Introduction and Objectives
Vesicovaginal fistulas are rare but one of the most serious complications after a gynecologic surgery or radiotherapy of pelvic cancers. An important factor in the choice of a treatment method depends on the origin of a fistula and the previously undergone radiotherapy A growing number of detected neoplasm in the pelvis, more aggressive treatment methods and a wide use of tele-and/or brachy therapy increase a number of patients who need surgery.
Material and Methods
We operated on 85 patients with vv fistulas between 1991–2008. The youngest patient was 21, the oldest 75, mean age 54. In our group 19 patients had fistula repair operations in other hospitals earlier and 56 patients had RT in the past-the received dose within recommended range. Teletherapy alone in 2 cases. Both tele and brachytherapy in 54 cases. 3 patients had reirradiation after few years. 14 patients were reported to have cancer in histopathology specimenthere are confirmed neoplasmatic fistulas.120 operations were performed in different techniques Benign-uterine myoma was a primary disease for 14 patients, inflammatory process in the pelvis for 2, 2 – obstetrics. Neoplasm was diagnosed in 68 cases, endometrial cancer in 3, bladder cancer in 2, uterine sarcoma in 1. The rest of patients – 62 had diagnosed uterine cervix cancer.Postoperative iatrogenic fistulas were diagnosed in 31 cases. 1 after urologic procedure, 1 after cesarean section, 28 after gynecologic operations.
Type of performed operations: suture from vaginal approach was done 12 times, recurrence in 6 cases, closure by transabdominal, transvesical approach 36, recurrence in 9, we used tissue glue in, 2 recurrence in 1, cystojejunoplasty was done in 21, recurrence in 14, urinary diversion in (5 continent reservoir) 43, laparoscopic suture in 5, recurrence 4, definitive nephrostomy (single kidney) in 1. Some patients had to have more than 1 operation due to a recurrence of fistula: 1 patient(RT+) was operated 7 times and the fistula was closed without urinary diversion The survival status for all patients is monitored
The best results of surgery we obtained in the group of postoperative fistulas. Patient with neoplasmatic fistulas can received much better quality of life with urinary diversion, even when expected life time is short. Patients with cancer treated by radiotherapy of the pelvis in the past had worse prognosis for the good results of fistula repair operations so radiotherapy in the past is an important factor while selecting the type of surgery. Temporary urinary diversion can be performed for relatively young patients. The laparoscopy is not best solution for fistula repair surgery. Selection of patient should be very precise to every method to avoid unnecessary operations.
© 2009 European Association of Urology. Published by Elsevier Inc. All rights reserved.