Prof. Dr. Mustafa SOFİKERİM | Urology

What is Vezicovaginal fistula (VVF)?

Vesicovaginal fistula (VVF) is a subtype of fistulas occurring in the urogenital system (between the urinary tract and female genitals) in women. An abnormal canal formation occurs between the vaginovaginal fistula (VVF) and the bladder (bladder) and the vagina. This abnormally developed canal is called fistula.

Due to this fistula that occurs between the bladder and the vagina, the urine in the bladder escapes into the vagina and flows out of the vagina and causes involuntary and continuous urinary incontinence. It is extremely troublesome for women due to continuous day and night urinary incontinence and is a condition that deeply affects social life.

The correct diagnosis and correct evaluation of the structure of the fistula before treatment are of great importance in the success of the treatment. Vezicovaginal fistula should be considered and the necessary approaches for diagnosis should be started when the unintended urinary incontinence has started recently, especially in women who have undergone difficult birth, or who have undergone gynecological diseases or who have received radiotherapy due to gynecological diseases.

Vezicovajinal fistula is the most common cause of damage to the bladder and urethra during unintended open surgery for 90% female diseases. It may occur that the bladder or urine channels formed during the operation may be accidentally interrupted during the operation, due to accidental suturing of the bleeding control or due to burning due to electrocautery. The development of vesicovaginal fistula plays an important role in the development of this suture and vaginal bleeding in the bladder and vagina. From the moment the urine escapes from the bladder to the vagina through the canal that develops between the two organs, the mucous membrane surrounds the inside of the canal and the result is the irreversibly full fistula table. In all urogenital fistulas, such as vesicovaginal fistula, the basic symptom is involuntary urinary incontinence. This current is usually continuous. However, it also manifests itself as intermittent urinary incontinence in thin fistulas.

What are the treatment options of vesicovaginal fistula?

If the vesicovaginal fistula is recognized immediately within a few days of gynecological surgery, a 30-day drainage with a probe placed through the urinary tract or abdomen can be curative. Especially if the fistula diameter is thin, this approach will be successful with continuous catheter drainage. In other urogenital fistulas such as vesicovaginal fistulas, the decision as to the time when the repair should be done is given on the basis of the nature of the tissue, the condition of other diseases of the patient and his/her psychology.

However, it is necessary that a period of 8 and 12 weeks passes between the surgery which traditionally causes vesicovaginal fistula and repair. If infectious fistulas or fistulas due to irradiation have been developed, it is recommended to wait longer. Especially after irradiation, it may be necessary to wait 1 year for the vascular development of the tissues to reintroduce and restore tissue healing as much as possible.

Surgery in VVF Treatment

The surgeon's most successful treatment can only be achieved by the technique most frequently used by the surgeon. However, vesicovaginal fistula with laparoscopic technique can be used in treatment easily as a minimally invasive procedure. It is not recommended to leave the patient in an unnecessary situation both physically and cosmetically with a treatment method and open surgery, which will be further worsened once again with a difficult post-operative social aspect for a woman suffering for weeks and months.

Laparoscopic Sacrocolpopexy in bladder and organ sagging (POP)

There are various treatment alternatives depending on the degree of bladder sag. Some treatments offer temporary solutions, while some treatments may be long-term and include low-risk. It is the most beneficial option to discuss the treatment options with the patient about efficacy, side effects, cost and identify the most beneficial treatment for the patient. The sags in this condition do not heal spontaneously or go through medication. These loosened or torn tissues must be supported and reattached, which can only be performed surgically. It is an intervention based on the laparoscopic support of the anterior and posterior wall in the prolapse of the bladder, uterus and intestine within the pelvic bone. It is a treatment that is considered to be “the gold standard” which is superior to all other techniques and is still considered as the gold standard.. The most important advantages of this process are the absence of tissue erosion with prolene mesh, preventing the future development of sexual inability and elimination of pain during sexual intercourse.

Today, this intervention is now performed as laparoscopic sacrocolpopexy by experienced specialists. The most important characteristic of this method is that the structure of the vagina is just corrected and supported without any changes in its form. In the laparoscopic sacrocolpopexy operation, the vagina is completely sutured and fixed in two layers of “mesh” to the front and back walls between the vaginal peak and the base. Thus, not only the vaginal wall is supported, but also the bowel and bladder sides are fully supported. The extensions of this support tissue in the anterior and posterior wall are brought to the coccyx and strongly fixed to the bone therein.

Laparoscopic sacrocolpopexy is one of the surgeries requiring advanced laparoscopic surgical experience. Some surgeons perform this surgery with an open surgical incision on the abdomen as the old technique. Today, laparoscopic method provides the most effective success, instead of open surgery, which has a serious disadvantage in terms of both cosmetic ugliness and postoperative pain, and the effectiveness of the operation.

TOT Operation in the Treatment of Urinary Incontinence

Stress urinary incontinence (SUI) is the most common type of urinary incontinence. There are many factors that cause SUI. However, it often occurs as a result of bladder and uterus sagging. The most common causes of these sagging are the weakening of the connective tissue after pregnancy. Particularly difficult and traumatic births and the baby being bigger than normal promotes the incidence of stress incontinence. Other factors that increase the risk include advanced maternal age, pregnancy status, weakening of connective tissue due to menopause, obesity, and non-absolute hysterectomy.

TOT Operation (Transobturator Tape Application)

In the TOT operation, a tape called a polypropylene mesh is placed with the help of a special needle to tighten the urethral canal with a thin incision made by a vaginal route. In TOT surgery, which we apply for only appropriate patient, the wound healing of the patient is quite fast, and the hospital stay is very low (mean one day). The catheter is placed in the bladder for 24 hours after the operation to drain the bladder. Then the catheter is pulled. You can return to your normal everyday life immediately after discharge.