Vesical calculi associated with vesicovaginal fistulas: management considerations

Vesical calculi were detected in 5 patients with a vesicovaginal fistula. Of these patients 3 had undergone unsuccessful repair of the fistula previously. The predisposing factors for vesical calculous formation in patients with a vesicovaginal fistula in whom urine leaks continuously into the vagina and urinary stasis does not occur in the bladder, as in patients with neurogenic bladder dysfunction or bladder outlet obstruction, are a foreign body (for example nonabsorbable suture material used during previous surgery), incrustation around an indwelling catheter and infection. The vesical calculus is removed transvaginally after enlarging the fistula by a vertical incision at the 6 o'clock position. The incised edges do not usually bleed because of fibrosis and scar formation, and they need not be approximated at that operation. Indwelling catheter drainage is not necessary after transvaginal cystolithotomy in this situation. This operation is preferable to suprapubic cystolithotomy, which may lead to more morbidity from urine leakage in the retropubic space and subsequent fibrosis, in addition to producing bladder scarring, hindering any future reconstructive surgery requiring the use of vesical flaps. Transvaginal cystolithotomy is contraindicated when the fistula is situated close to the bladder neck (for fear of damaging the bladder neck and the vesical continence mechanism) or when the stone is large. Repair of the fistula is undertaken after an interval of 3 months to allow for resolution of stone-induced edema and friability of the vesical wall.