Original Article

Prevention and cure of post vesico-vaginal fistula repair incontinence by insertion of skin graft in the bladder neck area of vagina. Update on hypothesis and interim report

  • ANDREW BROWNING
  • GORDON WILLIAMS
  • PETER PETROS

Pelviperineology 2017;36(1):11-12

Background:

There are 2 million women who suffer from vesicovaginal fistula (VVF), and more than 130 000 new cases develop each year in Africa alone. Though the cure rate for the VVF itself is more than 90%, up to 45% of patients continue to leak heavily after successful VVF closure.

Aim:

To present an interim report of the testing of a hypothesis which states that the major cause of post fistula repair incontinence is tissue necrosis consequent upon obstructed labour which leads to scarring in the bladder neck area of the vagina and invalidation of the closure mechanisms.

Methods:

The hypothesis was tested by application of a skin-on Singapore graft to the bladder neck area of the vagina, both prophylactically and in patients with ongoing incontinence following successful VVF repair surgery.

Results:

The flap has been used in 24 cases with severe day/night ongoing incontinence after fistula closure. Some cases had been operated on 9 times before and deemed incurable. After dissection and releasing of the tethered anterior vagina on average there was a 2cm gap created in the anterior vaginal wall that needed to be covered. With urethralisation, sling and the flap 71% of cases were completely dry and 29% improved, often satisfied with their improvement or dry using a urethral plug. The average standard ICS one hour pad test on these patients was 224ml in one hour before the operation and 29ml afterwards with a range of 0-176ml. The same method of urethralisation and sling without the flap yielded a 26% dry rate on the most severe cases of ongoing incontinence with multiple previously failed procedures. Using the graft as a primary repair (n=41), for Goh type 4, 46% with the flap were completely dry as against 19% without.

Conclusions:

The skin flaps restore the closure mechanisms and continence as hypothesized. We believe the initial results from the graft technique are sufficiently convincing to announce this as a significant advance in fistula surgery. Nevertheless, more data is being assembled to complete a statistically valid comparative analysis of the new methods with the old.

Keywords: Vesicovaginal fistula; Post-fistula repair incontinence; Singapore graft; Tethered vagina syndrome.