Observations on prevention and management of vesicovaginal fistula after total hysterectomy.
A retrospective study of genital fistulas of the lower urinary tract revealed 91 percent to be postsurgical. Of these, 91 percent occurred after gynecologic procedures. Total hysterectomy was the most common antecedent procedure (n = 110), and the resulting lesion was the vault fistula. Abdominal total hysterectomy was the most frequent operation to precede a vault fistula (n = 92) and almost 70 percent occurred in the absence of factors identified as placing the patient at risk for injury to the bladder. Such risk factors included prior uterine operation, especially cesarean section, endometriosis, recent cold-knife cervical conization and prior radiation therapy. Twenty-four fistulas occurred despite recognition at the time of hysterectomy of injury to the bladder and its prompt repair. Thirty patients had undergone prior failed attempts at repair elsewhere. Three fistulas closed spontaneously. One hundred and seven were repaired by the Latzko technique. There were nine failures, each of which was successfully repaired by a repeat Latzko operation when vaginal reepithelization was complete. Suggestions to avoid injury to the bladder during abdominal total hysterectomy include use of a two-way indwelling catheter when risk factors are present, use of sharp dissection to isolate the bladder, use of extraperitoneal cystotomy when dissection is difficult, filling the bladder when injury is suspected and repair of an overt bladder injury only after mobilization of the injured area. A Latzko repair of a vault fistula is advised because complications are minimal, the postoperative patient is comfortable and the period of hospitalization is five days or less.