Vesico-vaginal fistula after childbirth. Preparing for the operation

A fistula is a pathological canal, a message that is formed for various reasons between two adjacent hollow organs or cavities. Relatively common pathology. A fistula in the vagina can be a congenital disease, in which case its treatment is carried out even in childhood. In adult women, such formations are most often of a traumatic nature: a consequence of complicated childbirth, surgical interventions, inflammatory processes of the rectum, etc. How to deal with the disease?

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Causes of fistulas in the vagina

With the formation of congenital fistulas in girls, the pathology begins to manifest itself after birth, therefore, it is noticed almost immediately, less often - at 3-4 months of age. As a rule, such fistulas are treated quite successfully and subsequently do not give relapses. The reasons for the formation of such messages are violations in the development of the organs of the gastrointestinal tract and vagina. At some stage, incomplete fusion of cells and ducts occurs, resulting in the formation of fistulas.

As for the formation of pathological fistulas in women of the reproductive period, they are acquired. This is facilitated by a very close arrangement of the pelvic organs, often they are separated from each other only with the help of a small connective tissue septum. The vagina borders behind the rectum. In front - with the urethra, bladder and ureters. Also, loops of the small and large intestines can approach the vagina. Fistulas can form between all these parts.

postpartum trauma

This is one of the common causes of fistula formation in young girls. As a rule, their childbirth is difficult, prolonged, with numerous ruptures or with the use of additional techniques (imposition of obstetric forceps, vacuum extractor, etc.). Moreover, in most cases, fistulas are formed after suturing the posterior wall of the vagina and with ruptures of the 3rd and 4th degree of the perineum.

Pathological anastomoses after childbirth can be formed without previous injuries. Sometimes for their formation, a long stay of the fetus in the same plane is sufficient. In this case, excessive compression of the tissues, their ischemia, and then necrosis and, as a result, fistulas occur.

Risk factors for the formation of injuries of the birth canal and subsequent pathological fistulas are the following:

• discrepancy between the size of the pelvis of a woman and the parameters of the child;
• large and giant fruit;
• primary or secondary weakness of labor activity;
• rapid childbirth;
• incorrect presentation of the fetus;
• a long anhydrous gap (the fetal bladder is a kind of “pillow” between the baby and the pelvic organs in a woman, as a result, they are not under such strong pressure).

Postpartum fistulas are quite effectively treatable. It's all about the structure. As a rule, the inlet and outlet are at the same level in the vagina and rectum, so some complications develop very rarely (such as streaks, abscesses of the rectovaginal area, etc.). The same applies to most fistulas that form after surgical interventions.

Quite the opposite picture with injuries of the type of "falling on a stake." Here, the fistulous tract has many branches and deviations, streaks, abscesses, etc. are often formed. They tend to recur even after radical treatment.

Fistulas after surgery

Other operations on the pelvic organs can also lead to the formation of fistulous tracts. These include:

• Interventions for genital prolapse, urinary incontinence. During such operations, the vaginal tissues are detached from nearby structures. A very close location often leads to accidental injury or stitching.
• Supravaginal amputation of the uterus and extirpation. More often, after such operations, fistulas develop between the intestinal loops and the vagina in those women who suffer from Crohn's disease, ulcerative colitis, etc.
• After removal of cysts of the vagina.

Fistulas after inflammatory processes in the pelvis

Various inflammatory processes in the small pelvis with inadequate treatment or its absence at all can lead to the formation of fistulas. Most often these are the following diseases:

• paraproctitis and proctitis,
• complications of anal fissures,
• diverticulitis and some others.

Other causes of fistulas

Fistulas can form after other pathological conditions. Therefore, when such false moves are detected, it is also necessary to exclude the following points:

• malignant tumors of the anorectal region (including the rectum);
• recent courses of radiation therapy in this area;
• injuries received during sexual intercourse (including rape);
• chemical or thermal burns, etc.

Classification of internal fistulas by shape and location

Fistulas are classified according to the location of their outlets, as well as which organs or cavities are involved in their formation.

According to the height at which the mouths are located on the back wall of the vagina, they distinguish:

• low (no more than 3 cm from the vestibule);
• medium (at a height of 3 to 6 cm);
• high (at a distance of more than 6 cm).

According to which organs of the small pelvis are reported, they distinguish:

• rectovaginal - the most common, located between the rectum and the vagina;
• cystovaginal - the bladder is involved;
• urethrovaginal - connected to the urethra;
• ureterovaginal - communicate with the ureters;
• small-intestinal and large-intestinal - with loops of the small and large intestines, respectively.

Watch the video about the vaginal-rectal fistula:

Symptoms of a fistula in a woman

Fistulas do not form immediately after childbirth or some kind of injury. Their formation takes time - from 2 - 3 weeks to several months. But some symptoms may appear immediately, for example, with a simultaneous defect in the rectal sphincter, a woman will notice complete or partial incontinence of feces and gases immediately after the injury.

All fistulas, regardless of their origin, have approximately the same clinical picture. The main symptoms are as follows:

• Flatulence from the vagina under normal conditions or on exertion. The process may or may not be accompanied by some sounds.
• Discharge of liquid feces from the vagina. Solid masses, as a rule, do not pass, since the defects in most cases are small. But this is not excluded either.
• Urine excretions. This can be either periodic leakage (if the fistula is located high), or permanent (if it is low).
• Due to constant secretions, a woman may develop maceration of the skin of the perineum and inner thighs. In these places, an infection can also join, which will aggravate the clinical picture.
• Concerned about constant inflammatory processes in the vagina - colpitis, etc. It is even possible to spread to the uterine cavity, fallopian tubes and ovaries with the formation of hydrosalpings, pyosalpingxes and abscesses. The latter conditions may be accompanied by an increase in body temperature, the appearance of weakness, lethargy and other symptoms of intoxication. They require surgical treatment, sometimes with the removal of the uterus.
• Chronic constantly recurring infectious processes in the urinary system. It can be pyelonephritis, urethritis, etc. It all depends on the location of the fistula, its age and size.
• The general clinical picture may be accompanied by a violation of the sphincter of the rectum with incontinence of feces and gases. This is especially common with extensive ruptures and injuries after childbirth, with divergence of seams, etc.
• A woman is forced to limit her sexual life due to all such secretions and inflammatory processes. As a result, problems may arise in family life.
• Along with everything, psychological dissonance arises, which can turn into all kinds of mental trauma.

In the clinical picture of the disease, certain symptoms may predominate. It all depends on how and where the fistula is located, what contents pass through it.

Problem Diagnosis

Such conditions can be suspected based on the complaints of a woman. It is also possible to monitor the healing process of wounds after operations and childbirth by checking whether fistulas have formed.

The choice of research method will largely depend on which organs are involved in the pathological process. The main diagnostic manipulations are as follows:

• Gynecological examination. The study of the posterior wall of the vagina is a simple procedure, and the location of the fistula can be clearly established.
• Sigmoidoscopy - examination of the rectum and sigmoid colon using special instruments.
• If necessary, colonoscopy (complete examination of the intestine with a special technique) or irrigoscopy (contrast with barium suspension drunk inside and subsequent X-ray exposure). They are performed to rule out Crohn's disease, ulcerative colitis, etc. Intestinal perforations at their sites of foci can directly lead to the formation of fistulas.
• Fistulography - "staining" of the fistulous passages with special contrast solutions. The procedure helps to identify all the moves and directions of pathological messages.
• Cystoscopy is an examination of the bladder and urethra. If necessary, urography and other similar ones are performed.
• If a rectal sphincter incompetence is suspected, anorectal manometry, electromyography, sphincterometry, etc. are performed.

The list of examinations may change, be supplemented depending on the clinical picture of the disease and associated symptoms.

Surgery is the only way to cure a fistula

Conservative measures will not lead to the closure of fistulous passages in 95% of cases. The only radical treatment is surgery. Moreover, the volume, methodology and stages can differ significantly depending on the location of the fistula and its type. In the same way, various accesses for intervention are used:

• vaginal,
• rectal,
• perineal,
• abdominal and others.

The following surgical options may be used:

• One step operation. With this chosen path, the fistulous passage and all possible conditions for its recurrence are immediately removed. In parallel, levator and sphincteroplasty can be performed (with the failure of the muscles that close the anus). These operations in most cases have a non-classical execution, sometimes it is necessary to carry out autotransplantation - the borrowing of tissue flaps to close defects.
• two-stage operations. They are performed if the water or outlet of the fistula has obvious signs of inflammation, there are granulations characteristic of this - tissue growth. In such situations, the colostomy is initially removed. The essence of the method is that the intestinal loop is cut off at a certain level and its outlet is attached to the anterior abdominal wall. Thus, the intestinal masses will not exit through the rectum, but will move through the colostomy into a special reservoir, which is attached to the anterior abdominal wall.
• After 2-3 months, the inflammation at the site of the fistula disappears during treatment, and the necessary surgical interventions can be performed. After that, some more time is given for healing. As soon as the opportunity arises, the colostomy is removed, the normal passage of intestinal contents is restored again.

When can you return to normal life after treatment?

When a woman is able to lead her normal life depends largely on the type of treatment she has received. Minimum term - 2 - 3 weeks, maximum - up to a year. In the latter case, we are talking about the installation of a colostomy. Such treatment involves at least three major operations, in between which a woman can lead a fairly active lifestyle.

Prevention of recurrence of fistulas

• Any inflammatory diseases of the vagina, urinary system and rectum should be treated in a timely manner.
• You need to follow a diet rich in dietary fiber for regular bowel movements. Chronic constipation will exacerbate the difference in pressure in the rectum and vagina, provoking a recurrence of fistulas.
• After surgical treatment, it is even allowed to plan a pregnancy, but the method of delivery is only a caesarean section, since with natural there is a high risk of scar rupture and relapse of the disease.
• Pelvic floor muscle weakness should be prevented, for example, by Kegel exercises.
• It is necessary to treat comorbidities (Crohn's disease, etc.) that can lead to the formation of fistulas, sometimes in a different place.

Vaginal-rectal and other types of fistulas are unpleasant and in many ways change the lifestyle of a woman and her psychological state of the disease. The right attitude for childbirth, strict adherence to all recommendations during them and competent suturing of wounds is the basis for the prevention of the disease. You should also promptly seek medical help if you have problems with the rectum, urinary organs. In many ways, this helps prevent the formation of pathological anastomoses.

A vesicovaginal fistula is an abnormal communication between two abdominal structures: the bladder and vagina. The main reasons for the formation of vesico-vaginal fistulas are the consequences of unintentional damage to the bladder during gynecological operations, or resulting from pathological childbirth.
Vesico-vaginal fistulas are among the most painful conditions that cause a woman not only physical and moral suffering, but also have a negative impact on the anatomical and functional state of the entire urinary tract.
A number of gynecological operations performed for the most common cancers of the cervix, vagina, as well as for endometriosis, may be accompanied by the formation of a vesicovaginal fistula.
One of the most problematic for treatment, severe and debilitating during the course, is post-radiation damage with urogenital fistulas that have arisen.
Recently, the number of cases of bladder injuries with the formation of a secondary fistula has increased, as laparoscopic operations in the pelvic region have become more common.
Sometimes in clinical practice there are severe types of fistulas due to the presence of a foreign body in the vagina during self-masturbation. Combined damage to the pelvic organs can occur as a result of causing bodily harm to a woman. However, the last two causes are rare, and gynecological operations play a major role in bladder damage. At the same time, hysterectomy for benign uterine fibroids accounts for up to 70% of the etiology of all gynecological fistulas.
In economically developed countries, the incidence of obstetric vesicovaginal fistulas is no more than 10%. At the same time, they differ in the mechanism of damage, mainly due to abnormalities in the position of the fetus, the need to use obstetric forceps, or the resulting atonic (massive bleeding), requiring hasty removal of the uterus. In the pathogenesis of the formation of obstetric fistulas, the main role is played by ischemia of the tissues of the birth canal due to prolonged pressure on them from the fetal head.

Symptoms

The main symptom that characterizes the presence of a formed fistula is the constant (day and night) urine output from the vagina after a pelvic operation. Often in the early postoperative period, this is preceded by an increase in vaginal discharge, which can be either serous-bloody (like lymphorrhea) or contain the secret of the fallopian tubes.
An unexplained increase in the amount of wound discharge or the appearance of blood in the urine may indicate the formation of a fistula. With its small size, often the only objective sign is watery vaginal discharge with normal urination preserved.
Preoperative diagnosis of vesicovaginal fistulas
1. Anatomical characteristics. Clarification of the following parameters (vaginal examination):

• localization and size of the fistula, its connection with the cervix, urethra and urethro-vesical segment;
• the degree of prolapse of the bladder wall into the vagina;
• the number of fistulas;
• the direction of the fistula;
• condition of the urethra;
• mobility of the vaginal wall;
• the presence of scars;
• degree of inflammatory changes.

2. Endoscopic data (cystoscopy):

• the size of the fistula and its localization;
• the degree of inflammation of the bladder mucosa;
• the ratio of the mouths of the ureters to the edge of the fistulous opening;
• the presence of stones and ligatures.

An objective examination using vaginal speculums helps pinpoint the location of the leak, which is often located in the vaginal fornix. In the case of an insufficiently clear definition of the fistula opening, the method of intravesical administration of indigo carmine or a sterile blue solution is used. It is possible to recognize the localization of the vesical fistula during cystoscopy, which allows you to identify the relationship of the fistula to the mouths of the ureters. If the size of the hole does not allow filling the bladder with a sterile liquid, it is possible to conduct an examination by putting on a condom attached to the optical system of the cystoscope.
Unlike ureterovaginal fistulas, the clinical symptoms of which develop later, vesicovaginal fistulas in 2/3 of cases appear within the first 10 days after injury. The possibility of multiple fistulas should be considered, especially in cases due to obstetric trauma or radiation therapy. About 10% of vesico-vaginal fistulas are associated with concurrent ureter injury or obstruction. Therefore, it is mandatory to perform excretory urography to clarify urodynamic disorders. Fistulas caused by radiation therapy or obstetric trauma may appear months or even years after injury.
During a vaginal examination in the mirrors, the condition of the tissues in the circumference of the fistula, its dimensions are assessed. An additional examination method is to perform a cystourethrogram, which allows you to determine not only the size of the fistula, but also to identify concomitant prolapse of the bladder, vesicoureteral reflux, or to confirm stress urinary incontinence.

Treatment

One of the most difficult issues in the treatment of vesicovaginal fistulas is the timing of fistuloplasty. There are two approaches: early intervention and delayed surgery. Most gynecologists - the "culprits of the unfortunate outcome" of the operation - advocate the fastest elimination of the resulting fistula. Their arguments can be understood - they are driven by the desire to get rid of the mistake they made as soon as possible. Early surgery saves patients from the possible progression of inflammatory processes, inevitable companions of ongoing operations in the small pelvis, and also prevents possible shrinkage of the bladder due to forced afunctionality. However, the main argument is still the desire to quickly get rid of this flaw, which unintentionally turned out to be a heavy burden for a woman. Most patients themselves strive to quickly get rid of this very tragic condition. However, the "short wait" method is fraught with the risk of recurrence with all the ensuing adverse consequences. The enormous psychological stress of the patient, faced with the need for another, sometimes more complex, operation, is hard to imagine. One of the founders of urogynecology, Professor Dieffenbach wrote: “It is difficult to imagine the tragic state of a woman who, after removal of the uterus, has urine discharge from the vagina with all the painful consequences. All family relationships are torn because of this disgusting disease. The husband is disgusted with his wife, and the previously affectionate mother tries to avoid communication in the circle of her children.
Most experts support the justified tactics of delayed fistuloplasty. The optimal time for its implementation is 4-6 months from the moment of fistula formation. This timing is in line with the classic strategy for successful fistuloplasty, as long-term treatment ensures that the inflammatory response caused by the surgery is maximally subsided. During this time, a comprehensive preparation of the object of intervention is carried out - ligature stones are removed, mechanical cleaning of the vaginal cavity from necrotic masses is performed, sources of necrosis and swelling of damaged tissues are eliminated.
Preoperative preparation includes estrogen replacement in menopausal women or after hysterectomy. In modern conditions, the principles of antibacterial treatment have also changed - preference is given to perioperative antibiotic prophylaxis.
The complex of necessary preparation for the asepticity of the surgical field includes means of washing the vagina with antiseptic solutions or the introduction of tampons with anti-inflammatory drugs. At the same time, antiseptic liquids are instilled into the bladder. An excellent sanitizing effect is found by proteolytic enzymes (trypsin, chymotrypsin), which accelerate the processes of tissue cleansing. In order to eliminate dermatitis, the skin of the perineum and thighs is treated with disinfectant indifferent ointments and creams. Long-term preparation is necessary for post-radiation vesico-vaginal fistulas, since in addition to typical complications, a pronounced circulatory disorder with the presence of non-viable tissues is noted in the affected area.
A complex of preparatory therapeutic measures leads to the restoration of the plastic properties of the bladder wall and vaginal tissues. All this creates the necessary conditions for successful fistuloplasty and prevention of fistula recurrence. The disadvantage of a long waiting period is the continued distress and persistent weeping experienced by the patient.
Transvesical or vaginal access to close the fistula?
Among scientists, discussions about the rational choice of access to suturing vesicovaginal fistulas do not stop. While some experts advocate the convenience of the vaginal approach, considering it to be anatomically justified, optimal due to its proximity to the operator, others consider transcystic access appropriate.
It can be assumed that both of them put forward arguments based on their own experience. We believe that the main and decisive choice can only be the degree of severity of the existing pathological and anatomical conditions: the location of the fistula, its size, the presence of cicatricial changes and the relationship to the mouths of the ureters. Equally important is the extensibility of the walls of the vagina, the depth of the fistula and involvement in the pathological process of the ureter. It is necessary to take into account the type and extent of previous attempts to eliminate the fistula.
To eliminate the fistula, one has to resort to complex surgical interventions. The failures of the latter are due to both the underestimation of the existing pathological changes and the insufficient experience of the operator.
It should be emphasized that not only an adequately performed first operation has the greatest chance of success, but also the method that the surgeon is better at. The choice between vaginal and transvesical access depends on the skill and experience of the operator.
Vaginal access has the following advantages:

• low trauma;
• no bladder incision;
• a simplified version of fistula closure;
• relatively quick recovery and no severe complications.

Vaginal method for suturing vesicovaginal fistulas
The vaginal method is preferred in patients with small, uncomplicated fistulas and in women with flexible vaginal walls that are easily stretchable. This method is used to repair fistulas where assisted tissue interposition is not required.
The method of W. Latzko (1942) is also popular, in which a circular incision of the vaginal mucosa is made around the Foley catheter inserted into the fistulous opening, with an indent of 1 cm from the edge of the fistula. Then the cruciformly dissected cicatricial-altered vaginal mucosa is removed, and the walls of the mobilized tissues are sutured in layers - first the bladder, then the vagina.
Transvaginal access is distinguished by good visibility, spatiality, accessibility for manipulation by the operator and, no less important, physiology. The main reasons limiting its use are due to the depth or lack of control over the orifices of the ureters, since their capture in the suture, stitching, or even pulling up to the fistulous edge zone can cause severe urodynamic disturbances with adverse consequences of postoperative urine passage.
The classical principle of vesico-vaginal fistula closure includes excision of the fistulous tract in order to remove the cicatricial ring, separation of the vesical and vaginal walls and their separate suturing with multidirectional suturing. This tactic is widely used by both operating gynecologists and urologists. In most medical institutions, urologists have priority in the elimination of genital fistulas of any etiology.
The most popular, accessible and effective is the classical version of excision of the fibrous ring, mobilization of 1.0-1.5 cm of the bladder and vaginal walls with their layer-by-layer separate suturing. The risk of damage to one or both orifices of the ureters can be avoided by their preliminary catheterization (Fig. 1).
The technique of suturing disjointed walls with a Foley catheter previously introduced into the fistula is distinguished by high efficiency. With a catheter balloon inflated, the vesico-vaginal complex (with moderate tension) is fed into the wound, the edges are refreshed and sutured separately with purse-string and semi-purse-string sutures (Fig. 2).
The duration of urethral drainage of the bladder is a significant factor in the success of the operation. To reduce spastic contractions of the bladder, patients are prescribed anticholinergic drugs (vesicar, oxybutynin). Antibiotics are continued until the catheter is removed (within 7-10 days).
Transvesical method for suturing vesicovaginal fistulas
Transvesical access, often accompanied by the need to open the abdominal cavity, is used in patients with extensive or complicated fistulas (simultaneous involvement of the ureter) when the orifice of the ureter/s is close to the edge of the fistula opening. Transvesical access is indicated in cases of concomitant intestinal damage, when simultaneous cystoplasty or elimination of intra-abdominal pathology is necessary.
Access through the bladder involves exposure of its anterior wall, wide spreading of the edges and visual examination of the cavity. The fistulous opening is examined, its localization, size, relation to the mouths of the ureters and the internal opening of the urethra are determined. Difficulties in suturing the fistula are due to the depth of its occurrence, the existing cicatricial layers and the proximity of the mouths of the ureters to the fistula opening. To improve access to the fistula, you can use an inflatable rubber ball inserted into the vagina. Facilitates the separation of the bladder and vaginal walls by pulling up the edge of the fistula with an Alice clamp. The existing jumpers dividing the fistula into separate openings are dissected and excised. Transvesical approaches do not always provide good exposure in the area of ​​the resulting fistula, especially in obese patients.
Excision of the cicatricial ring and separation of the walls is usually accompanied by an increase in the fistulous opening, which should not confuse the operator. For the imposition of separate knotted sutures, it is necessary to use apyrogenic synthetic threads (vicryl). Suturing is carried out in different directions and carried out in bloodless conditions. The wound of the bladder is sutured tightly, followed by catheterization and the introduction of a tampon richly treated with aseptic ointment into the vagina.
Prolonged drainage of the bladder is essential to the success of the operation. To reduce spasm of the bladder, anticholinergic drugs are prescribed, and oral antibiotics are continued until the catheters are removed on the 7-10th day after surgery. Before removal of the drains, a cystogram is performed to document the integrity of the bladder.
The fibrous ring can be excised not all at once, but in stages, starting from the most deeply located one of the edges. This is followed by the imposition of the first, defining suture, which captures the edges of the vaginal wall, indented from the edge by 0.5-1 cm. Details of the transvesical closure of the urinary fistula are shown in Figure 3. The best suture material is Dexon-II - atraumatic, durable, with a long resorption period, which does not cause tissue edema and inflammatory infiltration.
The defect of the vaginal wall is sutured firmly and tightly. When suturing the bladder wall, special attention should be paid to the distance between the mouth of the ureter and the fistula. We consider it justified to perform ureterocystone anastomosis where the orifice opens less than 0.5 cm from the suture line.
Usually the distance becomes clearly defined as soon as the edges of the bladder approach. There should be no “dead space” between the sutured walls of the vagina and the bladder, i.e. cavity in which wound contents can accumulate. We do not at all consider the transverse-longitudinal decussation of the superimposed two-layer sutures to be obligatory. The main thing is that the seams are applied without tension and ensure tightness.
Drainage of the bladder is best done by the imposition of a cystostomy, which, as a rule, guarantees adequate diversion of urine and wound contents. An aseptic ointment swab moistened with an antibiotic solution is inserted into the vagina. The tampon should be changed daily for 5-6 days, and the suprapubic drainage should be removed on the 12-14th day after the operation. A smooth postoperative course allows you to restore an adequate act of urination already in the immediate postoperative period.
Transabdominal approach for suturing vesicovaginal fistulas
Abdominal access to close the fistula is indicated in the following cases:

• when it is necessary to open the abdominal cavity to perform related operations;
• with extensive fistulas;
• with involvement of the ureters;
• with combined fistulas.

The technique of the operation is as follows. The pelvis is opened from the lower-middle laparotomy access, extraperitonization is performed. The wall of the bladder is dissected in the sagittal direction with the transition to the upper and rear, with the mobilization of which it is possible to reach the fistula. A pair of sutures are applied to each wall of the bladder to facilitate subsequent suturing. The bladder is separated from the vagina, then the fistula is excised along with the fibrous ring. All this should be done very carefully so as not to damage viable tissues. To facilitate the dissection of the vaginal wall, a long clamp is inserted into it, in which the ball is clamped, which is palpated in the retrovaginal zone. The vaginal wall is sutured with double row sutures. Then the defect of the bladder is sutured, and it is recommended to do this in layers, with chrome-plated catgut. An omental flap is inserted between the vagina and the bladder (Fig. 4).

Treatment of postradiation vesicovaginal fistulas

The most severe damage to tissues and the vagina is provided by radiation therapy. Errors associated with prescribing excessively high doses of radiation, disproportionate beam directivity and the lack of protective therapy cause the development of extensive post-radiation injuries of the bladder and terminal ureters. Obliteration of the latter leads to post-radiation strictures due to scarring. Where these formidable complications are combined with the formation of bladder fistulas, the prospect of an adequate cure for patients becomes completely problematic. Even isolated vesicovaginal fistulas resulting from radiation therapy are difficult to treat. This is due to many factors: the large size of the fistula, its localization in the triangle of the bladder, the extensive area of ​​radiation damage to neighboring tissues, the involvement of the mouths of the ureters, and a sharp inhibition of the processes of repair of irradiated tissues. Reasoned indications and noble impulses to cure the patient turn into incredible suffering and create a situation in which the treatment method turns into more serious consequences than the existing disease.
In this regard, the thought arises of the need for careful prescribing of radiation therapy for oncological diseases of the genitals in women. It is not out of place to reflect on the fact that the severe consequences and functional damage to the urinary tract lead to immeasurably greater suffering than the dubious success in curing cancer.
Reconstructive surgeries in patients with post-radiation vesicovaginal fistulas are among the most difficult in urogynecology. The reasons lie in the fact that radiation therapy has a through the same type of damaging effect on the walls of the bladder and vagina. The tissues around the fistula undergo distinct fibrotization, become inelastic and incapable of healing. The vascular network becomes empty and, consequently, vascularization is sharply disturbed. These circumstances should be taken into account in the preparatory period, which is more than half longer than the interval required for plastic surgery in women with purely post-traumatic vesicovaginal fistula. The ultimate goal of preoperative therapy, which is carried out for at least a year, is the complete elimination of necrotic tissues, visualization of the demarcation line and restoration of blood supply. The treatment plan, along with vaginal douching with antiseptics, periodically includes broad-spectrum antibiotics, dimexide intravesically and enzymatic therapy to improve the reparative ability of mucous membranes. A good sanitizing effect is provided by the introduction of fish oil suspension into the bladder.
If there is no simultaneous involvement of the ureters or rectum, for the treatment and elimination of isolated post-radiation vesico-vaginal fistulas in the clinic, the technique of tissue interposition is used intraoperatively. Its founder was the German gynecologist H. Martius (1928). He proposed to place a flap cut from the small muscle of the thigh between the sutured walls of the bladder and vagina. Rehabilitation and restoration of Martius equipment began in the last decade. For interposition, a fibrous-fat flap is used from the labia majora, peritoneum, femoral muscle (m. gracilis), serous-muscular intestinal flap, segments of the stomach wall or omentum, as well as preserved dura mater. In clinical practice, the bulbocavernosal flap is most commonly used for interposition. The original technique of the Martius operation is shown in Figure 5.
From the vaginal access, the fistulous ring and tissues are circularly excised, the conglomerate of which forms a single frame. The walls of the bladder and vagina are widely mobilized, which is necessary to prevent subsequent tension. Good exposure allows the bladder wall to be hermetically sealed, avoiding trapping of the ureteral orifices. For suturing, absorbable suture material of the Dexon type on an atraumatic needle is used. Once the wall of the bladder is sutured, a vertical incision is made in the labia majora; and, starting from the top, a flap about 4 cm wide, about 8-10 cm long is cut out from the bulbocavernosus muscle along with fatty tissue. Often, vascular trunks pass along the lateral surface of this flap, which must be preserved. The length of the flap must be sufficient to avoid tension. To do this, its selection should begin from the upper corner, projectively orienting to the middle of the vagina. A tunnel is made in the subcutaneous tissue with an exit under the previously exfoliated vaginal wall. Its width should be such that the muscle-fat flap is not infringed in the channel made. The sutured wound of the bladder is completely covered with the latter with fixation with such threads that were used in primary fistuloplasty. The vaginal wall is sutured, and at the end of the operation it is tamponed with an ointment pad. The incision of the labia majora is sutured in layers, a rubber strip is used as drainage. It is preferable to drain the bladder by imposing a cystostomy for 3-4 weeks.
Some specialists use a fragment as a material for closing large post-radiation fistulas. m. gracilis(thin muscle of the thigh), for which an incision is made on the thigh with cutting out a muscle flap and maintaining blood supply. The distal end of the muscle is carried out in a tunnel formed between the inner surface of the thigh under the vaginal wall. The muscle flap is fixed to the pubocervical fascia so as to completely cover the bladder defect.
The literature describes separate proposals for the use of segments of the omentum or a segment of the gastric wall, which is cut out with a base at the greater curvature of the stomach. The motivation for such interventions is explained, on the one hand, by the need to close large bladder defects, and, on the other hand, by the possibility of maintaining maximum blood supply. In our opinion, the excellent plastic properties of the stuffing box are also important.

Conclusion

If we summarize the numerous conditions that determine the results of the treatment of vesicovaginal fistulas, they can be summarized in the following groups.

1. Etiology. Fistulas that have arisen after obstetric aids or gynecological interventions for benign diseases have a more favorable prognosis during treatment than fistulas after oncological operations and radiation.
2. Dimensions and localization. Fistulas located in the cervical region, as well as large fistulas involving the orifice(s) of the ureter, neighboring organs (colon), conceal a particularly high risk of failure compared with the likely cure of small fistulas.
3. The number of previous unsuccessful interventions increases the risk of poor prognosis.
4. The skill and experience of the operator: where they are more, the higher the success of the fistula cure.

Vesico-vaginal fistulas appear as a result of obstetric trauma, pelvic surgery, progressive cancer, and radiation therapy for pelvic cancer.

The basic principles of the treatment of this disease have changed little since the work of Marion Sims in the middle of the 19th century. These principles are: 1) before performing an operation to close the fistula, be sure that there are no signs of inflammation, swelling and infection in its area; 2) to excise poorly blood-supplied scar tissues and connect various layers of tissues widely, without tension. In the 20th century, another principle was added, namely, the use of a transplanted feeding flap either from the adipose tissue of the vestibule, or from m. bulbocavernosus, or from t. gracilus, or from the omentum.

Subject to the above principles, the type of suture material does not play a big role. We mainly use glycolic acid materials (Dexon or Vicryl) because of their absorbability and low tissue irritancy. Many surgeons prefer to suture the vaginal mucosa with non-absorbable monofilament nylon or proline suture. Such sutures should not be placed on the bladder mucosa. If they remain in the bladder for a long time, the formation of urinary stones is possible.

The goal of the operation is to close the fistula permanently, but without involving the urethra or its orifice.

physiological consequences. The fistula closes and normal urination through the urethra is restored.

Warning. It is necessary to ensure a good blood supply to the tissues surrounding the fistula. To close the fistula, it is extremely important to excise scar tissue. Recently, a tissue graft has been used to provide additional blood supply to the fistula area. This is an extremely important point in cases where the fistula occurs as a result of radiation therapy. In these cases, we additionally make a temporary diversion of urine into the ileum. All this greatly increased our possibilities for the final closure of post-radiation fistulas. In a subsequent operation, when the fistula is completely closed and the function of the bladder becomes sufficient, the ileal loop can be reimplanted into the dome of the bladder.

With all fistulas, the most important condition for healing is double drainage. The transurethral as well as the suprapubic Foley catheter can remain in place until the fistula is completely healed. Typically, the transurethral catheter is removed after two weeks, although the suprapubic catheter is left in the bladder for up to three weeks. Acidifying the urine with ascorbic acid or cranberry juice is helpful in preventing urinary tract infections. However, regular urine cultures and appropriate antibiotic therapy should be performed.

If, in the presence of a fistula, urine has an alkaline reaction, then it is able to precipitate trisulfate crystals, which are deposited in the area of ​​\u200b\u200bthe entrance to the vagina. They are painful and must be completely removed before surgery can begin.

METHOD:

The patient lies on her back in the lithotomy position. The vulva and vagina are treated and covered.

A wide selection of the entire fistulous tract should be made. Most of the failed attempts at surgical treatment of the fistula were the result of the inability to perform a full fistula isolation, poor conditions for suturing and tissue tension during fistula closure. Often, a wide mid-lateral episiotomy has to be made to open the fistulous tract.

After a wide opening of the fistulous canal, it is excised with a scalpel. The incision is made along the circumference of the fistula.

The edge of the fistulous tract is lifted with a pint and completely excised with scissors. Often, after excision of dense scar tissue, the size of the fistula turns out to be 2-3 times larger than expected before the operation.

Each layer of the wall of the bladder and vagina must be carefully examined and isolated for subsequent layer-by-layer imposition of thin sutures without any tissue tension.

Interrupted synthetic absorbable 4/0 sutures are placed on the bladder mucosa. It is necessary to try to capture only the submucosal layer in the suture, without involving the mucosa. We do not use a continuous suture, as we believe that it reduces the blood supply and worsens the healing conditions.

Synthetic absorbable 2/0 sutures are placed on the second muscle layer.

The muscular layer of the bladder is completely sutured over the area of ​​the fistula with interrupted synthetic absorbable sutures.

At this stage, it is necessary to provide additional blood supply to the area of ​​the excised fistula. This can be done with a bulbous cavernous muscle taken from the base of the labia majora. In cases where a large amount of tissue has been removed or the fistula was located high in the vagina, the blood supply is improved with the help of m. gracilus from the thigh or rectus abdominis, which are moved to the area of ​​the removed fistula.

If it is decided to use the bulbocavernosus muscle, then access to it can be provided by two options for incisions. The first can pass along the inner surface of the labia minora, as shown in Figure 9. The second - along the labia majora. When choosing the second option, the muscle should be inserted into the episiotomy wound in the tunnel under the labia minora.

The edges of the wound are bred to the sides on the clamps, and a scalpel is used to make a dissection deep into the muscle. It is important that the size of the wound allows you to see the entire muscle as a whole.

To close the wound without tension, the vaginal mucosa must be well mobilized. Usually, for this purpose, interrupted synthetic sutures are applied with an absorbable thread 0.

The bulbous-cavernous muscle was found and mobilized. Often it is necessary to pinch and ligate the vascular branches of the pudendal arteries and veins, which approach the muscle at the indicated level. In a blunt and sharp way, the muscle should be mobilized up to the level of the clitoris. Cross the muscle at the place of its interlacing in the perineal tissue.

If the first incision was made along the inner surface of the labia minora, then the mobilized bulbous-cavernous muscle is simply shifted to a new location, closing the fistula area. It is sutured to the perivesical tissues with interrupted synthetic absorbable 3/0 sutures. If the first incision passed through the labia majora, it is necessary to make a tunnel under the labia minora using a curved clamp leading to the episiotomy wound. The muscle is passed through this tunnel to the desired location and fixed with 3/0 interrupted synthetic sutures.

The incisions of the vagina, perineum and the incision for the muscle graft are sutured.

A Foley catheter was inserted through the urethra. The bladder is filled with 200 ml of methylene blue solution or sterile barium solution. This allows you to check how reliably the operation is performed. We often perform this manipulation after the 7th and 8th stages of the operation to ensure the quality of the fistula closure.

In addition to the urethral catheter, a suprapubic catheter is inserted (as shown in section 3, page 136). After such operations, double drainage is very important.

3
1 Federal State Budgetary Institution "Clinical Hospital" of the Administration of the President of the Russian Federation, Moscow
2 Federal State Budgetary Institution National Medical Research Center of the Ministry of Health of Russia, Moscow
3 Research Institute of Urology and Interventional Radiology. ON THE. Lopatkina - branch of the Federal State Budgetary Institution NMIRC of the Ministry of Health of the Russian Federation, Moscow; Medical Institute for Advanced Training of Doctors FGBOU VPO MGUPP, Moscow

Vesico-vaginal fistula is one of the most significant and sad complications in gynecology and oncogynecology. A vesicovaginal fistula is an abnormal communication between the bladder and the vagina. Starting from the 7th century Surgical treatments for vesicovaginal fistulas continue to evolve. There are 3 surgical approaches for the treatment of vesicovaginal fistulas: transvesical, transabdominal and transvaginal. The article presents an overview of surgical techniques for the treatment of vesicovaginal fistulas and their evolution from the refreshing method to the splitting method. Particular attention is paid to the treatment of complex vesicovaginal fistulas - formed after irradiation or as a complication of a malignant neoplasm, as well as recurrent fistulas and large fistulas. In these cases, standard transvaginal or transabdominal methods must be modified. Many tissue interposition techniques have been described to provide an additional layer for suturing and improve the quality of the reconstruction. The ideal technique for the surgical treatment of vesicovaginal fistulas is considered to be the one that achieves the fastest and best result, with a minimally invasive approach. New techniques, such as laparoscopy and robotic surgery, help reduce trauma compared to open abdominal access.

Keywords: vesicovaginal fistula, vaginal access, abdominal access, fistuloplasty, flap interposition.

For citation: Eliseev D.E., Alekseev B.Ya., Kachmazov A.A. Surgical treatment of vesicovaginal fistulas: the evolution of the concept // BC. 2017. No. 8. pp. 510-514

Surgical treatment of vesicovaginal fistulas: Evolution of the concept

Eliseev D.E. 1 , Alekseev B.Ya. 1,2 , Kachmazov A.A. 1
1 Research Institute of Urology and Interventional Radiology named after N.A. Lopatkin - a branch of the Federal Medical University "National Medical Research Radiological Center"
2 Physicians" Continuing Education Institute of Moscow State University of Food Production
Vesicovaginal fistula is one of the most significant and distressing complications in gynecology and oncogynecology. A vesicovaginal fistula is an abnormal communication between the bladder and vagina. Since the seventeenth century surgical methods for treating vesicovaginal fistulas have been continued to develop. There are three surgical approaches for the treatmen of vesicovaginal fistulas: transvesical, transabdominal and transvaginal. The article presents an overview of surgical methods of treating and their evolution from the method of refreshment to the method of splitting. Special attention is paid to the treatment of complicated vesicovaginal fistulas. Complex vesicovaginal fistulas include those associated with prior irradiation or malignancy, recurrent fistulas, fistulas with large size. In these cases the standard transvaginal or transabdominal techniques must be modified. Many techniques of tissue interposition have been described. These provide an additional layer when suturing and improve the quality of the reconstruction. The ideal technique for surgical treatment of vesicovaginal fistulas is the one that ensures the best results with a minimal invasion. New techniques, such as laparoscopy or robotic surgery, can reduce the surgical abdominal injuries.

key words: vesicovaginal fistula, vaginal approach, abdominal approach, fistuloplasty, interposition of flaps.
For quote: Eliseev D.E., Alekseev B.Ya., Kachmazov A.A. Surgical treatment of vesicovaginal fistulas: Evolution of the concept // RMJ. 2017. No. 8. P. 510–514.

Possibilities of surgical treatment of vesicovaginal fistulas are presented

Vesico-vaginal fistulas remain a serious problem of urogynecology, which is of great medical and social importance. Over the past 30-40 years, the number of "obstetric" fistulas has significantly decreased, but the proportion of traumatic "gynecological" and post-radiation fistulas has increased. This is due to the fact that hysterectomy performed for benign and oncological pathology of the uterus and appendages remains one of the most common "major" gynecological operations worldwide, and radiation therapy is included in the schemes of combined treatment of cancer of the body and cervix, in the latter case, in addition, it is also used as an independent method of treatment. Therefore, the issues of surgical treatment of vesicovaginal fistulas have not lost their relevance for many decades.
As A.M. Mazhbits, "before proceeding to describe the various methods of treating urogenital fistulas, it is necessary to recall those patients in whom fistulas heal spontaneously" . We will do the same.
The results of conservative treatment of vesicovaginal fistulas, according to D.V. Cana, very modest . According to M.P. Rutman et al., about 10% of small vesicovaginal fistulas heal spontaneously with prolonged bladder drainage with a Foly catheter. O. Singh et al. observed spontaneous closure of the vesicovaginal fistula in 8% of patients (3 out of 37). According to R. Hilton, who analyzed the experience of treating urogenital fistulas in 348 women in UK clinics from 1986 to 2010, vesicovaginal fistulas accounted for 73.6%, urethrovaginal fistulas - 10.9%, ureterovaginal fistulas - 6.0 %, others - 9.5%. In 24 of 348 patients (6.9%) spontaneous closure of the fistula was observed on the background of bladder drainage or ureteral stenting (7 patients). All these patients had fistulas of gynecological (19 patients), obstetric (4 patients) or mixed (1 patient) etiology. Of the 36 patients with radiation fistulas, none had spontaneous closure of the fistula. R. Hilton associates the low probability of spontaneous closure of radiation fistulas with impaired blood supply in tissues due to radiation endarteritis.
Given the low effectiveness of conservative treatment, it is necessary to recognize the surgical method as the main one in the treatment of vesicovaginal fistulas. The main goal of the operation in patients with vesicovaginal fistulas is to restore urination in a natural way. Again, in the words of A.M. Mazhbitsa, "surgery of urogenital fistulas in women is, in fact, the history of the issue of fistulas" . The first doctor who proposed in 1663 the surgical treatment of vesicovaginal fistulas by refreshing the edges of the fistula and applying a twisting suture was Hendrik Von Roonhuyse. The first successful healing of a fistula by this method was achieved by Johann Fatio in 1675. J.M. Sims in 1852 published his classic work on the treatment of vesicovaginal fistulas by transvaginal access. The technique consisted in a simple refreshment of the edges of the fistula and their stitching. The use of vaginal mirrors and silver threads, operations in the knee-elbow position and on the side, drainage of the bladder after surgery improved the results of surgical treatment of vesicovaginal fistulas. In 1858, Bozeman, a student of Sims, brought the method of wide refreshment to Paris, where it was called the American method and immediately entered into practice. G. Simon improved vaginal mirrors, which made it possible to abandon the knee-elbow and lateral position of the patient, which were associated with certain inconveniences for anesthesia. J. Krenar wrote: “However, Simon already understands that the vesico-vaginal fistula is not only an opening, but rather a canal with two mouths - cystic and vaginal - and emphasizes that the wound area must be of sufficient size in close contact over the entire surface refreshed channel". Later, in 1905, A. Doderlein and B. Krönig spoke of the refreshing method in the following way: “However, this whole method of bleeding is no longer favored; especially with large defects, one should lag behind him, because due to the increase in the opening, the possibility of connecting the fistulous edges with a suture is decreasing ... But here another circumstance sometimes turns out to be an unpleasant hindrance, namely, a complication from the ureters ... If they are not noticed during refreshment and do not take special precautions, the inevitable consequence is that their openings are sutured or fall into the wound itself and interfere with healing. The refreshing (bloody) method, which gives a significant percentage of failures, was replaced by the splitting (stratification) method proposed by M. Collis in 1857. With this technique, after excision of the edges of the fistula, the wall of the bladder and the anterior wall of the vagina are separated and both are sutured separately. In 1864, Dubué writes about this technique. in Russia in the second half of the 19th century. the method was used by Oberman, Shimanovsky, Geptner, Fenomenov. In 1983, K. Schuchardt proposed a pararectal incision to improve the exposure of the fistula during vaginal access.
Despite the good results of vaginal operations performed by the splitting method, there remained a number of fistulas that “are inaccessible to this operational method, because the defect is too large, its edges from the side of the vagina are not sufficiently achievable and there is too little tissue for direct connection” . For the treatment of such fistulas in 1881–1890. F. Trendelenburg developed the transvesical suprapubic approach. He proposed to drain the bladder with cystostomy drainage. As A. Doderlein and V. Krönig wrote: “Trendelenburg praised in his method the benefit that they are much better than with vaginal methods, complications from the ureters are eliminated.” Although F. Trendelenburg performed fistuloplasty using the refreshing method, J.L. Faure wrote about transvesical access in 1933: “Here, as, indeed, during surgery from the vagina, it is best to perform stratification of the septum.”
It should be mentioned that a number of authors have proposed non-physiological operations to stop the discharge of urine from the vagina in vesicovaginal fistulas. Such operations - episiorrhaphy, colpoclesis - consisted in obliteration of the vagina. Non-physiological operations deprived a woman of the opportunity to have a sexual life and were used only in extreme cases. In cases where the urethra and bladder neck are completely destroyed, Backer-Brouwn, Maisonneuve, Roze suggested performing episiorrhaphy (refreshing and stitching the labia tightly) with the preliminary creation of a rectovaginal fistula, forming transanal urination in patients. The high risk of infection of the urinary tract with intestinal flora has prevented the widespread use of such operations. Currently, episiorrhaphy can be performed in patients with incurable combined vesico-vaginal-rectal fistulas in the presence of a colostomy.
Thus, the principles of surgical treatment of vesicovaginal fistulas were developed more than 100 years ago by Sims, Collis and Trendelenburg. Regardless of the chosen approach, the surgical principles of fistula treatment remain essentially unchanged today: excision of the scar tissue of the fistula, splitting of the vesico-vaginal septum with extensive tissue mobilization, separate suturing of the bladder and vagina without tissue tension, long-term drainage of the bladder after surgery.
Further development of surgery for vesicovaginal fistulas followed the path of improving the splitting method. D.N. Atabekov proposed to use an anchor-shaped incision for the greatest mobilization of the bladder, and a cross-shaped incision in case of damage to the sphincter of the bladder. N. Füth in 1930 described a fistuloplasty technique for small and medium-sized vesico-vaginal fistulas, in which, after an incision of the vaginal mucosa fringing the fistula, the resulting cuff from the scar tissue was not excised, but screwed into the bladder. The advantage of this technique was to reduce the risk of injury to the ureters when the latter are close to the edge of the fistula. In 1942, W. Latzko described the technique of high partial colpocleisis in the treatment of high post-hysterectomy fistulas. After removal of the vaginal mucosa around the fistula, the anterior and posterior walls of the vagina are stitched together, the defect in the bladder is closed with the posterior wall of the vagina. Actually the fistula is not sutured. According to N.A. Hirsh, S.R. Kaser, F.A. Ikle, the W. Latzko technique has the following advantages: the defect can be sutured without tension, there is no risk of damage to the ureter, temporary overdistension of the bladder in the postoperative period does not affect the results of the operation, the efficiency of the operation is high even with unsuccessful previous surgical interventions. The negative side of this technique is the possible shortening of the vagina. However, the efficiency of the Latzko operation of 93% and 95% was registered in two series of 43 and 20 patients, respectively, without complaints on their part of a significant shortening of the vagina or other sexual dysfunctions. ABOUT. Laurent modified the Latzko method. The essence of the proposed technique, called "oblique colpoclesis", is that after excision of scars in the fistula zone and extensive mobilization of the tissues of the vagina and bladder, it becomes possible to suture the defect in the bladder wall, and then connect the anterior and posterior walls of the vagina in an oblique direction . According to O.B. Laurent et al., the effectiveness of oblique colpocleisis was 81%.
In the 50s of the XX century. V. O "Conor and J. Sokol developed and popularized abdominal access for fistuloplasty. At the same time, they emphasized the importance of selecting patients for each operation. The O" Conor fistuloplasty technique is based on a complete dissection of the bladder to the fistula and a wide separation of the bladder from the vagina. In the original description, the operation is performed extraperitoneally, but transperitoneal access is sometimes necessary. Transperitoneal abdominal access is indicated for localization of the fistula near the mouth of the ureter, vaginal stenosis, large size of the fistula, combined vesicoureteral-vaginal fistulas, decreased bladder capacity and the need to perform augmentation cystoplasty.
Discovery at the end of the 19th century X-rays and the phenomenon of radioactivity has become an attractive alternative to surgical methods for the treatment of patients with advanced forms of cervical cancer (CC) . The era of radiation therapy for cervical cancer began in 1903, when M. Cleaves reported the first experience of using radium for application to a tumor in two patients with cervical cancer. And already in 1913, as P. Werner and J. Zederl wrote, “at the congress in Halle, for the first time, detailed reports were made on the successful treatment of cancer with mesothorium and radium, and all the speakers testified to the excellent results of radiation therapy.” The first works on radiation damage to the organs of the urinary system were published already in the 1920s. (Heyneman, 1914; G.N. Berman, 1926; W. Schmidt, 1926) . In the etiological structure of vesicovaginal fistulas, another category has appeared that has become the most difficult for curation - radiation fistulas.
The main obstacle to performing reconstructive operations in these cases was tissue trophic disorders that developed under the influence of radiation therapy. Therefore, standard surgical techniques for radiation fistulas are ineffective. The basis of most methods for the treatment of radiation fistulas was the use of a pedicled flap, cut from non-irradiated tissues, to improve vascularization and trophism in the fistula zone and create a “pad” between the dissociated organs. These tasks can be most fully realized using flaps of different tissues. The basis of the flap can be muscle or adipose tissue, fascia. Sometimes, if necessary, skin is included in the composition of the flap. The selection of the donor site and the planning of the size of the flap should be carried out taking into account the characteristics of the blood circulation of the donor site. The length, diameter and location of the axial vessel form the basis for flap geometry planning, since adequate blood supply to the flap is the prevention of postoperative complications, primarily flap necrosis. Currently, more than 300 different tissue complexes with axial blood supply have been described. There is practically no area of ​​the body left where some kind of complex flaps would not be cut out.
In 1928, professor of gynecology H. Martius from Göttingen first described a flap based on the adipose tissue of the labia and superficial muscles of the urogenital diaphragm (bulbospongiform and ischiocavernosus muscle) for plastic surgery of urethrovaginal fistulas. In 1984 R.E. Symmonds modified the Martius flap into a complex axial islet musculocutaneous fat flap, essentially adding only a dermal component. The axial vessels of the flap are the branches of the internal and external pudendal arteries, which anastomose with each other in the middle of the flap. According to K.S. Eilber, E. Kavaler, L.V. Rodríguez, N. Rosenblum, S. Raz, who analyzed ten years of experience in the treatment of vesicovaginal fistulas, the effectiveness of fistuloplasty using the Martius flap was 97%, but among the operated patients, only 4% had post-radiation fistulas. According to A. Benchekroun et al., the effectiveness of primary fistuloplasty using the Martius flap in obstetric fistulas was 75%, and after repeated operations it reached 90%. S.V. Punekar et al. reported a 93% success rate for primary surgery using the Martius flap in patients with gynecological and obstetric fistulas.
In 1928 J.H. Garlock first reported experience in the treatment of vesicovaginal fistulas using the m. gracilis. M. gracilis is a long, thin muscle of the medial group of the thigh, starting from the anterior surface of the pubic bone and attaching to the tuberosity of the tibia. The main functions of the muscle are adduction of the thigh, flexion at the knee joint, and internal rotation of the lower limb. The main blood supply to the muscle is provided by the deep femoral artery and the medial circumflex femoral artery. To pass the muscle into the fistula, the author used a continuous incision from the upper third of the thigh to the fistula through the vulva. A. Ingelman-Sundberg modified this operation by performing m. gracilis from the thigh to the area of ​​the vesicovaginal fistula through the obturator foramen by perforating the obturator membrane. He pointed out the need to avoid trauma to the obturator nerve and blood vessels, and also recommended creating a tunnel in the obturator membrane of sufficient width to avoid compression and ischemia of m. gracilis. Later R.H.J. Hamlin and E.S. Nicholson simplified the technique of the operation by offering subcutaneous insertion of m. gracilis, which has become the standard . Great length and good blood supply m. gracilis ensure the efficiency of its use for interposition. In addition, m. gracilis can be used to cover a large wound by splitting the muscle into an anterior and posterior segment and suturing them together. According to Dr. Deepak Bolbandi et al., who successfully operated on 13 out of 14 patients with vesicovaginal fistulas using a m. gracilis, the efficiency of the operation was 93%.
In 1967 R.L. Byron Jr. and D.R. Ostergard also reported the successful use of the m. sartorius for reconstruction of radial fistulas. Later there were a number of reports about the use of m. rectus abdominis (recto-abdominal flap) for fistuloplasty interposition. The axial vessels of the flap are the lower epigastric vessels. The large length, mobility, ease of rotation, good blood supply to the recto-abdominal flap, as well as the possibility of including skin in the flap make it convenient for fistuloplasty and pelvic floor reconstruction. The skin component of the flap may be longitudinal (vertical recto-abdominal flap) or transverse (transverse recto-abdominal flap) direction, depending on the size and orientation of the pelvic floor defect. Another advantage of the transverse recto-abdominal flap is the possibility of using it for vaginal reconstruction as part of integrative measures for the prevention of empty pelvic syndrome and pelvic floor repair. To close the donor area and prevent the formation of postoperative ventral hernias, synthetic polypropylene prostheses are used.
In 1900, Enderlen, in experiments on cats and dogs, substantiated the possibility of closing bladder defects with a displaced greater omentum, the surface of which is quickly covered with urothelium. For the first time in the clinic for the treatment of recurrent vesicovaginal fistula, the greater omentum was used by W. Walters in 1937. However, the technique did not find wide application until the classic works of I. Kiricuta undertaken in 1955, published in 1961, in which all potential use of the greater omentum in the treatment of fistulas, including radiation fistulas. Mobility, good blood supply and high reparative abilities have become predetermining properties for the use of the greater omentum in pelvic reconstruction surgery. The technique of omentoplasty consists in mobilizing the omentum from the transverse colon and the greater curvature of the stomach, forming an omental flap on the right or left gastroepiploic vessels, followed by bringing the greater omentum into the pelvic cavity and fixing it to the wall of the bladder and vagina. Further lengthening of the omental flap can be achieved by dissecting it and creating a J-flap. These methods are described in the literature. Depending on the options for the location of the vessels, the lengthening method is specified in each specific case. In case of large vesico-vaginal and combined vesico-rectal-vaginal fistulas, the omental flap is passed through the vaginal stump to the vulva, where it is fixed with sutures. Additional suturing of the fistula in this case can be omitted, since the omentum provides sufficient sealing. The growing granulation tissue is removed by diathermoelectrocoagulation. The anatomical features of the structure of the greater omentum, its involvement in the adhesive process after surgery or the performed omentectomy limit the use of this method. With the combined abdominal-vaginal approach, H.J.L. Orford and J.L.L. Theron successfully closed 52 and 59 fistulas, respectively, with omentoplasty.
A number of authors use a peritoneal flap for fistuloplasty. W.G. Hurt, both with vaginal and transperitoneal access, separates the peritoneum from the bladder wall and sutures it to the intervention area so that it separates the suture line on the vaginal wall and bladder. According to S. Raz et al., the efficiency of using the peritoneal flap was 82%, according to M. Eisen et al. - 96%.
In the 40-50s of the XX century. in fistuloplasty, various allomaterials (pericardium, placenta) were actively used to improve trophism in the area of ​​operation and seal the sutures. P.M. Buyko proposed to use placental tissue in the form of an allograft for vesicovaginal fistulas. To close fistulas, he developed several techniques with fixation of placental tissue on the vaginal mucosa or between the bladder and vagina. Placental tissue for closure of vesicovaginal fistulas was also used by N.E. Sidorov, N.L. Kapelyushnik, K.I. Poluiko and others. The positive effect was explained by the effect on cell proliferation of the decay products of placental tissue, rich in hormones, vitamins, enzymes, as well as biochemical restructuring in tissues under the influence of the stimulating effect of the drug on the nervous system. V.A. Orlov and A.M. Polyakova in 1971 reported on the use of preserved pericardium for fistuloplasty. Encouraging results have been obtained with the use of lyophilized dura mater in closure of vesicovaginal fistulas. At present, the use of collagen biomaterials is promising for creating an interfistula barrier. ABOUT. Laurent et al. in 2007 they reported the successful use of biological material in 3 out of 4 operated patients with complex urinary fistulas. The basis of this biomaterial is type I collagen, which acts as an extracellular matrix and provides guided contact between epithelial cells and fibroblasts, creating their optimal migration and orientation, as well as binding cells to form new tissue.
The last decades are characterized by the rapid development of laparoscopic technologies. Endovideosurgical operations, which are increasingly being introduced into urological practice, are devoid of such disadvantages of open operations as wide and traumatic access, prolonged hospitalization and temporary disability of patients. In 1994 C.H. Nezhat et al. reported the first laparoscopic transvesical repair of a vesicovaginal fistula, and already in 1998 P. von Theobald et al. reported the first laparoscopic extravesical repair of a vesicovaginal fistula. In two series of patients, including 6 (plus 2 patients with vesico-uterine fistulas) and 15 cases of vesico-vaginal fistulas, laparoscopic fistuloplasty was performed and success was achieved in 100% and 93% of cases, respectively. B. Ghosh et al., analyzed the results of surgical treatment of 26 patients with vesicovaginal fistulas for the period from 2011 to 2014, dividing the patients into 2 groups - in the first group (13 people) fistuloplasty was performed by open abdominal access, in the second - laparoscopic. The authors concluded that laparoscopic access is associated with less trauma and shorter hospital stays without compromising treatment outcomes.
In 2005 O. Melamud et al. performed robot-assisted vesico-vaginal fistula repair for the first time. The advantages of robot-assisted operations are better visualization and a greater degree of freedom of manipulators compared to laparoscopic instruments and the surgeon's hands. V. Agrawal et al. in 2015 reported a 100% success rate for robot-assisted vesicovaginal fistula repair in a series of 10 patients. C.S. Pietersma et al. consider the robot-assisted fistuloplasty technique possible and promising good results.
Surgical treatment of vesicovaginal fistulas is still a difficult problem. According to O.B. Lorana et al., despite the observance of all the rules and principles of surgical interventions, the improvement of surgical techniques and the emergence of suture materials with improved properties, the effectiveness of operations with complex urinary fistulas remains low. The abundance of fistuloplasty techniques and surgical approaches indicates the lack of satisfaction of doctors and scientists with the results of surgical treatment of vesicovaginal fistulas. The study of the history of the issue, the evolution of the principles and methods of fistuloplasty will allow us to analyze the experience of doctors of previous generations, take into account mistakes, accept all achievements and determine the vector for further development of this area of ​​urogynecology. One of these areas should be the creation of clinical guidelines for the treatment of patients with vesicovaginal fistulas. This is of particular importance for patients with radiation fistulas, since in all works on this topic it is noted that each case of a fistula is unique and requires an individual approach. The main argument in favor of developing clinical guidelines is the need to improve the quality of medical care for this group of patients and reduce the number of severe and incurable clinical situations.

Literature

1. Mazhbits A.M. Operative urogynecology. L.: Medicine, 1964. 416 p. .
2. Kan D.V. Guide to obstetric and gynecological urology. Moscow: Medicine, 1986. 488 p. .
3. Matthew P. Rutman, Larissa V. Rodrigues, Shlomo Raz. Vesicovaginal fistula: vaginal approach. In: Raz S., Rodriguez L.V. Female Urology, 3rd ed. WB Saunders, Philadelphia, Pa., P. 794-801.
4. Gupta S.S., Mathur R.K. Urogenital fistulas in women: 5-year experience at a single center // Urol J. 2010. Vol. 7(1). P. 35‒39.
5. Hilton P. Urogenital fistula in the UK: a personal case series managed over 25 years // BJU Int. 2012. Vol. 110(1). P. 102–110.
6. Loran O.B., Lipsky V.S. Medical and social rehabilitation of women suffering from vesicovaginal fistulas. Saratov: Privolzhsk. book. publishing house, 2001. 110 p. .
7. Mazhbits A.M. Obstetric-gynecological urology with atlas. L., 1936. 646 p. .
8. Von Roonhuyse H. Medico-Chirurgical Observations. London, Moses Pitt at the Angel, 1676.
9. Falk H., Dancer M. Vesicovaginal fistula: an historical survey // Obstet Gynecol. 1954 Vol. 3(3). P. 337–341.
10. Mariangela Mancini, Walter Artibani. Abdomenal approach for the treatment of vesicovaginal fistula. In: Raz S., Rodriguez L.V. (ed) Female Urology, 3rd ed. WB Saunders, Philadelphia, Pa. P. 802–815.
11 Sims J.M. On the treatment of vesico-vaginal fistula // Int Urogynecol J Pelvic Floor Dysfunct. 1998 Vol. 9(4). P. 236–248.
12. Faure J.L. Operative gynecology. M., 1933. 414 p. .
13. Krenar J. Plastic surgery in gynecology. Prague. Avicenum, 1980. 256 p. .
14. Doderlein A., Krönig B. Operative gynecology. SPb., 1907. 536 p. .
15. Collis M. Further remarks on a new successful mode of treatment for vesicovaginal fistula. Dublin Q J. 1861. 31. P. 302–316.
16. Schuchardt K. Eine neue Methode der Gebarmutterextirpation. Zentralbl Chir. 1893.20:1121.
17. Trendelenburg F. Discussion zu Helferich. Zuganglichmachung der vorderen Blasenwand. Verbandlung der Deutsche ges F Chir. 1888. 17:101.
18. Hurt G. Operative urogynecology. M.: GEOTAR-Med, 2003. 276 p. .
19. Loran O.B., Sinyakova L.A., Seregin A.V., Tverdokhlebov N.E. Surgical treatment of patients with complex urinary fistulas // Urology. 2010. No. 5. S. 76–79.
20. Atabekov D.N. Urinary defects and fistulas in women and their surgical treatment. M., 1925. 71 p. .
21. Atabekov D.N. Essays on urogynecology. 3rd ed. M.: Medgiz, 1963. 144 p. .
22. Füth H. Zur Operation der Mastdarm-Scheidenfisteln // Zbl Gynäk 1930. Vol. 54. P. 2882.
23. Latzko W. Postoperative vesicovaginal fistulas: genesis and therapy // Am J Surg. 1942 Vol. 58. P. 211–218.
24. Hirsch H., Keser O. Ickle F. Operative gynecology: Atlas. Per. from English. / ed. Kulakova V.I., Fedorova I.V. M., GEOTAR-Medicine, 1999. 656 p. .
25. Dancer M.L. The post-total hysterectomy (vault) vesicovaginal fistula // J Urol. 1980 Vol. 123. P. 839–840.
26. D "Amico A.M., Latzko L.K. Repair of vesicovaginal fistula // J Urol. 1999. Vol. 161. P. 202–227.
27. Loran O.B., Gumin L.M., Zaitsev A.V., Lipsky V.S. High (oblique) colpocleisis in the treatment of post-radiation vesicovaginal fistulas. Urology. 2000. No. 4. P. 41–42.
28. O "Conor V., Sokol J. Vesicovaginal fistula from the standpoint of the urologist // J Urol. 1951. Vol. 66(4). P. 579–585.
29. O "Connor V.J., Sokol J.K., Bulkley G.J., Nanninga J.B. Suprapubic closure of vesicovaginal fistula // J Urol. 1973. Vol. 109(1). P. 51–54.
30. Zharinov G.M., Neklasova N.Yu. Radiation therapy for cervical cancer - history, current state // Radiation diagnostics and therapy. 2011. No. 3‒2. pp. 34‒42.
31. Cleaves M. Radium therapy. Med Rec. 1903. P. 601–604.
32. Bokhman Ya.V. Clinic and treatment of cervical cancer. Kishinev: Shtiintsa, 1976. 236 p. .
33. Werner P., Zederl J. Radical Wertheim operation for cervical cancer. Per. with him. ed. Persianinova L.S. M.: Medgiz, 1960. 76 p. .
34. Loran O.B., Seregin A.V., Dovlatov Z.A. Modern approaches to the treatment of post-radiation urogenital fistulas in women: a literature review // Experimental and clinical urology. 2015. No. 4. pp. 42‒45 .
35. Eliseev D.E., Eliseev E.N., Aimamedova O.N., et al. Surgical treatment of rectovaginal fistulas. Experience in plasty of a radial rectovaginal fistula with a Martius-Symmonds flap // Oncogynecology. 2015. №2. pp. 59‒69.
36. Kichemasov S.Kh., Skvortsov Yu.R. Skin plasty with flaps with axial blood supply for burns and frostbite IV degree. St. Petersburg, Hippocrates, 2012. 288 p. .
37. Martius H. Die operative Wiederhellstellung der volkonmmen fehlenden Harnrohare und des Schlessmuskels derselben // Zentralbi Gynakol. 1928 Vol. 92. R. 480-486.
38. Symmonds R.E. Incontinence: Vesical and urethral fistulas // Clin Obstet Gynecol. 1984 Vol. 27(2). P. 499–514.
39. Eilber K.S., Kavaler E., Rodriguez L.V. et al. Ten-year experience with transvaginal vesicovaginal fistula repair using tissue interposition // J Urol. 2003 Vol. 169(3). P. 1033‒1036.
40. Benchekroun A., Lachkar A., ​​Alami M. et al. The Martius flap in the treatment of vesicovaginal fistulas. Report of 20 cases // Ann Urol (Paris). 1999 Vol. 33(2). P. 85–88.
41. Punekar S.V., Buch D.N., Soni A.B. et al. Martius" labial fat pad interposition and its modification in complex lower urinary fistulae // J Postgrad Med. 1999. Vol. 45(3). P. 69–73.
42. Garlock J.H. The cure of an intractable vesicovaginal fistula by use of a pedicled muscle graft // Surg Gynecol Obstet. 1928 Vol. 47. P. 255–260.
43. Fitzpatrick C., Elkins T.E. Plastic surgical techniques in the repair of vesicovaginal fistulas: A review // Int Urogynecol J. 1993. Vol. 4 (5). P. 287–295.
44. Ingelman-Sundberg A. Pathogenesias and operative treatment of urinary fistulas in irradiated tissue. In: Youssef AF (ed) Gynecology urology. Springfield, Ill: Charles C. Thomas, 1960, 263‒279
45. Hamlin R.H., Nicholson E.C. Reconstruction of urethra totally destroyed in labor // Br Med J. 1969. Vol. 2(5650). P. 147–150.
46. ​​Ezzat M., Ezzat M.M., Tran V.Q., Aboseif S.R. Repair of giant vesicovaginal fistulas // J Urol. 2009 Vol. 181(3). P. 1184‒1188.
47 Deepak Bolbandi, Raghuveer, Mayank Agarwal. Role of gracilis muscle transfer in complex vesico vaginal fistula // Indian J Applied Research. 2016. Vol. 6(8). R. 10-11.
48. Byron R.L. Jr, Ostergard D.R. Sartorius muscle interposition for the treatment of the radiation-induced vaginal fistula // Am J Obstet Gynecol. 1969 Vol. 104(1). P. 104–107.
49. Menchaca A., Akhyat M., Gleicher N. et al. The rectus abdominis muscle flap in a combined abdominovaginal repair for difficult vesicovaginal fistulae: a report of 3 cases // J Reprod Med. 1990 Vol. 35(5). P. 565–568.
50. Salup R.R., Julian T.B., Liang M.D. et al. Closure of large postradiation vesicovaginal fistula with rectus abdominis myofascial flap // Urology. 1994 Vol. 44(1). P. 130–131.
51. Viennas L.K., Alonso A.M., Salama V. Repair of radiation-induced vesicovaginal fistula with a rectus abdominis myocutaneous flap // Plast Reconstr Surg. 1995 Vol. 96(6). P. 1435‒1437.
52. Horch R.E., Gitsch G., Schultze-Seemann W. Bilateral pedicled myocutaneous vertical rectus abdominus muscle flaps to close vesicovaginal and pouch-vaginal fistulas with simultaneous vaginal and perineal reconstruction in irradiated pelvic wounds // Urology. 2002 Vol. 60(3). P. 502–507.
53. Perata E., Severoni S., Schietroma M. et al. Post-partum vesicovaginal fistula: abdominal muscle strip treatment // Minerva Ginecol. 2001 Vol. 53(3). P. 165-170.
54. Frasson M., Flor-Lorente B., Carreño O. Reconstruction techniques after extralevator abdominoperineal rectal excision or pelvic exenteration: meshes, plasties and fl aps // Cir Esp. 2014. Vol. 92(Suppl 1). P. 48–57.
55. Pawlik T.M., Skibber J.M., Rodriguez-Bigas M.A. Pelvic exenteration for advanced pelvic malignancies // Ann Surg Oncol. 2006 Vol. 13(5). P. 612–23.
56. Diver E.J., Rauh-Hain J.A., Del Carmen M.G. Total pelvic exenteration for gynecologic malignancies // Int J Surg Oncol. 2012. Vol. 2012: 693535.
57. Schmidt A.M., Imesch P., Fink D., Egger H. Indications and long-term clinical outcomes in 282 patients with pelvic exenteration for advanced or recurrent cervical cancer // GynecolOncol. 2012. Vol. 125(3). P. 604–609.
58. Enderlen E. Über die Transplantation des Netzes auf Blasendefecte // Dtsch Z Chir. 1900 Vol. 55.P. 183‒197.
59. Big omentum. Per. from English. ed. D. Lieberman-Meffert, H. White. M., 1989. 336 p. .
60. Walters W. An omental flap in transperitoneal repair of recurring vesicovaginal fistulas // Surg Gynecol Obstet. 1937 Vol. 64. P. 74–75.
61. Kiricuta I., Goldstein M.B. Das Omentum als Ersatzmaterial der Blasenwand bei durch Strahlen verursachten Blasenscheidenfisteln // Krebsarzt. 1961 Vol. 16. P. 202–207.
62. Kiricuta I. Use of the greater omentum in the treatment of vesicovaginal and rectovesicovaginal fistulae after radiotherapy and cystoplasties // J Chir (Paris). 1965 Vol. 89(4). P. 477–484.
63. Kiricuta I., Goldstein A.M. The repair of extensive vesicovaginal fistulas with pedicled omentum: a review of 27 cases // J Urol. 1972 Vol. 108(5). P. 724–727.
64. Kiricuta I., Berariu T. The simplified technic of treatment by omentoplasty of irradiated and injured large vesico-vaginal fistulas. Apropos of 130 surgical cases // J Urol (Paris). 1988 Vol. 94(4). P. 205–209.
65. Kiricuta I. Treatment by omentoplasty of vesicorectovaginal and rectovaginal fistulae // J Urol (Paris). 1988 Vol. 94(5‒6). P. 289–293.
66. Alday E.S., Goldsmith H.S. Surgical technique for omental lengthening based on arterial anatomy // Surg Gynecol Obstet. 1972. Vo9l. 135(1). P. 103–107.
67. Das S.K. The size of the human omentum and methods of lengthening it for transplantation // Br J Plast Surg. 1976 Vol. 29(2). P. 170–244.
68. Palfalvi L. Reconstruction of the pelvic floor and management of the empty pelvis; correction of pelvic hernias // Nogyogyaszati ​​Onkologia. 1998. No. 2. P. 175–176.
69. Orford H.J., Theron J.L. The repair of vesicovaginal fistulas with omentum: a review of 59 cases // S Afr Med J. 1985. Vol. 67(4). P. 143–144.
70. Raz S., Bregg K.J., Nitti V.W., Sussman E. Transvaginal repair of vesicovaginal fistula using a peritoneal flap // J Urol. 1993 Vol. 150(1). P. 56–59.
71. Eisen M., Jurkovic K., Altwein J.E. et al. Management of vesicovaginal fistulas with peritoneal flap interposition // J Urol. 1974 Vol. 112(2). P. 195‒198.
72. Buyko P.M. Surgical treatment of vesicovaginal fistulas in women using placental tissue. Clinical and experimental study. Kyiv: Med. ed., 1948, 76 pp. .
73. Chukhrienko D.P., Lyulko A.V., Romanenko N.T. Atlas of urogynecological operations. Kyiv: Vishcha shkola, 1981, 343 p. .
74. Kelami A., Korb G., Lüdtke-Handjery A. et. al. Closure of urinary tract fistula in experiments and in the clinic with the aid of lyophilized human dura // Urol Int. 1970 Vol. 25(5). P. 466–472.
75. Ramos C., de la Rosa F., Castro M. et. al. Vesicovaginal fistulas: correction using lyophilized dura mater // Actas Urol Esp. 1991 Vol. 15(2). P. 143–147.
76. Alagöl B., Gözen A.S., Kaya E., Inci O. The use of human dura mater as an interposition graft in the treatment of vesicovaginal fistula // Int Urol Nephrol. 2004 Vol. 36(1). P. 35–40.
77. Tverdokhlebov N.E. Surgical treatment of patients with complex urinary fistulas: dis. … cand. honey. Sciences. M., 2010. 120 p. .
78. Loran O.B., Sinyakova L.A., Dement'eva A.V., Tverdokhlebov N.E. The use of synthetic and biological materials in the treatment of complex urinary fistulas and stress urinary incontinence in women // Consilium medicum. 2007. No. 4. P. 46–49.
79. Pavlov V.N., Pushkarev A.M., Izmailov A.A. et al. Application of laparoscopic technologies in urology // Medical Bulletin of Bashkortostan. 2006. Vol. 1(1). pp. 107‒110. .
80. Kogan M.I., Medvedev V.L., Aboyan I.A. and others. Laparoscopy in urology: mater. X Russian Congress of Urologists. M., 2002. S. 742. .
81. Petrov S.B., Rakul S.A. Experience in laparoscopic operations: Mat. X Russian Congress of Urologists. M., 2002. S. 684‒686. .
82 Harrison R.M. The development of modern endoscopy // J Med. Primatol. 1976 Vol. 5(2). P. 73–81.
83. Nezhat C.H., Nezhat F., Nezhat C., Rottenberg H. Laparoscopic repair of a vesicovaginal fistula: a case report // Obstet Gynecol. 1994 Vol. 83(5 Pt 2). P. 899–901.
84. Von Theobald P., Hamel P., Febbraro W. Laparoscopic repair of a vesicovaginal fistula using an omental J flap // Br J Obstet Gynaecol. 1998 Vol. 105(11). P. 1216‒1218.
85. Chibber P.J., Shah H.N., Jain P. Laparoscopic O'Conor's repair for vesico-vaginal and vesico-uterine fistulae // BJU Int. 2005 Vol. 96(1). P. 183–186.
86. Sotelo R., Mariano M.B., Segui A.G. et al. Laparoscopic repair of vesicovaginal fistula // J Urol. 2005 Vol. 173(5). P. 1615–1618.
87. Ghosh B., Wats V., Pal D.K. Comparative analysis of outcome between laparoscopic versus open surgical repair for vesico-vaginal fistula // Obstet Gynecol Sci. 2016. Vol. 59(6). P. 525‒529.
88. Melamud O., Eichel L., Turbow B., Shanberg A. Laparoscopic vesicovaginal fistula repair with robotic reconstruction // Urology. 2005 Vol. 65(1). P. 163-166.
89. Agrawal V., Kucherov V., Bendana E. et al. Robot-assisted Laparoscopic Repair of Vesicovaginal Fistula: A Single-center Experience. // Urology. 2015. Vol. 86(2). P. 276-281.
90. Pietersma C.S., Schreuder H.W., Kooistra A., Koops S.E. Robotic-assisted laparoscopic repair of a vesicovaginal fistula: a time-consuming novelty or an effective tool? // BMJ Case Rep. 2014. Pii: bcr2014204119.
91. Naigovzina N.B., Filatov V.B., Borozdina O.A., Nikolaeva N.A. Standardization in health care. Overcoming the contradictions of legislation, practice, ideas. M.: GEOTAR-Media, 2015. 208 p. .

Vesico-vaginal fistulas are a severe and relatively common complication that occurs in obstetric and gynecological practice.

Causes

They arise mainly as a result of injuries of the urinary organs or trophic disorders during pathological childbirth, obstetric and gynecological. Less common causes are chemical and electrical burns, domestic injuries, or gunshot wounds.

Traumatic vesicovaginal fistulas

Injuries to the urinary tract during gynecological operations are the most common type of injury leading to the occurrence of vesicovaginal fistulas. Traumatic vesicogenital fistulas that form after gynecological operations are mainly due to the severity of the gynecological pathology itself and the complexity of the surgical aid, insufficient qualifications. With the widespread introduction of laparoscopic access in operative gynecology in the last decade, vesicogenital fistulas of burn origin have appeared.

Vesicogenital fistulas due to obstetric trauma often occur after surgical interventions for severe obstetric pathology, and are the result of an extreme situation, the need to urgently remove the fetus (obstetric forceps, caesarean section) or remove the uterus (hysterectomy).

Symptoms

The main symptom of vesicovaginal fistulas is involuntary leakage of urine from the vagina. If a fistula occurs as a result of an unnoticed injury to the bladder, urine leakage begins on the very first days after surgery, and with trophic changes in the bladder wall (wall stitching), it is delayed (usually on days 7-11) and depends on the nature and extent of the pathological process. It is clinically very important to establish whether urine leakage occurs against the background of preserved urination or the latter is completely absent. According to this symptom, one can judge the diameter of the cystic fistula: with pinpoint fistulas and located above the interureteral fold (high), spontaneous urination may persist. With the progression of the disease, pain appears in the bladder and vagina. A constant symptom is psycho-emotional disorders caused by urine leakage.

Diagnostics

Diagnosis is based on a carefully collected anamnesis, analysis of the clinical course of the disease and examination data of the patient. Difficulties arise with highly located fistulas that open into the cicatricial fornix of the vagina. The scheme of examination of patients with vesico-vaginal fistulas:

• history taking and gynecological examination;
• carrying out a three-tampon test;
• cystoscopy and vaginography;
• kidneys;
• if necessary - excretory urography, radioisotope renography, cystography in three projections.

A three-tampon test is a simple and affordable way to diagnose both vesicovaginal and ureterovaginal fistulas, as well as urinary incontinence. The test is performed when urine leakage is combined with preserved voluntary urination. Three gauze swabs are placed in the vagina, filling its entire cavity. Inject a solution of methylene blue into the bladder through the catheter. With vesicovaginal fistulas, the upper and middle tampons turn blue; with ureterovaginal fistulas, all tampons get wet with light urine and do not turn blue; with urinary incontinence, the lower tampon turns blue.

Vesico-vaginal fistulas of inflammatory origin

They are formed as a result of purulent-inflammatory diseases of the internal genital organs. Unlike vesico-vaginal fistulas of traumatic origin, in which the general condition of patients is often satisfactory, in vesico-adnexal, parametric-adnexal and complex fistulas of purulent-inflammatory etiology, it is disturbed due to intoxication and a destructive process in the small pelvis.

Symptoms

The clinical picture of the disease is determined by the stage of the purulent inflammatory process and its prevalence in the small pelvis. The main complaints are pains over the womb of varying intensity, radiating to the thigh and lower back, dysuric phenomena, fever, chills, purulent discharge from the genital tract, pyuria, and rarely menouria (hematuria during menstruation).

Diagnostics includes:

• gynecological examination;
• laboratory tests of blood and urine;
• Ultrasound of the pelvis and kidneys;
• cystoscopy, chromoscopy, hysteroscopy;
• renography;
• excretory urography;
• CT scan of the pelvis;
• MRI of the pelvis.

Treatment

When a vesicovaginal fistula is detected, as a rule, an attempt is made to conservative treatment: the introduction of a permanent catheter into the bladder for 8-10 days, washing the bladder with antiseptics, ointment swabs in the vagina, antibiotic therapy,

uroseptics. According to the literature, in 2-3% of patients, small fistulas are scarred. The vast majority of patients with vesicovaginal fistulas undergo surgery.

There are vaginal and transperitoneal accesses of the operation. The choice of surgical aid depends on the location of the fistula and the associated pathology of the genital organs. When choosing a vaginal approach, the possibility of complete mobilization of the fistulous tract, excision of scar tissues, adequate and complete restoration of the functional integrity of the organ is taken into account.

Transperitoneal access of the operation is indicated in the presence of purulent and non-purulent pathology in the pelvic cavity, requiring surgical treatment: narrowing of the ureter, causing a violation of the passage of urine, complex localization of fistulas, requiring plastics of a number of organs of the small pelvis and the anterior abdominal wall, high location of the fistula, close to the mouth of the ureter , the presence of urinary streaks.

In the treatment of vesicovaginal fistulas, it is important to determine the timing of surgical intervention. The classical strategy is to wait 3 to 6 months after injury to achieve maximum subsidence of the inflammatory response caused by surgery.

Prevention

Prevention of vesico-vaginal fistulas consists in preventing background diseases of the urinary and genital tract, improving methods of contraception, predicting the course of labor and timely cesarean section, wide use of the modern arsenal of methods for early diagnosis of postpartum purulent-septic diseases, adequate treatment of developed complications.

The article was prepared and edited by: surgeon