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SURGICAL APPROACH

In the presence of vesicouterine fistula and urinary incontinence, the surgical treatment is the most adequate. This may consist in removing the fistulous tract, preserving the uterus, when we wish to maintain fertility 10. But in women with multiple births close to menopause with no interest in maintaining fertility, total hysterectomy is indicated 11,12.

When the option is total hysterectomy, the removal of the fistulous tract renewing the borders of the bladder is carried through. The bladder lesion must be sutured in two planes, with absorbable thread, followed by indwelling catheter. When we want the preservation of the uterus we must remove the fistulous tract and closed separately the uterine and bladder walls 13. Dissection must be meticulous, with the separation of the anterior uterine wall from the bladder and the vaginal wall, obtaining sufficient mobility to allow reparation of these structures with no tension. In some situations of bigger surgical difficulty, the bisection of the bladder, till reaching the fistulous tract, facilitates its dissection, separating it from the perifistulous inflammatory process. This way we attain the vesicle closing in good technical conditions 14. In many cases we advise a previous catetherization of the ureters as to avoid the lesion of these structures. We may interpose, between the bladder and the uterus, epiploon, fatty pediculate, peritoneum or pediculate muscular flap or bladder mucosa to avoid fistula recurrent. Meantime, in most of the related cases the interposition of these structures did not allow using the big epiploon to be interposed between the bladder and the uterus. However, the transvesicle abdominal way may be used, this presents surgical limitations.

The vaginal way has been used a lot. In this approach the bladder is separated from the anterior cervical region and the inferior portion of the uterus with the removal of the fistulous tract and the separate suture of both organs. Nowadays, this way exceptionally used, being proposed in cases with previous sub total hysterectomy 17,18.

One of the discussed aspects in literature is the most opportune moment for the surgical treatment of these fistulas. Most authors advocate not to have precocious surgery, waiting 2 to 4 months 19,20. The justification for this conduct is that the existence of an edema, a certain degree of infection, hematoma, destruction and tissue necrosis would compromise the surgical result, even enlarging the size of the fistula. In these conditions, while awaiting surgery, it is recommended to use a urethral catheter for 4 to 6 weeks. After this period, if there is no spontaneous cure, there is no justification for vesicle draining for a longer period of time 21.