Question

How will you manage a case of vesicovaginal fistula detected on the second day of abdominal hysterectomy?

Hint:

Early identification and catheterization are key to preventing complications in VVF cases after hysterectomy. If conservative management fails, surgical repair is the definitive treatment.

Answer 1

Step 1: Immediate Management.
The detection of a vesicovaginal fistula (VVF) on the second day post-abdominal hysterectomy requires prompt management. The management plan involves both conservative and surgical approaches.
Step 2: Conservative Management (if the fistula is small or asymptomati.
- Catheterization: Immediate placement of a Foley catheter is essential to divert urine from the vagina and allow the fistula to heal. The catheter should remain in place for a minimum of 2-3 weeks.
- Antibiotic therapy: To prevent infection, broad-spectrum antibiotics are started.
- Observation: If the fistula is small, it may close spontaneously over time with catheterization. The patient should be closely monitored for healing.
Step 3: Surgical Management (if the fistula persists or is large).
If conservative management fails or if the fistula is large or symptomatic, surgical intervention is required:
- Fistula Repair: The most common surgery for VVF repair is transvaginal fistula repair. This involves excising the fistulous tract and suturing the bladder and vaginal tissues to restore the normal anatomical continuity.
- Postoperative Care: After surgery, a catheter is usually retained for a period of 2-4 weeks to ensure healing and prevent recurrence.
- Follow-up: Close follow-up is required to ensure the fistula has healed properly, with regular voiding cystourethrograms (VCUG) or cystoscopy to check for any leakage.
Step 4: Prevention and Long-Term Care.
- Prevention: Prevention of VVF during abdominal hysterectomy involves careful surgical technique, especially when dissecting the bladder away from the uterus.
- Long-Term Care: For patients with chronic VVF, options include more complex repairs, possibly using tissue grafts if initial repairs fail.