Vesicovaginal fistula: Etiology, Diagnosis, Treatment and Prevention

Introduction
A vesicovaginal fistula (VVF) is an abnormal fistulous tract extending between the bladder and the vagina that allows the continuous involuntary leakage of urine into the vaginal vault. Currently, there is no standardized protocol for the optimal surgical approach in the treatment of vesicovaginal fistula. In modern medicine, in addition to conservative treatment and classic open surgery, there are also new modern surgical methods that are less invasive, such as endoscopic, laparoscopic, and robot-assisted surgery.
Objectives: Determining the etiology and method of preoperative diagnosis of patients with vesicovaginal fistulas to determine a timely indication for conservative or surgical treatment of the patients. Analysis of patients with vesicovaginal fistulas, treated surgically, and finding the most adequate surgical approach for treatment. Determining the postoperative complications of each surgical approach as well as the method of their resolution. Determining preventive measures to prevent the occurrence of vesicovaginal fistulas based on our current practice.
Materials and Methods: The study was conducted at the urology department of the City General Hospital “8th September” - Skopje in the period from January 2015 to the present. The study included patients of all ages with dysuria complaints, urinary incontinence, urine and feces leakage through the vaginal canal or patients already diagnosed in another institution. The patients included in the study underwent ultrasonography, cystoscopy (gold standard), MRI of the pelvis, MRI fistulography, cystography and micturition cystography. 24 patients will be included. The patients were examined in the urology office and then referred for further examinations. Patients in whom cystoscopy revealed changes consistent with vesicovaginal fistula were referred for cystography, MRI fistulography or CT urography and subsequently for preoperative analyses for treatment. The study will use the quantitative and comparative method for data processing. The variables will be processed and presented in percentage, tabular and graphical form. Standard deviation will be used to present statistical values.
Results: The analysis will include 24 patients who were examined and treated at the City General Hospital “8th September” - Skopje. Of these, 20 patients (83%) were diagnosed with vesicovaginal fistula, while 4 patients (17%) were diagnosed with vesicorectovaginal fistula. Research data showed that vesicovaginal fistulas are most common in patients aged between 51–60 years (42%) and 61–70 years (33%). In most cases, the cause of vesicovaginal fistula is a hysterectomy (85%). Transvesical fistulectomy is the most commonly used technique for repairing vesicovaginal fistulas, in 70% of cases. 80% оf patients with vesicovaginal fistulas were successfully treated.
Conclusion: Based on the study we conducted at the City General Hospital “8th September” - Skopje, we determined that the leading cause of vesicovaginal fistulas in 85% of cases is hysterectomy. Also, according to the data obtained from studies conducted in the USA, we can conclude that gynecological operations, i.e., hysterectomy, are the main cause of vesicovaginal fistulas. According to the analysis of our study group at the City General Hospital “8th September” - Skopje regarding the treatment of vesicovaginal fistulas, we determined that the transvesical approach for smaller and medium-sized fistulas and the transperitoneal approach for larger and complex fistulas provide better results compared to the currently available reference literature, where the transvaginal approach is used as the standard method for the treatment of vesicovaginal fistulas.