SURGERY FOR THE OBSTETRIC VESICOVAGINAL FISTULA - A REVIEW OF 100 OPERATIONS IN 82 PATIENTS

OBJECTIVE: Vesicovaginal fistula resulting from prolonged obstructed l abor remains a major problem in developing countries where medical car e is limited. For many years surgical closure of the fistula was almos t impossible. However, closure rates today range between 65% and 95%. Attention now is being focused on training more surgeons to repair sim ple fistulas, identifying and preventing complications that occur even with successful vesicovaginal fistula closure, developing new techniq ues to close the most difficult fistulas to repair, and working to imp rove obstetric care to prevent future vesicovaginal fistulas. This stu dy reviews contemporary efforts to manage vesicovaginal fistulas with these goals in mind. STUDY DESIGN: One hundred consecutive vesicovagin al fistula repair operations that I performed in 82 patients are revie wed. Specific repair techniques are described for each vesicovaginal f istula type by anatomic vesicovaginal fistula classification. Primary closure rates and complications are examined by vesicovaginal fistula type, location, size, and number of prior repair attempts. RESULTS: Af ter 100 operations, 78 of the 82 patients (95%) had successful vesicov aginal fistula closure. Primary closure rates were noted to be 31 of 3 3 (94%) for suburethral fistulas, 10 of 14 (71%) for midvaginal fistul as, 9 of 10 (90%) for juxtacervical fistulas, 10 of 12 (83%) for ureth ral fistulas, 6 of 6 (100%) for uterovesical fistulas, but only 4 of 7 (57%) for combined vesicovaginal and rectovaginal fistulas. Repairs w ere only 50% successful on second attempts and only 33% successful on third attempts. Even in those patients who had successful closure of t he fistula, serious complications occurred in 59% of patients, includi ng other types of urinary incontinence, gynatresia, amenorrhea, and le g weakness. CONCLUSION: Basic principles of fistula surgery remain imp ortant in all types of vesicovaginal fistula repairs. Further research is needed into prevention and management of associated complications, into innovative repair of those few patients who do not have successf ul closure, and into training more surgeons to address the vesicovagin al fistula problem.