Vaginal repair of pouch-vaginal fistula after orthotopic bladder substitution in women.

OBJECTIVE: To report the diagnosis, technique, and treatment outcome of pouch-vaginal fistula (PVF) with particular stress on the vaginal repair.

METHODS: Between January 1995 and March 2010, 298 women (mean age, 52 years) underwent orthotopic neobladder reconstruction after radical cystectomy. A standard radical cystectomy was conducted in 283 patients and genitalia-sparing cystectomy in 15. Certain modifications were adopted after 100 patients to prevent chronic urinary retention and PVF. Hautmann or hemi-Kock pouch was used. Patients were oncologically and functionally evaluated and asked about any sexual complaint. Eight PVF (2.7%) were diagnosed by voiding radiography of the pouch and preoperative endoscopy. Transabdominal repair was used in 2 patients(high, large, vaginal atrophy) and the other patients underwent a vaginal repair in nonopposing layers 3 to 6 months after cystectomy.

RESULTS: The incidence of PVF was 5 of 100 (5%) before and 3 of 198 (1.5%) after the technical modifications. In one patient, repair of the fistula was conducted in 2 stages. After repair (mean follow-up, 146 months), all repaired patients were continent during daytime and only one had nocturnal incontinence. The urodynamic parameters were comparable to these in other women undergoing orthotopic neobladder reconstruction and not having a fistula.

CONCLUSION: Transvaginal repair of PVF is feasible with good functional outcome. It is recommended in low, small fistula and if postmenopausal vaginal atrophy is absent. The repair does not compromise the external urethral sphincter. However, these conclusions need to be consolidated in future studies including a larger number of patients.