(Video Poster 06) Neobladder-Vaginal Fistula Repair with Paravaginal Tissue an Innovative Approach

Objectives: We sought to use an innovative approach to repairing a neobladder-vaginal fistula using a transvaginal approach and paravaginal tissue, as opposed to using a Martius flap for repair.

Methods: We present the case of a 58 year old female with a history of urothelial carcinoma, who underwent neoadjuvant chemotherapy, followed by radical cystectomy and orthotopic ileal neobladder and adjuvant chemotherapy. She presented approximately one year post-operatively with persistent urine leakage that had progressively worsened. Urodynamics revealed continuous vaginal leakage of fluid and subsequent exam under anesthesia confirmed a 3x3cm neobladder-vaginal fistula located approximately 3cm proximal to the urethral meatus, near the expected site of the neobladder-urethral anastomosis. We present our techniques for performing a neobladder-vaginal fistula repair transvaginally. The repair was in two layers. In the first layer, the neobladder mucosa was reapproximated. To generate the second layer, fibromuscular and adipose tissue were dissected from the paravaginal spaces to the level of the ischial spines. The second layer was brought over the first layer in a tension free fashion and without overlapping sutures. This case illustrates the utility of mobilizing the paravaginal tissue as an interposition layer which may obviate the need for a Martius flap procedure.

Clinical Relevance: Neobladder-vaginal fistula is a known complication of cystectomy, occurring in 3-5% of women. Risk factors include history of pelvic radiation, excision of anterior vagina as part of radical cystectomy, urine leak or poor healing at neobladder-urethral anastomosis, and local tumor recurrence. For fistulas in the region of the neobladder-urethral anastomosis, a transvaginal approach is optimal for surgical management. Surgical repair can be challenging due to vaginal atrophy, shortened vaginal length, decreased vascularity due to previous dissection, and or less fibromuscular tissue. Augmentation of repair can be achieved using the Martius flap. Our work shows the use of paravaginal tissue in the repair of a neobladder-vaginal fistula repair. The paravaginal tissue is not typically accessed for fistula repairs, but we were able to easily access this space and mobilize the tissue between the vagina and pelvic sidewall, likely due to dissection and radical excision from prior cystectomy. Post-operatively, our patient had a foley catheter in place for two weeks. 3 months post-operatively, our patient did not have any urinary leakage, showing that our surgery was successful.