Transvaginal repair of Neobladder Vaginal Fistula with Martius Flap

Abstract

_______________________________________________________________________________________ Introduction: Neobladder vaginal fistula (NVF) is a known complication after cystectomy and orthotopic diversion in women, occurring in 3-5% of women. Possible risk factors for fistula formation include compromised tissue vascularity due to surgical dissection and/or radiotherapy, suture line proximity, local tissue recurrence, and injury to the vaginal wall during dissection. The surgical repair of a NVF can be challenging secondary to vaginal shortening, atrophy, local inflammation from chronic exposure to urinary leakage, and the proximity of the neobladder to the anterior vaginal wall. In this video, we present transvaginal repair of a NVF with Martius flap interposition. Materials and Methods: This is the case of a 47 year old woman with a history of radical cystectomy and creation of a Studer pouch secondary to bladder cancer two years prior who subsequently developed a NVF. Evaluation included an office cystoscopy which demonstrated a 3-4mm left-sided neobladder vaginal fistula at the level of the ileal-urethral anastomosis. No pelvic organ prolapse or evidence of bladder cancer recurrence was appreciated. Results: A vaginal approach for the NVF repair was performed with a Martius flap interposition. A watertight closure was achieved without any intraoperative or immediate postoperative complications. The urethral Foley was removed at 2 weeks and by 4 weeks the patient did not report any urinary leakage. Conclusions: Neobladder vaginal fistula is a rare complication following cystectomy and orthotopic urinary diversion that can be repaired using a transvaginal approach. A Martius flap interposition is important to augment success of the repair. If a transvaginal approach fails a transabdominal approach or conversion to cutaneous diversion may be necessary.

Urinary diversions for radical cystectomy: a review of complications and their management

“…In women submitted to vaginal-sparing radical cystectomy with orthotopic neobladder creation, a neobladder-vaginal fistula can form in 2.7%-8.8%, result of a much thinner neobladder wall [31] . Injury to the vaginal wall during dissection of the posterior bladder wall and urethra is an important risk factor, in which case conversion to other urinary diversion may be advisable [32] . Omental flap interposition between the neobladder and the vaginal stump during cystectomy or avoidance of overlapping suture lines are preventive measures, although it may not always prevent fistulization [31] .…”