transvesical repair

Bladder vaginal fistula is a common disease in rural women. The cause of the disease: 1 childbirth injury: the most common, accounting for about 88%. Mainly due to the compression of the vagina and bladder over the fetal head during childbirth, resulting in ischemia and necrosis. 2 surgical injury: about 5%, such as hysterectomy and vaginal surgery. 3 secondary to cervical cancer and bladder cancer are rare, accounting for 1% to 2%. Treatment: All cases of traumatic vesicovaginal fistula require surgical treatment. Generally, the repair operation is performed 3 months after the injury. Therefore, the inflammation at the injury has subsided, the wound around the pupil has completely healed, and the scar has softened, which has created favorable conditions for the operation. The choice of surgical approach: such as low bladder vaginal fistula can be repaired by the vagina. It has the advantages of small trauma, little impact on the whole body, less complications and reproducible repair. The lower vaginal vaginal fistula can be repaired through the suprapubic bladder. The high bladder vaginal fistula needs to be repaired through the posterior wall of the bladder. Complex vaginal fistula should be repaired by a combination of abdominal and vaginal routes, and if necessary, repaired via the pubic symphysis. Curing disease: Indication Posterior wall repair of the bladder is suitable for high and large vaginal vagina. Contraindications Bladder vaginal fistula caused by cervical cancer and bladder cancer. Preoperative preparation 1. If the vulva has urinary eczema, it can be washed with 1/5000 potassium permanganate bath, dried and coated with 20% zinc oxide ointment to protect the skin. 2. Start vaginal washing 1 or 2 times a day before 3 days of local cleansing. The vulva is cleaned 4 times a day. 3. Indwelling catheter was inserted into the urethra 3 days before bladder irrigation, and the bladder was perfused 2 to 3 times per day with 1/2000 nitrofurazone solution or gentamicin. 4. First, urine culture, counting and drug sensitivity test. Preoperative use of bacterial sensitive antibiotics to control infection. 5. Enema was given 1 day before surgery. Surgical procedure 1. Incision: a midline incision or a curved transverse incision in the lower abdomen. 2. Reveal the fistula: Cut the bladder and reveal the pupil. Pay attention to the relationship between the pupil and the ureteral orifice. Two ureteral catheters were inserted into the two ureters to the renal pelvis to prevent damage, and the ureteral catheter was fixed on the bladder mucosa to prevent prolapse. Push the peritoneal fold back up to separate it from the bladder and free the bladder to the pupil. Extend the bladder incision to the pupil. If the bladder, cervix and peritoneum adhere, the peritoneum can also be cut for separation. 3. fistula resection: circular incision along the edge of the pupil, and free fistula, posterior wall of the bladder and vagina, the separation range up to about 2cm around the pupil, be careful not to damage the two ureters. Then, the fistula and its surrounding scar tissue are removed. If ureteral injury is unavoidable, ureteral bladder replantation should be performed. 4. Stitching the vaginal wall: After thoroughly flushing the wound, the vaginal wall is sutured with a 0-absorbable line transversely interrupted or intermittently valgus. Remove the two ureteral catheters. 5. Peritoneal filling: The peritoneum was incised, and the pedicled peritoneum was cut between the vaginal incision and the bladder incision to cover the vaginal suture. 6. Stitching the bladder wall: Starting from the lower corner of the incision of the bladder, the entire layer of the bladder wall was sutured continuously from the bottom to the bottom with a 2-0 absorbable line. A F26 sacral catheter was placed on the anterior wall of the extraperitoneal bladder for the bladder stoma. The wire is then used as a discontinuous -inverted suture reinforcement. 100 ml of methylene blue solution was injected from the bladder stoma tube, and after observing no leakage of the vagina, the peritoneum was continuously sutured with a silk thread to close the abdominal cavity. A rubber tube drainage was placed in the posterior pubic space. The abdominal incision is sutured layer by layer. The skin suture is used to fix the bladder stoma. complication 1. Wound infection. 2. Damage to the ureteral orifice and lower end. 3. Vaginal leakage of urine. 4. Urinary incontinence.