Repair of giant vesicovaginal fistulas.

PURPOSE: We evaluated the long-term success rate of an abdominovaginal approach using a rotational bladder flap to repair giant vesicovaginal fistula.

MATERIALS AND METHODS: A total of 35 patients were included in this study. Of these patients 28 had a large vesicovaginal fistula and 7 had complete loss of the urethral floor. Fistula etiology was secondary to obstructed labor in 25 patients, the result of iatrogenic surgical injuries in 5, sling erosion in 3 and pelvic irradiation in 2. Using combined abdominal and vaginal approaches the bladder was bisected sagittally, and a bladder flap was rotated downward and medially to fill the extensive fistula defect. An additional vascularized flap was interposed in 23 patients including gracilis muscle flap in 13, omental flap in 5, peritoneal flap in 2 and Martius flap in 3.

RESULTS: Fistulas were successfully repaired in 31 of 35 patients (88%). The remaining 4 patients underwent surgical correction with a second, more limited repair. This group included 2 patients with fistula from obstructed labor, 1 due to sling erosion and 1 due to irradiation.

CONCLUSIONS: A combined abdominovaginal approach with the use of a generous rotational bladder flap for repair of a complex vesicovaginal fistula allowed for excellent results. There was a high success rate on the first attempt due to the excellent exposure and healthy, well vascularized tissue used for repair.