Complex circumferential obstetric fistula-a urologist's worst nightmare

Circumferential vesicourethrovaginal fistula is a severe form of obstetric injury that is challenging to repair and carries a poor prognosis related to eventual continence. Here, we report the successful repair of a circumferential vesicovaginal fistula associated with near total loss of the urethra. The use the anterior bladder flap technique along with an autologous rectus sheath sling resulted in the creation of an effective continence unit.

A 31-year-old woman had a history of obstructed labor resulting in intrauterine death followed by trans-abdominal hysterectomy for postpartum hemorrhage. Since then she had had total urinary incontinence. She had an attempted repair through the vaginal route, which had failed. Physical examination and endoscopic evaluation revealed a large vesicourethrovaginal fistula with near total loss of the urethra leaving only the meatus. Intraoperatively, we found that it was a large circumferential defect in the infratrigonal region with no anterior bladder wall left at the site of the fistula.

We performed an anterior bladder flap procedure as described by Tanagho along with an autologous rectus sheath sling for additional support. Postoperatively, the patient was completely continent.

The anterior bladder onlay flap technique, which has been used extensively for female urethral reconstruction in developed countries, along with an autologous rectus sheath sling is an effective technique for management of circumferential fistulas allowing good continence. Incorporation of this technique into the armamentarium of surgeons managing fistulas in developing countries will go a long way toward helping this unfortunate group of women with this morbid complication of obstructed labor.