內視鏡膀胱內修補手術對於膀胱陰道瘻管有良好的成效

李宗叡、黃志平、葉進仲

中國醫藥大學附設醫院 泌尿部

Endoscopic Intravesical Repair as a Feasible and Promising Approach for Vesicovaginal Fistula

Tzung-Ruei Li, Chi-Ping Huang, Chin-Chung Yeh

Department of Urology, China Medical University Hospital, Taichung, Taiwan

Purpose:

Vesicovaginal fistula (VVF) is an abnormal tract between urinary bladder and vagina. Though in rare incidence, it generates annoying symptoms in women. Transperitoneal laparoscopic, transvaginal or transabdominal repair are the common procedures if failure to conservative treatment. However, the above methods might be limited due to the abdominal adhesion from previous surgery or when handling supratrigone. We shared our experiences of endoscopic intravesical VVF repair, this unique approach, with promising outcomes and efficacy.

Materials and Methods:

This retrospective study recruited 18 patients with vesicovaginal fistula from Jan.2015 to Dec.2021 in our hospital. All patients were diagnosed of vesicovaginal fistula by cystoscopy. Some received additional CT or cystogram. These patients then received VVF repair in different approaches (transvaginal, transabdominal, laparoscopic and endoscopic repair) based on the preference of surgeons or the condition of patients. We introduced the endoscopic repair: Two 5-mm working trocars were placed percutaneously to the bladder cavity above the pubic bone. We performed excision of fistula and wound closure in a single layer with 3-0 resorbable sutures with needles holder introduced from urethra meatus, under cystoscope manipulation and bladder instillation. We listed the result and focus on endoscopic repair.   

Results:

Of all 18 patients, 4 patients received endoscopic repair, while 12, 4, 2 patients received transvaginal, transabdominal, and laparoscopic repair respectively. The median age was 54 year-old. 16 patients suffered from gynecologic surgery, while one with bladder injury after delivery. Among the 4 patients undergoing endoscopic repair, the median diameter of fistula is 5 (5-10) mm. Two of them had supratrigonal fistula, one of them had trigonal fistula, and one of them had infratrigonal fistula. Two of them received previous VVF repair before but failed. The median operation time was 135 minutes, which was similar to transvaginal approach (131mins), but superior to open (440 mins) and laparoscopic (269 mins) approaches. The blood loss was minimal. There was no fever or the need of intravenous antipyretics use. Neither of the patients suffered from recurrence then with the median follow up of 33 months, while there were 3 patients had recurrence in transvaginal repair group.

The advantages of this approach include the familiar surgical field for urologist, easier handling of deep supratrigonal fistula if narrow vaginal, and easier suture (horizontal to the wound), compared with laparoscopic setting.

Conclusions:

Our experienced showed endoscopic VVF repair had compatible outcomes to other approaches due to its special technique and small wound. We therefore recommend that this procedure merged with endoscopic and laparoscopic techniques can be provided to patients with relatively small and even recurrent VVF due to its good outcomes and safety.