This is 36 years lady presented to us with continuous urine leak per vagina for 20days.

Past history of TAH for uterine prolapse 1months back.
She is using more than 5 pads per day...very worried about urine smell all the time..
How to investigate her.
How to manage her?



  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    17 Mar 2020 01:21:29 PM

    Cystoscopy picture...showing supratrigonal 3cm vesicovaginal fistula?

    CT Ivu...showing vesico vaginal fistula?
    What is  role of dye test??
    Any more investigation needed for this case?

  • Lalit Shah
    Lalit Shah
    17 Mar 2020 01:38:15 PM

    1/- dye test for all practical purposes is obsolete,specially with urologists( in my opinion, I have never done dye test while dealing with VVF/UVF,and have no reason to regret)

    2/-as per description sufficient diagnostic tests have been done,further needed are fitness tests, urine culture etc.
    3/- cystoscopy is the key diagnostic investigation ( at least in hands of urologists)
    4/- I know few may not agree,but there is absolutely no need to wait for surgical repair ( wait for three months philosophy), sooner the better.
    5/- omentum interposition is the key step for surgical success in addition to other basics of VVF repair.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    17 Mar 2020 01:42:56 PM

    Thanks Dr. Lalit Sir to open the discussion in strong words.

    @ Tikenjit, is there a catheter in place, in posted picture I am seeing tube in bladder?

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    17 Mar 2020 01:54:26 PM

    Sir , patient was put on catheter due to continuous leak,but.still she was leaking but a bit decrease d n less..thank u

  • Utsav Shah
    Utsav Shah
    17 Mar 2020 02:07:15 PM

    This patient has a supratrigonal VVF as demonstrated by Contrast CT and confirmed on cystoscopy. 

    An ideal case would be:
    History —> Suspicion of urogynec fistula —> OP Ultrasound Screening —> Renal function test —> CT urogram —> cystoscopy —> definitive treatment. 

    If the VVF is small(<5 mm), away from bladder neck, not associated with UVF then catheterisation can be tried as a treatment. This patient has already failed that. 

    Conventional teaching is to wait for 3 months and then operate. Some papers are saying early repair within one week is also equally efficacious. Depends on what you follow in your institute. 

    Small fistulae(<5 mm) with oblique tract and no inflammation around the tract have also been subjected to fulguration. I remember reading a paper in J. of Endourology by Dr Shrenik Shah sir where sir has done fulguration as a treatment for small VVF with good success rates. 

    This patient needs O’Conor’s repair with the principles of exposure of the fistula tract by going beyond it, closure of both the bladder and the vagina separately with perpendicular Stitch line to each other, tension free and watertight anastomoses with omental interposition as Lalit sir suggested.

  • JG Lalmalani
    JG Lalmalani
    17 Mar 2020 03:58:48 PM

    If Vagina is capacious, would do a transvaginal repair in prone position. With or without Martius Flap.

  • Rahul Kapoor
    Rahul Kapoor
    17 Mar 2020 04:12:44 PM

    Actually CYSTOSCOPY is sufficient. 

    I usually do USG to look for and HNU.
    Thats it. No further tests are usually needed. 
    Listening to Lalit sir, now i operate when patient present and they all heal. 
    I dont keep PUC, it causes mucosal edema 

  • Jaideep Mahajani
    Jaideep Mahajani
    17 Mar 2020 04:15:13 PM

    If ureteric orifices are more than 2 cm away, vaginal approach is very good. I always put Martin's flap. If VVF is high, I put catheter from vagina into bladder and pull. As plan is created in between vaginal wall and bladder, bladder can be pulled easily. 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    17 Mar 2020 05:58:01 PM


    For this case of supra trigonal fistula, will you prefer vaginal approach or abdominal approach? Will you wait till 10 to 12 weeks or you will repair in couple of days as advised by Dr. Lalait Sir
    @ Utsav, Why CT IVU in all cases?
    As Rahool has mentioned, we can look at USG, if no HUN or no upper tract symptoms, can we avoid CT?

  • Jaideep Mahajani
    Jaideep Mahajani
    17 Mar 2020 06:38:10 PM

    For traumatic VVF, either I will operate within 5 days of surgery  or wait for 6 weeks.

    For obstetric fistula (which we do get at times) I wait for 4 to 6 months. 
    For post radiation fistula it is recommended to wait for one year.
    As far as investigation is concerned, I prefer bilateral RGP in selected cases, when I suspect associated UVF. It can be easily done during cystoscopy (done under GA). It is more reliable & cost effective also.

  • Utsav Shah
    Utsav Shah
    17 Mar 2020 09:28:09 PM

    Respected Anil Sir, 

    CT IVU will give us a lot of info which will be missed by USG:
    1) Hint to the exact location of fistula on delayed phase imaging 
    2) Upper tract delineation is better on CT
    3) Perivesical, pelvic and periureteric events(inflammation, etc) can be seen
    4) In case of a large VVF, there will be continuous leak per vaginum and thus the bladder cannot be distended enough for ultrasound examination
    5) planning of surgery is entirely based on location of fistula which is possible on CT urogram and not USG. 

    Thus, CT Urogram is mandatory acc to me.  

  • Dr Prashant Mulawkar
    Dr Prashant Mulawkar
    18 Mar 2020 10:54:15 PM

    i rarely do trans abdominal repair. usually trans vaginal route is used. would share a video tomorrow

  • Ravindra Sabnis
    Ravindra Sabnis
    19 Mar 2020 07:20:30 PM

    Surgeons choice to select the rout of surgery. Principles - whichever way you do, vaginal, transvesical, O conor - remain same. 

    Catheter keeping is counterproductive - as causes infection & mucosal edema & hyper granulation.

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    19 Mar 2020 11:03:50 PM

    Thank u sir..

    did O'Conor transvesical repair with greater omentem transposition.surgery picture attached
    Patient sent home,came on pod 15 with urine leak again.
    Did scopy... fistula develop in Trigon n near left ureteric orifice...around 1.5 cms...
    Cystoscopy picture attached..what investigation to do again?
    What can be the cause of failure?
    How to manage now?

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    19 Mar 2020 11:05:30 PM


  • Dr. Anil Takvani
    Dr. Anil Takvani
    20 Mar 2020 08:15:17 AM

    Thanks Tikenjit for posting follow up and failure, very occasionally we speak about our failures or complication though we all know failures and/or complications are bound to be there in surgical procedures.

    Reasons of failures could be:
    1. Inadequate separation of both the system; bladder and Vagina
    2. Bladder closure under tension because of inadequate separation or mobilization of bladder
    3. Damage to the vascularity by excess use of cautery near fistula margins, in specific around bladder margins
    4. Inadequate mobilization and/or inadequate omentum interposition of healthy omentum
    5. Post fistula closure frequent or prolong catheter and/or SPC blockage because of blood clots
    6. Infections
    As I am working at peripheral center and urologists are few, I have experience of VVF/UVF repairs in three digits in last 20 years at single center with good follow up.
    I have one failure on my name.in a already twice operated, difficult case of big fistula with involvement of left ureteric orifice. I had to do left reimplantation with mobilization and creation of flap from right bladder wall to close bladder tension free. It failed with small fistula on right side of the closure. Subsequently after wait of 3 months she was re-operated at another center where laparoscopic fistula repair was carried out and fortunately she cured of her problem.
    We have many masters in this group, I would like to request them to share their views on failure of VVF repairs and their own failures and possible reasons behind failures.

  • Rahul Kapoor
    Rahul Kapoor
    20 Mar 2020 09:26:58 AM

    Thanks Tikenjit

    Nice u updated this case to end and shared failure. 
    One learns more from failure than from success... 
    Retrospectively think which step probably had a problem and probably thats the cause of failure..
    I feel either of these 2 things happened...
     Adequate Bladder mobilisation laterally so suturing can be tensionless was compromised .. sometime not possible as pelvis is small
     or separation of fistula had a problem or was inadequate... this is most important. Sharp dissection, no mucosal stripping from the muscle is needed to preserve vascularity.  In obese patients and pt. With small bladder, its become a problem. 

    Transposition of omental patch or Martius flap (during transvaginal repair) is important, but lot od urologist dont do. So its the primary tensionfree repair which is the crux. 
    If one see the literature and see the causes of failure... they follow as
    1. Small bladder capacity
    2. OAB
    3. URETHRAL injury 
    4. Scarred vagina ( when doing transvaginal approach... probably leading to jnadequate mobilisation). 

    Beside all these factors, pt Hb and Albumin level can also be reason for poor wound healing.. 
    Beside this few caused as Anil sir said like clot and catheter blockade etc are also responsible 

  • Utsav Shah
    Utsav Shah
    20 Mar 2020 11:09:04 AM

    Great to see follow up of the patient Dr Mazumdar. 

    Sad to hear abt the failure. 

    Apart from the points highlighted above by Anil sir and Rahul sir, I would like to make a few comments: 
    1) Maybe the patient got operated early(within 40 days of previous prolapse surgery). Waiting for 2 months more is the traditional teaching to let fibrosis set in and tissues develop vascularity.

    2) Pls tell us abt your naked eye and tactile nature of the tissue during the surgery: was it thick enough to hold the sutures or papery thin? Such intraop findings abt native tissue strength might help in postop counselling abt possible chance of failure. 

    3) We recently experienced a failure in a case where omental interposition wasn’t done. Rest everything(technique, mobilisation, tissue strength) appeared ok to me(I assisted the case). So omental interposition should have been done for my case

  • Dr Prashant Mulawkar
    Dr Prashant Mulawkar
    20 Mar 2020 07:25:11 PM

    Sharing my video on Transvaginal repair of VVF. Earlier presented in one of the WZUSICONS

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    20 Mar 2020 09:37:06 PM

    Very grateful for all ur time...thanks for all expert comments

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    21 Mar 2020 11:41:15 AM

    Patient again reoperated after 3months through transabdominal transvesical route...

    This time came to follow up with a Smile.
    My q is what is role of culdoclysis?is there any role?
    Would it have been  a bit easy operation with vaginal route?

  • Ravindra Sabnis
    Ravindra Sabnis
    21 Mar 2020 06:44:53 PM

    I again wish to state, rout does not matter. Somewhere, principles get compromised & failure occurs. What is important is that in spite of failure, patient remained with you, you operated again & had success. This speaks a lot. Failure is part & parcel of surgery. But explaining  & gaining the confidence of pt, in spite of failure is laudable. Congratulations. Well done. 

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    21 Mar 2020 06:48:03 PM

    Thank u for encouraging wards sir...it means a lot

  • Lalit Shah
    Lalit Shah
    23 Mar 2020 12:48:04 PM


    I know quite many would label failure due to not following three month philosophy.( not discussing about radiation or post obstruction labour cases)
    I have been strongly advocating always to do ASAP,and had no reason to regret.
    Many points already mentioned above about possible cause of failure.( we all become wiser in retrospect)
    Good omental interposition is the key.
    Most probable reason would be
    # inadequate mobilisation of bladder for tension free suturing.
    #inadequate mobilisation of bladder distal to fistula( minimum1.5 cms) so as to fix omentum 
    # inadequate quantum of omentum used for interposition 
    # omentum used for interposition was under tension, which probably compromised vascularity 
    In general one doesn’t need omental mobilisation, as usually significant amount of omentum is available without tension.
    ( needs mobilisation if doesn’t reach down without stretching)
    # my all VVF repairs are trans abdominal with omental interposition.(I do counselling about other options as well with disclaimer that my results are good with this approach and I would do this only)
    Regarding failures:
    I feel very lucky that for all practical purposes I haven’t seen a failure yet,in significantly large number of cases even with repair ASAP( not waiting three months).
    I remember only one technical failure, she was an obese lady with multiple large VVF of 20 years duration.Past history of three caesarean, hysterectomy,twice VVF repair attempts in past.
    She presented with large bladder stone,she was not willing for VVF repair( as staged procedure after stone management).
    We did cystolithotomy and VVF repair with omental interposition in the same sitting.
    Result: she had a small fistula (subcentimeter), needs one or two pads a day.She is so happy with ability for pleasure of voiding that she doesn’t want any further intervention.

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