In the now existing
medical literature there is an ample debate about the adequate moment for surgical
treatment. Some authors raport that it is necessary to wait between 3 and 6 months after
the event that determined the fistula, to render concrete surgical treatment.
The objectives of
a late intervention include total regression of the local inflammatory process, the
reestablishment of the tissue planes and the diminishment of the size of the fistula. This
waiting period is important, apparently, if the fistula will be treated by abdominal way
and if it appeared after an abdominal hysterectomy ³.
More recently publications appeared that compared tardy treatment (3-6 months) with a
precocious treatment (1 month). The result of these works showed similar success rates for
both approaches, allowing us to infer that a precocious therapy should be adopted due to
its shorter period of internment and less discomfort to the patients 14,15.
Before any surgical procedure it is recommended, in the pre operative, to collect a urine
culture for the diagnosis and adequate treatment of an eventual associated urinary
The prophylactic antibiotic treatment in the pre operative must
be done with antibiotics of an ample spectrum, for example, an aminoglycoside associated
with cephalosporin, which must be started 24 hours before surgery. The presence of a
vaginal or pelvic infection is a factor that is a counter indication of immediate
reparation of the fistulas, needing a prolonged antibiotic therapy and a previous
resolution of tissue infection. In cases of an infection of the vaginal dome an antibiotic
must be associated with an action on the anaerobic germs ³.
and Raz ³ mentioned some
important principles that must be remembered during the closing of a vesicovaginal
fistula: an adequate exposure of the fistula, the use of a waterproof suture, the use of
well vascularized tissues for repair, closing in several perpendicular suture planes one
against the other, absence of tension in the suture area, an adequate and premature
urinary drainage after the repair and the absence of local infection at the moment of
surgery. The attention to these basic surgical principles raises significantly the success
Traditionally, many surgeons choose to remove the fistula trajectory during the surgical
treatment, with the intention of reviving the lesion edges before suture. There are works
in literature showing that, in repairs through the vaginal way, excising the fistulous
trajectory is not necessary for surgical success. The maintenance of the fistula
trajectory avoids the risk of an iatrogenic enlargement of the lesion; it diminishes the
chance of a ureter lesion and allows that the suture may be executed in a non-crumbly
The post-operative vesical drainage, through a urethral catheter and a cystostomy, is
extolled in all cases, independently of the technique and the chosen approach3. A continuous
vesical drainage is recommended for 2 to 3 weeks. The non-inhibited vesical contractions,
related to the presence of the drainage catheters and frequently present in the
post-operative, must be treated precociously 4.
The use of vascularized patches, interposed to the suture planes, and many times are
necessary. The surgeon that carries out a surgery for the correction of vesicovaginal
fistulas must know these techniques previously. There is no consensus of when to use
patches in a VVF repair. However, traditionally, these are used in cases of recurring
fistulas, multiple, of large dimensions, complex, post-radiotherapy, localized in the
vaginal dome, of ischemic cause (obstetric), when the tissue used in the suture possesses
an intense fibrosis and in the cases where there is doubt of the quality of the suture
used in the correction (table 2).
The patches more frequently used are the ones of Marthius, the patches of the abdominal
rectal muscle or gracile, peritoneum and omentum 3,5,18 .
Evans and collaborators20
compared vesicovaginal fistula cases treated with the use of patches with cases in which
these were not used and they concluded that in all the fistulas treated abdominal way the
patches must be used.
Recently some authors have proposed correction techniques of vesicovaginal fistulas by
vaginal approach. They relate less morbidity, bleeding and vesical irritation, in
consequence of dissecting the bladder less, making it possible to leave the hospital
sooner. Patients operated vaginal way have a higher satisfaction degree and less
post-operative pain 4,5. The biggest argument
against using the vaginal way consists in the absence of a good exposition of the VVF with
difficulty for the execution of repairing the lesion22. On
the other hand, Miller and Webster raport, when necessary, the use of adequate perineal
separators (Omni or Bookwalter) associated to a posterolateral episiotomy, which allows a
good exposition of any vesicovaginal fistula4.
Leng et al22
compared cases of VVF operated vaginal way with cases operated via the abdominal way and
concluded that, following the recent tendency of other authors, the cases where they
cannot get a good exposition of the fistula, the cases with an intense fibrosis or atrophy
of the vaginal mucosa because of Hipoestrogenism and the cases of morbid obesity should be
operated via abdominal way, the others in which the exposition of the fistula is adequate
should be operated via vaginal way. Another indication to correct a VVF via abdominal way
is the need of a simultaneous treatment of other abdominal lesion (Ex: fistulas or ureter
stenosis, enteric fistulas, the need to make vesical enlargements or tumor extirpations,
When we compare the vaginal techniques we see that these approach the vesicovaginal
fistulas excising them or not. In their majority the fistulous trajectory is sutured in
several perpendicular planes among themselves and some flaps are created from the vaginal
mucosa in a U or a J to cover the suture area 26,27,28.
Urinary derivations may be created for the treatment of VVF using different segments of
the digestive tract. The use of this technique is associated, frequently, to cases of
post-radiotherapy fistulas of great dimensions, where some authors mention it as a choice
technique in these situations 29.
But, other surgeons relate that the use or urinary derivations for the treatment of VVF is
not common, as much as in cases post-partum or post-surgical, like in cases of
post-radiotherapy, 2% and 12% respectively 2,30,31.
Recently innovative techniques have emerged; among these fibrin glue stand out, Yag laser,
laparoscopy and endoscopy 6,32,33,34,35,36,37.
A numberless amount of authors have related success with the use of more conservative
techniques in the treatment of vesicovaginal fistulas, but such conducts seem to be really
effective in smaller than 5mm fistulas 36,38,39.