Vaginal reconstruction using the bladder and/or rectal walls in patients with radiation-induced fistulas

Objective. In irreparable or recurrent vesicovaginal fistulas and cloacal d efects following high-dose irradiation therapy for gynecological malignanci es, urinary diversion is the last resort to achieve a socially acceptable s olution. In a select group of young and tumor-free patients, additional vag inal reconstruction may be indicated. Multiple operative procedures are ava ilable, but the results are often disappointing in the previously irradiate d area. Materials and methods. In six such patients with large radiogenic vesicovag inal defects (n = 5) or a cloacal fistula (n = 1), a continent reservoir us ing the transverse colon with an umbilical stoma was performed. At the end of the operation, the bladder was incorporated into a neovagina by incising the urethra, anterior vaginal wall, and the posterior bladder wall with el ectrocautery from the urethral meatus to the dome of the fistula. Results. No postoperative complications related to the vaginal reconstructi on occurred. After a mean follow-up of 4.7 years, all patients had a capaci ous vagina and a wide introitus; the neovagina measured a mean of 18 cm in length. Five patients with a partner reported a normal sexual life. No dysp areunia or discomfort from bladder or urethral mucosa during intercourse wa s reported. Conclusions. Following continent urinary diversion due to irreparable vesic ovaginal fistulas, a neovagina can be created by simple dissection of the p osterior bladder and anterior vaginal wall. When a colostomy is present, th e neovagina can additionally be augmented with a bowel flap of the Hartmann stump or by incising the rectovaginal septum. The technique affords good f unctional and cosmetic results. (C) 2000 Academic Press.