[25] Urinary bladder repair after vesico-uterine fistulectomy and hysterectomy using ‘omentum wrap’: A novel technique

Objective To present a case of urinary bladder repair after vesico-uterine fistulectomy and hysterectomy using ‘omentum wrap’, as vesical fistulae, irrespective of their distal component, are a challenge for urologists and uro-gynaecologists alike. The complex nature of these fistulae and their repair has affected outcomes of the documented treatment modalities. In general, higher fistula origin and insertion, and prolonged presentation are indices of poorer outcomes of treatment. Methods We present the case of a 54-year-old multiparous woman who presented to our clinic with total urinary incontinence (UI). She has had a history of use of vaginal pessaries and misdiagnosis with stress UI that had led to the performance of trans-obturator tape (TOT) insertion, unnecessarily. Post-TOT the patient’s UI worsened from occasional to total. Investigations initially showed vesico-vaginal fistula, but examination under anaesthesia by cystoscopy and hysteroscopy showed a large vesico-uterine fistula. Lower midline fistula repair was complicated by a chronically inflamed friable bladder on cystostomy and total abdominal hysterectomy after uterine transection due to adherent uterine and anterior vaginal walls to the bladder. Bladder repair was augmented with omental flap interposition posteriorly to cover the fistula site, and omental flap wrapping superiorly, laterally and anteriorly to enhance its recovery. The patient had an uneventful postoperative recovery and follow-up cystography showed a small capacity bladder but no leakage. Results To our knowledge this is the first attempt of its kind to utilise an omental flap to support bladder repair in a wrapped fashion. The omentum is known for its extraordinary support mechanisms, mechanical and anti-inflammatory, and has been incorporated into many forms of repairs as a flap and graft. In what looked like a poor outcome bladder repair due to extremely inflamed tissue, the bladder healed completely in a short time. Conclusion Vesical fistulae are difficult entities to diagnose and treat. Incorporation of innovative surgical principles of repair from other experiences can improve outcomes of traditional procedures.