Management of giant vesicovaginal and vesicourethrovaginal fistulas

We herein report on 15 patients with giant vesicovaginal (7) and vesicourethrovaginal (8) fistulas repaired since July 1979. All fistulas were repaired by a suprapubic approach with or without a concomitant vaginal approach. All 7 patients with giant vesicovaginal fistulas underwent a standard racket incision of the bladder with excision of the fistula, closure of the vagina and bladder, and an omental interposition, and were cured. Four patients with giant vesicourethrovaginal fistulas had a similar successful closure but only 2 were cured of the incontinence, while 2 remained totally incontinent owing to failure of the bladder outlet sphincteric mechanism. The latter 2 patients were managed by a Tanagho bladder flap urethral reconstruction: 1 remained totally incontinent and finally underwent diversion, while 1 was improved but not cured totally. Four patients were managed by repair of the fistula simultaneously with a Tanagho bladder flap: 2 had no previous abdominal repairs and both achieved continence postoperatively, while 2 had numerous attempts at repair (including abdominal approaches) before referral and only 1 was cured. Giant vesicovaginal fistulas can be repaired successfully in almost all patients. Although vesicourethrovaginal fistulas can be closed as readily there is a high likelihood of sphincteric inadequacy in patients with extensive urethral involvement. A bladder flap urethral reconstruction is valuable in these patients, particularly in the absence of prior suprapubic procedures.