Use of a Cadaver Allograft Patch to Repair a Large Vesicovaginal Fistula in a Patient with Long-Standing Radiation Cystitis
Dr. Edward J. Stanford
Centralia, Illinois

 

An alternative method to consider when faced with a large vesicovaginal fistula.

DESCRIPTION OF TECHNIQUE: A 75-year female with a previous history of cervical carcinoma treated with radiation presented with a large vesicovaginal fistula who had failed a previous fistula repair 15-years earlier.  The patient was wheelchair bound and the associated incontinence had led to near total debilitation.  Radiation and hypoestrogenic changes were evident in the vaginal and vulvar regions.  The size of the fistula opening (approximately 4 cm) made mobilization of a bulbocavernosus muscle graft undesirable.  An alternative method was attempted using a cadaveric allograft interposed between the damage bladder epithelium and damaged vaginal mucosa.  After identification and stenting of the ureters bilaterally, the fistula was excised.  The fistula was intimate to the left ureteral opening.  Incomplete approximation of the damaged bladder mucosa left an incomplete seal of the bladder.  Mobilization of the vaginal mucosa was also incomplete although closure was possible.  A shaped patch of cadaveric allograft was introduced between the bladder and vaginal tissues as an interposed layer.  It was secured using interrupted absorbable suture until it was “water-tight”.  Confirmation of ureteral drainage was made cystoscopically.  The mucosa was closed with absorable suture and the vagina was packed for 24-hours.  A suprapubic catheter (SPC) was placed for 3 weeks.  Complete closure of the fistula was confirmed cystoscopically after removal of the SPC.

LONG-TERM FOLLOW UP:   Twenty-four month follow up reveals complete closure of the fistula using this technique.  Subsequent treatment of intrinsic urethral deficiency with periurethral injection has been successful and the patient is continent.  Additionally, the patient has left her wheelchair and is living independently.  This case illustrates the use of a previously unreported alternative method to close a large vesicovaginal fistula in a patient with long-standing radiation cystitis with excellent long-term results using an allograft as an interposing layer.