TRANSVAGINAL REPAIR OF VESICOVAGINAL FISTULAS AFTER HYSTERECTOMY BY VAGINAL CUFF EXCISION

Purpose: When repairing vesicovaginal fistulas after hysterectomy ther e is often reluctance to excise totally the fistula tract for fear of enlarging the tissue defect. It has been suggested that consequent ten sion on suture lines may cause recurrence of an even larger fistula. O n the other hand, a basic surgical principle is that scar tissue margi ns will not heal as quickly or at all compared to fresh viable margins . We reviewed whether our technique of total excision of the fistula t ract and vaginal cuff scar provides an efficient cure rate. Materials and Methods: We retrospectively analyzed the outcomes of 20 women who underwent vaginal cuff excision repairs of a vesicovaginal fistula aft er total hysterectomy. Women who had complex fistulas and/or prior rad iation therapy were excluded from study. Results: Of the 20 patients 3 (15%) sustained a bladder lesion that was repaired intraoperatively a nd 7 (35%) underwent 1 or more attempts at secondary repair. All fistu las were at the vaginal cuff. Mean fistula size was 0.7 cm. (11 women) . All repairs were performed as soon as possible after presentation ex cept 2 (10%) that were delayed because of the fistula appearance. The fistula tract was excised totally in all patients. All patients were c ured. There were no postoperative complications and no significant or symptomatic vaginal shortening. Conclusions: Transvaginal vaginal cuff excision repair is an effective first attempt cure of vesicovaginal f istulas after hysterectomy. Excision of the fistula tract and vaginal cuff scar enables the surgeon to suture viable tissues in every layer, thereby providing conditions optimal for wound healing. This procedur e obviates the need to wait for tissue readiness and to interpose a fl ap in the majority of patients.