Vesicovaginal fistulas: surgical strategy and rare clinical cases

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Abstract

Aim. To present our experience of surgical management of vesicovaginal fistulas (VVFs).

Materials and methods. From 1996 to 2025, 156 women with VVFs underwent surgical treatment at the Department of Urology, North-Western State Medical University named after I.I. Mechnikov. Age ranged from 21 to 79 years (mean 45.2±4.6 years). Recurrent fistulas were observed in 42 (26.9%) patients, who had previously undergone from one to six unsuccessful surgical attempts. The predominant cause of VVF formation was iatrogenic injury to the urinary bladder during gynecological interventions (77.5%). Fistula repair was performed in 140 patients, with a transvaginal approach used in 91.4% of cases. The transabdominal approach was employed in 12 women, including 10 cases with concurrent ureteral reconstruction and 2 performed via laparoscopic approach.

Results. Among 140 patients who underwent fistula closure, success was achieved in 139 cases (99.3%).

Discussion. In our clinic, transvaginal fistula closure is the preferred surgical method for managing vesicovaginal fistulas. We consider it the least traumatic open technique, even compared with its laparoscopic alternative.

Conclusion. Transvaginal vesicovaginal fistula closure remains the method of choice for treatment of VVFs. A transabdominal approach, including laparoscopic repair, is justified only when simultaneous ureteral reconstruction is required. Heterotopic cystoplasty is regarded as the most reliable reconstructive option for patients with radiation-induced fistulas.

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About the authors

Boris K. Komyakov

North-Western State Medical University named after I.I. Mechnikov

Author for correspondence.
Email: komyakovbk@mail.ru
ORCID iD: 0000-0002-8606-9791

Ph.D., MD, professor, Head of the Department of Urology, Honoured Physician of the Russian Federation

Russian Federation, Saint Petersburg

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Supplementary files

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2. Fig. 1. Contrast-enhanced MSCT of a 48-year-old patient 9 months after laparoscopic intestinal ureteroplasty of the right ureter and PVS.

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3. Fig. 2. Examination of the external genitalia. Recurrent urethrovesicovaginal fistula. The anterior vaginal wall is absent. In its place is a 7.0 x 6.5 cm defect in the urinary bladder (only the distal half of the fistula is visible). The urethra, through which the catheter was inserted, is preserved along the posterior semicircle as a narrow strip of tissue.

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4. Fig. 3. Examination of the external genitalia. Gentle straining through the fistula orifice causes the urinary bladder to evert outward.

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5. Fig. 4. Surgical stage. The urinary bladder is grasped with forceps and completely everted outward. The ureters are catheterized.

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6. Fig. 5. Transvaginal fistuloplasty stage. Completion of longitudinal suturing of the urinary bladder defect

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7. Fig. 6. Final stage of the surgery. The vaginal wall above the urinary bladder sutures is sutured obliquely.

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8. Fig. 7. Excretory urogram of the patient 3 years after surgery. Good renal and urinary tract function. The urinary bladder is of sufficient capacity and displaced inferiorly.

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9. Fig. 8. Speculum examination of this patient 3 years after transvaginal fistuloplasty. The normal condition of the external urethral opening is determined by the small size of the cystocele.

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