Vesicovaginal fistula.

Vesicovaginal fistulas are often the result of obstetric trauma in third world countries and gynecologic surgery in developed countries. Improvement in obstetric care and the increased use of cesarean section has resulted in a decrease in the incidence of obstetric fistulas in the United States. However, the incidence of fistulas as a result of surgery has remained relatively unchanged for years. Most postoperative fistulas occur under very normal operative circumstances. The keys to prevention of postoperative fistulas are wide dissection of the bladder from the cervix and vagina in the correct plane during surgery and recognition of bladder damage intraoperatively with appropriate repair. More than 90 percent of vesicovaginal fistulas can and should be repaired vaginally. The procedures available for repair are the flap splitting and Latzko techniques. On occasion an abdominal approach is indicated, particularly for vesicouterine fistulas. Requirements for successful repair include adequate surgical exposure, wide mobilization of the vagina, nonexcision of the fistula tract, tension-free closure of the bladder, and grafting when indicated.