The with repair of ve.sicovaginal omentum fistulas

2
SAMT DEEL 67 26 JANUARIE 1985 143 The with repair of ve. sicovaginal omentum fistulas A review of 59 cases H. J. L. ORFORD, J. L. L. THERON Summary The treatment of 59 consecutive vesicovaginal fistulas is described. Five patients were treated by simple vaginal repair; in 52 patients repair was carried out with the aid of an omental pedicle. Only 2 of these patients are not fully continent 1 awaits further sur- gery and 1 has stress incontinence but refuses a further operati on. A further 2 patients were treated by urinary diversion . The cure rate was 93%. The value of omentum in overcoming fibrosis and tissue loss is discussed. SAfrMedJ1985; &7: 143-144. The operative repair of a vesicovaginal fistula (VVF) can be extremely difficult and is not always successful. A recent report 1 hints at the difficulties encountered by listing eight different methods of treating the problem, including urinary diversion. Kiricuta and Goldstein 2 recommended the use of an omental pedicle in the repair of VVFs, and since their results appeared to be very promising we decided to investigate this method. We reported our initial findings in 1976,3 and now present a series of 59 consecutive cases. Methods We have previously reported the surgical techniques used in repairing a VVF with omentum . Kiricuta and Goldstein 2 and Turner-Warwick 4 have both given excellent accounts of the repair of urinary tract injuries with omentum. Details of our technique have previously been pub lished. 3 Intravenous pyelography and cystoscopy is performed on all patients before operation, which is carried out under general anaesthesia with the patient positioned for simultaneous vaginal and abdominal surgery. The vaginal surgeon commences the dissection of the vaginal epithelium before the laparotomy is undertaken, extending the sharp di ssection until normal tissue planes are reached. The bladder must be completely freed. The abdomen is then opened with a right paramedian incision, and the omentum-fashioned into a wide, long flap with a good blood supply. The omentum should be tethered to the abdominal wall when the abdomen is closed to prevent 'bowstringing' and torsion. State H os p ital, Windh oe k, Sou th Wes t Af r ica/Narni bia H. J. L. ORFORD, B.SC., M.B. B.S ., M.R. C. O.G. J. L. L. THERO ' M.B. CH. B. , F.C.S. (S.A.), M.MED. (SURG. ) The situation of the fistula determines whether it is closed from above or below. The bladder is usually opened extra- peritoneally. At this stage it is decided whether to pass the omentum into the vagina in the form of a sling or as a graft between the bladder and the uterus, the more awkward fistulas being closed by sutures inserted by both surgeons. A straight skin needle with 00 chromic catgut is passed through the bladder wall from the vaginal surgeon to the abdominal sur- geon, who guides it well wide of the fistula margin and returns it to the vaginal surgeon. A few widely placed stitches are inserted and tied in the vagina to close the fistula. No effort is made to achieve a meticulously watertight closure. The ureteric openings must be identified and when they are found to be in the margin of the fistula the bladder is only partially closed and then reinforced with omentum. The abdominal surgeon feeds t he omentu m into the vagina, where it is widely but loosely spread over the fistula and fixed in position to the anterior and posterior margins of the vaginal dissection. The stitches (4 - 6) are passed in and out of the vaginal epithelium and tied in the vagina. The vaginal epi- thelium is seldom sutured . The bladder is then closed supra- pubically by the abdominal surgeon. A Foley T o. 22 suprapubic catheter and a Foley No . 16 urethral catheter are used to drain the bladder. The latter is removed after 2 weeks and the suprapubic catheter after 6 - 12 weeks, depending on the size of the fistula. If the fistula involves the urethra or the bladder neck an omental sling is used. The vaginal surgeon dissects from the vagina into the cave of Retzius through an incision lateral to the urethra. The omentum is passed u nder the urethra in the form of a sling and the abdominal surgeon fixes it behind the pubic symphysis. The vaginal sur geon stitches it in place. The surgeons now decide whether to reinforce the repair by a rectus sheath and muscle sling. A rectus sling should be used in all cases in which major bl adder neck and urethral damage has occurred. Patients Between June 1972 and August 1983 59 patients with VVFs were treated. They came from Angola and SWA/ Namibia and nearly all were operated on in the Windhoek State Hospital. However, 4 operations were performed in hospitals in the RSA. The ages of the patients ranged fr om 15 to 65 yeai:s, parity ranged from 0 to 8, and the fistulas had been present for between 3 months and 12 years. In 7 patients the urethra was less than l em in length. The causes of the fistulas, their size and their situation in the bladder are summarized in Table I. We regarded the large fistulas and many of the smaller ones as difficult surgical prob lems. The following list of complica- tions associated with VVFs illustrates the difficulties we encountered while repairing them: (i) fibrosis due to previous uns uccessful attempts at repair; (ii ) total eversion of the bladder; (i ii ) a ureteric opening in the fistula margin (this was a common fi n ding); (iv ) a ur et er opening into the vagina and

Transcript of The with repair of ve.sicovaginal omentum fistulas

Page 1: The with repair of ve.sicovaginal omentum fistulas

SAMT DEEL 67 26 JANUARIE 1985 143

The with

repair of ve.sicovaginal omentum

fistulas

A review of 59 cases

H. J . L. ORFORD, J. L. L. THERON

Summary

The treatment of 59 consecutive vesicovaginal fistulas is described. Five patients were treated by simple vaginal repair; in 52 patients repair was carried out with the aid of an omental pedicle. Only 2 of these patients are not fully continent 1 awaits further sur­gery and 1 has stress incontinence but refuses a further operation. A further 2 patients were treated by urinary diversion. The cure rate was 93%. The value of omentum in overcoming fibrosis and tissue loss is discussed.

SAfrMedJ1985; &7: 143-144.

The operative repair of a vesicovaginal fistula (VVF) can be extremely difficult and is not always successful. A recent report 1 hints at the difficulties encountered by listing eight different methods of treating the problem, including urinary diversion. Kiricuta and Goldstein2 recommended the use of an omental pedicle in the repair of VVFs, and since their results appeared to be very promising we decided to investigate this method.

We reported our initial findings in 1976,3 and now present a series of 59 consecutive cases.

Methods

We have previously reported the surgical techniques used in repairing a VVF with omentum. Kiricuta and Goldstein2 and Turner-Warwick4 have both given excellent accounts of the repair of urinary tract injuries with omentum. Details of our technique have previously been published.3

Intravenous pyelography and cystoscopy is performed on all patients before operation, which is carried out under general anaesthesia with the patient positioned for simultaneous vaginal and abdominal surgery. The vaginal surgeon commences the dissection of the vaginal epithelium before the laparotomy is undertaken, extending the sharp dissection until normal tissue planes are reached. The bladder must be completely freed.

The abdomen is then opened with a right paramedian incision, and the omentum-fashioned into a wide, long flap with a good blood supply. The omentum should be tethered to the abdominal wall when the abdomen is closed to prevent 'bowstringing' and torsion.

S ta te H osp ital, Windhoek, South West Afr ica/Narnibia H. J. L. ORFORD, B.SC., M.B. B.S ., M.R.C. O.G.

J. L. L. THERO ' M.B. CH.B., F.C.S. (S.A.), M.MED. (SURG.)

The situation of the fistula determines whether it is closed from above or below. The bladder is usually opened extra­peritoneally. At this stage it is decided whether to pass the omentum into the vagina in the form of a sling or as a graft between the bladder and the uterus, the more awkward fistulas being closed by sutures inserted by both surgeons. A straight skin needle with 00 chromic catgut is passed through the bladder wall from the vaginal surgeon to the abdominal sur­geon, who guides it well wide of the fistula margin and returns it to the vaginal surgeon. A few widely placed stitches are inserted and tied in the vagina to close the fistula. No effort is made to achieve a meticulously watertight closure. The ureteric openings must be identified and when they are found to be in the margin of the fistula the bladder is only partially closed and then reinforced with omentum.

The abdominal surgeon feeds the omentum into the vagina, where it is widely but loosely spread over the fistula and fixed in position to the anterior and posterior margins of the vaginal dissection. The st itches (4 - 6) are passed in and out of the vaginal epithelium and tied in the vagina. The vaginal epi­thelium is seldom sutured. The bladder is then closed supra­pubically by the abdominal surgeon.

A Foley To. 22 suprapubic catheter and a Foley No. 16 urethral catheter are used to drain the bladder. The latter is removed after 2 weeks and the suprapubic catheter after 6 - 12 weeks, depending on the size of the fistula.

If the fistula involves the urethra or the bladder neck an omental sling is used. The vaginal surgeon dissects from the vagina into the cave of Retzius through an incision lateral to the urethra. The omentum is passed under the urethra in the form of a sling and the abdominal surgeon fixes it behind the pubic symphysis. The vaginal surgeon stitches it in place. The surgeons now decide whether to reinforce the repair by a rectus sheath and muscle sling. A rectus sling should be used in all cases in which major bladder neck and urethral damage has occurred.

Patients

Between June 1972 and August 1983 59 patients with VVFs were treated. They came from Angola and SWA/ Namibia and nearly all were operated on in the Windhoek State Hospital. However, 4 operations were performed in hospitals in the RSA. The ages of the patients ranged from 15 to 65 yeai:s, parity ranged from 0 to 8, and the fistulas had been present for between 3 months and 12 years. In 7 patients the urethra was less than l em in length. The causes of the fistulas, their size and their situation in the bladder are summarized in Table I.

We regarded the large fistulas and many of the smaller ones as difficult surgical problems. The following list of complica­tions associated with VVFs illustrates the difficulties we encountered while repairing them: (i) fibrosis due to previous unsuccessful attempts at repair; (ii) total eversion of the bladder; (iii) a ureteric opening in the fistula margin (this was a common finding); (iv ) a ureter opening into the vagina and

Page 2: The with repair of ve.sicovaginal omentum fistulas

144 SAMJ VOLUMES? 26JANUARY 1985

TABLE 1. CAUSES, SITE AND SIZE OF THE 59 VVFs

No.

Causes Radiotherapy Gynaecological surgery Obstructed labour Labour with caesarean section

Site Vesical, high Vesical, low Urethrovesical

Size < 2cm 2-4cm > 4cm

7 44

7

16 15 28

36 12 11

not into the bladder (this patient was treated by urinary diversion); (v) complete absence of the uterus as a result of avascular sloughing thereof during a 3-day obstructed labo~r - this complication does not appear to have been reported Ill the literature; (vi) multiple fistulas; and (vii) total destruction of the bladder base and the proximal urethra.

Results

Five patients had small and uncompHcated fistulas. _These were treated by vaginal repair only and sutured with 00 chromic catgut. All 5 patients are continent of urine.

The 52 more difficult cases were treated with the aid of an omental pedicle. Of these patients, 2 are incontinent of urine. One has stress incontinence but refuses further surgery and the other has had two repairs and is awaiting further surgery. One patient moved to South Africa after rwo unsuccessful repairs, where she was cured by a vaginal repair.

In addition to the repairs with omentum there were 2 patients in whom urinary diversions were performed. One of the two diversions was performed as a primary procedure. In this case the ureter was found to open into the vagina and not the bladder. The second patient had a large circumferential fistula with loss of the urethra. The fistula was successfully closed but stress incontinence remained a problem. An anempt at a Marshall-Marcheni repair destroyed our omentum repair and a urinary diversion had to be performed. After this experience we performed a rectus sling operation in 5 subse­quent cases, with complete success.

The majority of patients ( 4 7) required only one operation, 8 required two operations and 4 required three operations (the results are summarized in Table II). Patients were discharged from hospital 1 week after the removal of the last catheter. The time spent in hospital varied from 7 to 13 weeks, depending on the size of the fistula.

TABLE II. RESULTS IN 59 CASES No. of

No. of patients

operations

2 3 Dry Incontinent

Simple repair (no omentum) 5 5 0 0 5 0 Omentum repair 52 41 . 8 3 50 2 Urinary diversion 2 2 0

The long-term follow-up of these patients is inadequate since most of them Hve in outlying rural districts, but we believe that the severity of the social problem associated with incontinence would make them return for treatment should it subsequently recur.

No particular surgical complications were related to the surgical method, apart from a case in which 30 em of small bowel prolapsed through the vagina. The bowel was not gangrenous and was pulled up into the abdomen, and the vaginal defect was closed. One of the patients with a urinary diversion died from chronic renal failure 4 years after the procedure.

Discussion

The principal difficulties encountered in repairing a VVF are caused by the fact that the surrounding tissues are fibrotic and avascular. The result is unsuccessful repair, repeated operations, and loss of normal bladder function. The omentum brings a new blood supply to the damaged tissues, forms a third layer berween bladder and vagina and tends to plug small holes in the bladder. The result is to reduce the incidence of pin-hole fistulas, often a distressing postoperative complication. The major role of the omentum is the formation of new tissue. Goldstein and Dearden5 in experiments on rabbit bladder defects occluded with an omental flap found rapid and complete regeneration of the bladder epithelium. The bladder epithelium on the periphery of the defect appeared to result not only from extension of the bladder epithelium but also from multi potential mesenchymal cells in the omentum. They also demonstrated the formation of muscle bundles in the omentum.

We seldom close the vaginal epithelium over the omentum and on occasions have left defects in the bladder epithelium. We have seen clearly how these defects disappear, regenerating apparently normal vaginal and bladder epithelium. We have not demonstrated muscle fibres at the bladder neck, but the fact that postoperative bladder function is normal suggests that complete repair occurs. Coetzee and Lithgow6 reported that stress incontinence occurred in 25% of their cases, but we encountered this problem in only 1 case (2%) when using omentum.

We believe that a combined abdominoperineal approach with the use of omentum remains the treatment of choice in all but the simplest of fistulas. To obtain continence it is not sufficient to obtain closure of the fistula alone; normal bladder function must also be striven for.

We thank Professor H . Odendaal for reviewing this article, the late Dr V. Marais, formerly Medical Superintendent of Windhoek State Hospital, for permission to publish, and Dr C. J. H. Gr~ve and Dr M. Mphahlele for inviting us to Baragwanath Hospital and Gaborone Hospital respectively.

REFERENCES

I. Edwards JNT. Principles of managemet of the vesicovaginal fistula. S Af r Med J !983; 62: 989-991. . . .

2. Kiricuta I, Goldstein AMB. T he repair of extensive vesicovagmal fistulas with pedicled omentum: a review of 27 cases. ] Uro/1972; 108:724-727.

3. Baines REM, Orford HJL, Theron JLL. The repair of vesicovagmal fistulae by means of omental slings and grafts. S Af r MedJ 1976; 50: 959-961.

4. Turner-Warwick R. The use of omental pedicle graft m unnary rract reconstruction.] Uro/ 1976; 116: 341-347. .

5. Goldstein MB, Dearden LC. Histology of omemoplasty of the unnary bladder in the rabbit. l nvesc Ural 1966; 3: 460.

6. Coetzee T , L ithgow DA. Obstetric Fistulae of the urinary traer. J Obscec Gynaecol B r Cw/ch 1966; 63: 837-844.