Controlled Intramural Ureterotomy and Cystoscopic Assistance During Transvaginal Repair of Complex Vesicovaginal Fistula.

Transvaginal approach has long been described as a gold standard for vesicovaginal fistula (VVF) repair. But, presence of ureteral orifice at or near the fistulous margin presents unique challenges during VVF repair irrespective of the approach. We present a video on our novel techniques in these difficult VVF repair to aid in avoidance of ureteric orifice entrapment during VVF repair. Index patient is a 36-year-old woman gravida one, para one presented with complaint of continuous leakage of urine per vagina 2 weeks after vaginal delivery for prolonged obstructed labor. Before starting repair, cystoscopy was done and site of VVF was visualized in close proximity to right ureteric orifice, raising concern of ureteral orifice entrapment during repair. Next, right ureter was stented with 5Fr ureteric catheter, and the intramural length of ureter was estimated. Then, a controlled lay opening of ureteral orifice for half the intramural length was undertaken over ureteric catheter with Hol:YAG laser (550 micron,1.5 Joule, 10 Hertz). It resulted in cranial advancement of orifice away from fistula site, avoiding entrapment during suturing. Moreover, residual intact length of intramural ureter provides adequate antireflux mechanism. As an additional protective measure, cystoscopic visualization of suture needle was done, which aided in avoiding ureteral orifice entrapment during suturing. The patient had an uneventful postoperative course with no wound complications and dehiscence. There was no evidence of seroma formation. Per urethral catheter was removed after 3 weeks in postoperative period. Voiding cystourethrography done at 3 months reported no evidence of reflux. At the latest follow-up of 12 months, patient remained asymptomatic. Abovementioned novel techniques are feasible, easily reproducible, and can facilitate in avoiding ureteral orifice entrapment during transvaginal VVF repair.

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