A 72-year-old woman presenting with continuous urinary leakage per vagina was admitted to our centre in August 2011. In May 2011, she had undergone hysterectomy because of a benign disease.
The exams demonstrated a 3-mm wide fistula between the bladder trigone and the upper part of vaginal vault (). Microbiological examinations indicated typical chronic infection with Escherichia coli. All other laboratory parameters were within the normal range.
A cystourethrography scan shows contrast medium leaking into the vagina
Because of the localization of the VVF in the vaginal apex, we initially considered the laparoscopic approach. However, as our team had carried out several LESS transvesical operations over previous years, we decided to use this technique for VVF repair with a single port introduced directly into the bladder.
The patient was placed in the lithotomy position. Subsequently, both ureters, as well as the fistulous tract, were catheterized (). We introduced an 18 F Foley catheter into the vagina and filled its balloon with water up to 30 ml. This manoeuvre plugged the vagina, and decreased gas leaks during the procedure.
Figure 2 Intraoperative photographs. A – Ureteric catheterization to safeguard the ureters. Note another ureteric catheter through the fistula. B – Circuitous dissection of the VVF orifice from the bladder mucosa with a hook electrode. C – (more ...)
A 1.5-cm longitudinal skin incision was made 2 cm superior to the pubic symphysis. We used two stay sutures to facilitate the insertion of the port. The introducer with the inner ring of a TriPort+ access system (Olympus Winter&IBE GMBH, Hamburg, Germany) was inserted directly into the bladder via the skin incision under cystoscopic control. The rings of the TriPort+ were fixed to the abdominal wall area. The bladder was filled with carbon dioxide up to a pressure of 14 mm Hg.
We used a 10-mm, rigid, 30° videolaparoscope (Olympus Europa GmbH, Hamburg, Germany), which was introduced through the 10-mm channel of the TriPort+. The three 5-mm working channels were used as follows: 1) for a 5-mm standard laparoscopic dissector in the left hand, and 2) for a 5-mm monopolar rigid hook electrode or a 5-mm rigid needle-driver (Karl Storz, Tuttlingen, Germany) in the right hand. When needed, we introduced the suction tube through the third 5-mm channel of the TriPort+ or through the urethra.
The visualization inside the bladder was sufficient to recognize and control all anatomical structures. We separated the fistula from the bladder mucosa by a circular cut using a hook electrode (, ). The superficial rim of the fistulous tract was resected, and either the vaginal wall or the bladder defect was closed tightly with an absorbable 3/0 running suture (The V-Loc™ 90 Absorbable Wound Closure Device, Covidien, Norwalk, CT, USA) (, ). The integrity of the bladder was confirmed by filling it with 200 ml of saline. Betadine-soaked roller gauze was inserted into the vagina for one day. The skin incision was sutured with two stitches. The procedure was completed successfully with no extra port insertion. The operative time was 170 min, and the blood loss was insignificant. The postoperative period was uneventful. On the fifth postoperative day, ureteric catheters were removed and the patient was discharged home. She presented no vaginal leakage on discharge. An 18 F Foley catheter was retained for 2 weeks. Quinolone oral intake was administered for 3 weeks and pelvic rest was recommended for 2 months.
Five weeks after surgery, diagnostic scans (urethrocystography) revealed no presence of VVF (). During a 4-month follow-up, the patient remained continent, and laboratory examination results were all within the normal range.
A postoperative cystogram obtained 7 weeks later does not show any leak