Patients and Methods
All women with VVF who were treated between January 2002 and May 2013 and who agreed to participate in this prospective study were included in the analysis. Three patients declined participation: 1 woman declined to complete the questionnaire because she found the questions too personal, and the other 2 women did not state their reasons. Surgical procedures were standardized, and operations were performed or supervised by the same surgeon. The study was conducted in the University Women’s Hospital, Department of Urogynecology, Bern, Switzerland, which is a tertiary referral center. Ethical consent was obtained (Cantonal Ethics Committee Bern).
Patients were evaluated by medical history, physical examination (including bladder filling with methylene blue to demonstrate the fistula tract), urinalysis, and 30-degree cystoscopy.
Initially, all patients received a transurethral Foley catheter for 12 weeks. If the VVF did not heal during this period the vaginal approach was the first choice for patients with a small and/or easy-to-access fistula and for patients with reduced fitness. The abdominal route was chosen for fistulae of >1 cm in diameter, difficult vaginal access with the genital hiatus being <2 cm, and no vaginal descent on straining. Additionally, because approximately 5 mm of surrounding fistula tissue was excised, depending on the individual situation, VVF fistulae closer than 1.5 cm to the ureteric orifices were repaired abdominally with the insertion of ureteric catheters before fistula excision and repair to ensure uninhibited ureteric drainage.
Perioperatively, all patients received broad spectrum antibiotics; in all postmenopausal patients, a local estrogen cream (estriol cream, 0.05%) was applied. An indwelling urethral catheter was maintained for 10 days, and patients underwent a cystogram before catheter removal. Patients were clinically evaluated at 6 and 24 weeks after surgery, then annually.
During the Latzko procedure, the fistulous tract was excised. A Foley catheter was placed through the fistula opening with the balloon for traction on the tissues during dissection. Approximately 5 mm of tissue surrounding the fistulae was excised until the edges were of healthy, well-perfused tissue and until fibrotic tissue was completely removed. The vaginal epithelium around the fistula was sharply denuded and freed from surrounding tissues. The fibromuscular layer was closed with tension-free interrupted sutures with the use of delayed absorbable material (Vicryl 2-0; Ethicon, Zug, Switzerland). The muscularis layer of the vagina and vaginal epithelium were closed in the same way.
For the abdominal VVF repair, the bladder was mobilized from the vagina, which allowed direct visualization of the defect and resection of the fistulous tract. The vagina and bladder were closed separately, and an interpositional omental or peritoneal flap was placed.
Sexual activity was allowed to resume after medical check-up showed uneventful wound healing 6 weeks after surgery.
The primary outcome of this study was sexual function as determined by the Female Sexual Function Index (FSFI). Secondary outcomes were continence, quality of life, operation time, blood loss, and hospital stay. Outcome was recorded prospectively before surgical repair and at the 6-month postoperative follow-up examination.
Sexual function was evaluated by means of the FSFI, which is a validated instrument consisting of 19 questions. The questions are grouped for domains of desire, arousal, lubrication, orgasm, satisfaction, and pain; higher scores reflect better sexual function ( Figure 1 ). The FSFI has been validated based on Diagnostic and Statistical Manual of Mental Disorders IV (American Psychiatric Association, 2000). The questionnaire defines sexual activity as caressing, foreplay, masturbation, and vaginal intercourse.
