 after vaginal hysterectomy]. Preoperative demographic data and fistula characteristics [size, number and location of the fistula] were gathered. Postoperative review included successful repair and postoperative urinary and sexual dysfunction. The subjects were evaluated at 3 weeks and at 3 months. The outcome was assessed using subjective estimation, gynecologic examination and objectively by instillation of diluted methylene blue dye into the bladder. Five patients [45.5%] suffered VVFs after abdominal hysterectomy for benign conditions, three patients [27.3%] were after supravaginal hysterectomy [for ruptured uterus] and three patients [27.3%] were after vaginal hysterectomy. Seven fistulas [63.6%] measured 1 cm or more but less than 3cm in diameter and were located supra-trigonal, and the remaining four fistulas [36.4%] measured 5 mm or less and were located in the trigonal area without bladder neck involvement. Multiple fistulas were found in two cases [18.1%]. The fistula tract was excised totally and closure of the bladder and vaginal cuff scar excision were achieved in all patients. All patients were cured of their fistulas at their last follow-up. There were no major postoperative complications and no significant or symptomatic vaginal shortening. Mild self-limited gross hematuria occurred in 8 cases [72.7%], superficial wound infection in 1 case [9.1%] and paralytic ileus in 1 case [9.1%]. At 3 months postoperatively, one patient [9.1%] reported urinary urgency and increased frequency, the remaining denied any urinary dysfunction and one out of eleven sexually active patient [9.1%] reported mild deep dyspareunia. vaginal cuff excision in primary transabdominal repair of post-hysterectomy vesicovaginal fistulas is a safe and feasible procedure with excellent outcome and does not appear to cause postoperative irritative voiding symptoms or dyspareunia. Excision of the fistulus tract and vaginal cuff scar enable the surgeon to suture viable tissues in every layer, thereby providing conditions optimal for wound healing