Modification of O'Connor's technique for the treatment of vesico-vaginal fistula repair described

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Mar 30 2006

Vesicovaginal fistula (VVF) is a distressing disease with social, hygienic, and psychosexual consequences.

In third world countries, obstetric etiologies prevail, while in the west, 90% of cases are caused by inadvertent bladder trauma during surgery with hysterectomy being the most common procedure (75% of cases).

The transabdominal O’Connor’s operation has been the most accepted method of repair of supratrigonal fistula to date. The traditional O’Connor operation utilizes suprapubic access for extraperitoneal dissection of the retropubic space to dissect the bladder, followed by long sagittal cystotomy (bivalving the bladder) until the fistula is reached. The fistulous tract is excised, flowed by two-layer closure after tissue transposition between the bladder and vaginal walls.

A recent review by D. Dalela and colleagues from Lucknow, India, describes a transperitoneal modification of the O’Connor procedure which decreases the amount of bladder dissection and operative time. It also is postulated to decrease the post-operative voiding dysfunction and detrussor overactivity the goes with a larger and more involved cystotomy and vesical dissection. The study is published in the March, 2006 issue of European Urology.

The modification involves a smaller, posterior cystotomy that is carried toward the edge of the fistula. The fistula tract is excised, and the bladder defect is closed by advancing the flap that is created. The closure is completed in a single, running, locking layer of monocryl suture. An omental flap is utilized in all cases where the omentum is able to reach this far.

In the series of 26 cases reported, the mean fistula size was 2.8 cm. The mean age of the patient was 21.4 years with 22 patients having obstructed labor as the cause for their fistulas. Nine patients had had a prior attempt at repair elsewhere. Mean operative time was 104 minutes and blood loss was insignificant. Three patients required ureteroneocystotomy. In 24 cases, the greater omentum was able to be mobilized to interpose between the bladder and vaginal closures. In 2 patients, a paravesical peritoneal flap was utilized. Suprapubic and urethral catheters were utilized for two weeks post-operatively. All patients had a successful repair of the fistula after 2 or 3 weeks of catheter drainage.

The paper provided some illustrations to better describe the technique which appears to be less involved than the classic description from O’Connor. One would only suppose that less bladder dissection would mean less post-operative lower urinary tract symptoms. The avoidance of the retropubic space also is an advantage as it leaves this space undisturbed for stress incontinence procedures that may be needed later in life.

Reference:

Eur Urol. 2006 Mar; 49(3):551-56