Management of radiation-induced vesicovaginal fistula.

Abstract

Pelvic radiation used for the treatment of malignant diseases is the primary cause of delayed vesicovaginal fistula. We consider the Martius labial fatty flap technique and the Latzko upper colpocleisis as important tools for the urologist dealing with patients suffering from radiation-induced vesicovaginal fistula (RVVF). In our clinic, 216 patients with RVVF underwent surgical treatment. The vaginal approach was used in 210 cases (97.2%), and the abdominal approach was used in 6 cases (2.8%). The Martius flap technique was used in 41.0% of cases (86/210). In 35.7% of cases (75/210), the fistula repair was done by Latzko colpocleisis. Martius procedure includes mobilization of labial flap and its interposition between bladder and vaginal walls during fistula repair. In Latzko upper colpocleisis, only vaginal mucosa around the fistula is excised. Then fistula is closed with several layers through anterior and posterior vaginal walls obliterating the upper vagina. Primary RVVF repair was effective in 48.1% patients (101/210). One hundred and nine patients (51.9%) had failed surgery and remained incontinent. Ninety-eight patients were operated on again with cumulative success rate reaching 66.6% (140/210). Forty-two patients underwent tertiary surgery and 19 patients had more than three operations. Taken together, 169 patients out of 210 have had their RVVF successfully closed. This resulted in an overall efficiency of 80.4%. Presented data include our experience of more than 40 yr that limits standardization of treatment and lack of some data. The closure of the fistula may be done in several steps by reducing the size of the fistula and giving patients more time to recover. The Martius labial flap is a safe and effective procedure for these cases. Latzko upper colpocleisis is preferable when the risk of ureteral damage during surgery is present.