Discussion
Vesicovaginal fistulas are the most common fis-
tula in the urinary system [3], and their etiology
varies in different nati ons. In developed coun-
tries, at least 75% of vesicovaginal fistulas are
caused by pelvic operations of gynecology, urol-
ogy, and others, with obst etric operations making
up most of the oper ational causes. A ves-
icovaginal fistula after hysterectomy may be
caused by an intraoperative bladder incision that
was not recognized around the sleeve or other
mechanisms such as tissue necrosis due to cauter-
ization or suture. Intraoperative bladder injury is
a significant factor in the development of post-
operative vesicovaginal fistulas. Other causes in-
clude a past history of ut erus operation, endome-
triosis, infection, diabetes, and a past history of
radiotherapy. Vesi covaginal fistulas are at least
three times more common in hysterectomy con-
ducted by approaching through the abdominal
wall than in that conducted by approaching
through the vagina.
The most common symptom of vesicovaginal
fistula is urinary efflux via the vagina, and the
amount of urinary efflux is different in patients
and is proportional to the size of the fistula.
Other symptoms include i rritation of the vagina,
pudendum, or perineum recurrent cystitis mycotic
infection of the vagina and pelvic pain.
Physical examination is important in the diag-
nosis of a vesicovaginal fistula. For most ves-
icovaginal fistulas after hysterectomy, the fistula is
located along the posterior vaginal wall or the
sleeve of the vagina. Urinalysis and urine culture
tests are conducted, and cystography is favored for
detecting fistulas. Because ureter injury or ureter
fistulas can be produced in around 12% of post-
operative vesicovaginal fistulas, urography or retro-
grade urography is needed [4]. The number, size,
and location of the fistula are identified by using
cystoscopy. When a vesicovaginal fistula is sus-
pected, it can be definitely diagnosed after it is
seen at the vagina from the uretercatheter.
The purpose of treatmen t of a vesicovaginal fis-
tula is to correct urine efflux, and Davits et al.
[5] treated vesicovaginal fistulas of selective pa-
tients who were newly diagnosed by using re-
tention of the catheter an d administration of anti-
cholinergic agents. Such co nservative treatment is
useful when the fistula is small, with a diameter
of 2 to 3 mm.
The time of treatment of a vesicovaginal fistula
is still controversial. For a vesicovaginal fistula
caused by delivery, the op eration is delayed for 3
to 6 months to clarify th e boundary of ischemic
tissue and to allow recove ry from edema or in-
flammatory response. For a vesicovaginal fistula
caused by radiation, the operation may be de-
layed for 6 to 12 months. There are recent re-
ports of early operatio ns to lessen the incon-
venience and pain of patients with a simple ves-
icovaginal fistula after gynecological operations,
but these showed insufficient differences in the
success rates of the operations [6-7].
Operational methods can be roughly divided
into transabdominal and transcervical approaches.
In the transabdominal ap proach, the operation is
delayed for 3 to 6 months, and it has the merit
of not changing the length of the vagina.
Usually, the gastrocolic omentum is used as a
flap, followed by the peritoneum and Gracilis
muscles. In the transcervical approach, immediate
operation is possible when no complications or
68 HM Hong, et. al.
INJ April 2010
infection are observed. Th e approach can change
the length of the vagina, and a Martius flap is
usually used by using the subcutaneous fat of
the labium [8]. The oper ational approach is usu-
ally selected by preference of the operator. For
successful operation, certain basic principles must
be satisfied as follows. First, the ischemic tissue
should be completely removed by sufficient ex-
posure of the fistula, and healthy tissue with suf-
ficiently retained blood ve ssels should be used as
a flap. Second, the suture should be performed
in multiple layers, with out overlapped sutures,
and tension should be carefully avoided. Third,
urine efflux should be re tained by catheter post-
operativelyand inflammation should be avoided.
The success rate of treatment of a simple ves-
icovaginal fistula is reported to be around 75% to
97%, but that of combined vesicovaginal fistula is
reported to be lower in cases of recurrence, with
the existence of a tumor, or with a history of ra-
diation treatment.
We decidedto apply a common operational
Method
to the patient in this case study, because
only one vesicovaginal fist ula at the vaginal vault
was observed, the course of the fistula was ab-
normaland irregular, and a multicentric, large
vesicovaginal fistula was observed by cystoscopy.
Therefore, for complete removal, the vesicovaginal
fistula including the surrounding scar was excised
by using a transurethral pointed electrode. We
were able to precisely ex cise the ischemic tissue
of the vesicovaginal fistula with the transurethral
pointed electrode because it allowed us to view
the side of the excision due to the small amount
of bleeding by use of th e enlarged view. Also,
with this method, it is po ssible to identify injury
to the ureter when the fi stula is excised in the
medial inlet of the ureter.
As seen in our case, when excision of a ves-
icovaginal fistula using a transurethral pointed
electrode is applied to pa tients with multicentric
or combined vesicovaginal fistulas, it is easy to se-
cure a view and to arrest bleeding, and exact ex-
cision of the ischemic ti ssue is possible. Thus, the
success rate of the operation may be enhanced
when excision of a vesicovaginal fistula using a
transurethral pointed electrode is applied to pa-
tients with multicentric or combined vesicovaginal
fistulas.
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