TREATMENT OF VESICO-VAGINAL

FISTULiE.

By IDA A. SCUDDER,

Vellore.

Some years ago I wrote a paper on this subject. Since then I have tried various methods and

used various sutures, but have come back to my

original technique. I shall attempt here to sketch briefly the

salient points in the treatment of vesico-vaginal fistulte which I have found most successful.

To most of us the entire subject is an old

story. With what dismay have we examined a

patient to find an ulcerated, excoriated labia; bands of dense cicatricial tissue distorting all

outlines; vagina narrowed to abnormal propor- tions ; the entire floor of the bladder gone, and oft-times the urethra torn away from the bladder or entirely missing. The patient is often

dejected, hopeless, and in a very run-down condition.

Although there are various kinds of fistulse, I shall touch only upon the technique of the

large openings, with loss of tissue. I use the same methods in the simple, uncomplicated fistulas as in the larger. The chief factors are :?

1. The time for the operation. 2. Preparation of the patient. 3. Antesthetic. 4. Operation. 5. After-treatment. G. Complications.

1. Time for the Operation.?I prefer to operate from three to four months after the appearance of the fistula, as by that time the tissues are

firm and the stitches hold more satisfactorily. Sooner than three months, the stitches are apt to

I

Oct., 1918.1 TREATMENT OF VESICO-VAGINAL FISTULA. 373

tear out more easily. Later than this, cicatircial bands are more likely to have formed. Often we have no choice as to time, but get cases years after fistula formation, in which we find dense bands and thickened cicatricial tissue.

-? Preparation.?The preparatory treatment is very necessary and often tedious. I prefer keep- ing the patient in the hospital under close

observation. The patient oft-times grows tireH of

waiting for operation during this period, but 1

always regret yielding to the urgent request of the friends to hasten the operation, when 1 know that the conditions are not wholly satisfactory. We must pay attention to :

(<*) The general health. The patient must be built UP by good diet and tonics; baths and massage are advisable.

(&) If there is any inflammation of the bladder it should be treated by urinary antiseptics. The bladder should be irrigated at least twice daily with boric or saline solution, or a very weak lysol solution.

(c) As the urine is usually highly alkaline, and incrustations of phosphates are apt to be formed, it is

necessary to treat these beforeany operative work can be done. For this we use the following:

Emmet's Mixture :

ft Acid Benzoic ... ... 3jss Sodii Borat ... 5ij Aquae ... ... ... 5viij

Sty : Tablespoonful in water, three times daily. In four days reduce the dose to a teaspoonful.

Urotropine, gr.vij, b.d. (A) All excoriations must be healed by constant

bathing of the parts, drying carefully and applying antiseptic powders and vaseline.

(?) All ulcerations in the vagina and around the iistula should be treated.

3. Anccsthetic used.?We usually use chloro-

form followed by ether, but have done small

fistulae under local anaesthesia. As the severe

vomiting which sometimes follows chloroform

anaesthesia is a great drawback to the success of

the operation, I believe that spinal anaesthesia

would be the ideal in fistula cases, though I have never used it.

4. Operation.?The usual pre-operative treat- ment is given. Careful preparation is repeated after the patient is on the table. The parts are

carefully cleansed and thoroughly painted with iodine.

(a) As the maximum amount of space obtain- able is required for the operation, we use but

one metal speculum (ball-speculum) posteriorly with lateral retractors of heavy silk. These

are inserted as follows :?A large, half-curved needle threaded with a long silk suture is used ; the needle enters the labia in the upper quarter, the suture is carried down deeply into the vagina and emerges at the lower angle of the labia.

The suture is now drawn gently, but firmly, to one side, and should be long enough to be tied around the upright leg-support of the table. When

these silk retractors are once in place and secure- ly tied, they need not be touched again. This method does away with all metal retractors held

by a nurse, which are always in danger of

slipping. (b) Careful inspection of the vagina is made : All the dense cicatricial bands should be

freely incised, usually at the side. As these bands are of newly-formed tissue, one need not

hesitate to incise freely and deeply until all

tension is absolutely freed. No harm can be

done if one uses judgment and care. We

must have space to ivork in, but must avoid

incising too deeply and thus interfering with the blood supply.

(c) Careful inspection of fistula and bladder

is made:

If the entire floor of the bladder is missing, the ureters should be located and their position borne in mind during the next step.

(<d) Thorough and extensive separation of the bladder from the vaginal mucous membrane :

An incision is made at the junction of the

vagina with the bladder mucous membrane. This

I usually do with a rounded blade. The separation of the bladder now begins.

I always use Kelly's curved scissors. This

dissection has to be done very carefully and

extensively (for fear of button-holing the

bladder). At times when the bladder is adherent

to the pubic bone, this seems almost impossible, but by careful, painstaking dissection it can and must be done, so as to bring the site of the fistula within easy reach. This dissection is the

most trying as well as the most important part of the operation, as it requires the greatest care, the most delicate, painstaking dissection, and the utmost patience. (If one lacks patience, one had best avoid attempting a difficult fistula

operation.) An assistant keeps the operative field as clean as possible by constant swabbing. If 007,ing is considerable and it is difficult to keep the field free from blood, we use a constant stream of sterile water over the part. An

hypodermic of adrenalin is at times helpful. Unless the bladder is free at every point, failure is almost sure to result, as suturing is almost

impossible if the bladder is attached to any bony surface?the site of the fistula must be within reach. At times it is advantageous to insert a

glass catheter into the urethra and help bring the part to be dissected into closer view.

As soon as this extensive separation is

complete, there should be free mobilization of the bladder. The edges of the fistula must fall

together, without any tension whatever. One constantly tests the tension by placing the edo-es together, and should there be any tension, a

further separation is necessary. When satisfied that the bladder is free and movable, the edges

374 THE INDIAN MEDICAL GAZETTE. [Oct., 1918.

of the fistula are freshened and suturing may be

begun. (e) Closure of the fistula :

The needles used for closing the opening in the bladder wall are short, thin, curved, and

strong. I use a small needle-holder. The first

suture is taken well beyond an angle of the

opening, and should penetrate the muscular

coat only. It is to be taken in such a way as

to turn in the edges of the fistula. The needle

enters a short distance from the edge of the

fistula, is carried through the muscular coat and

emerges close to the edge ; it is then carried

over to the other side, entering near the edge and again passing through the muscular tissue

and emerging opposite the first suture. When

trying these sutures it is important to see that the edges are well turned in, to bring raw

surface against raw surface. There must be

accurate approximation of bladder wall. I would

again like to emphasize that there must be no tension. If, after the sutures are ready to be tied, one finds there is the least tension at any point, a further dissection should be done. The suture material I use is fine silkworm-gut, which after tying I cut as short as is safe. There should be no troublesome after-effects if one is careful to penetrate the muscular coat only, and never

the mucous membrane of the bladder. I have had trouble in one case only. The

patient returned to the hospital some months after the operation with a small calculus which

had formed on a suture which had penetrated the mucous membrane of the bladder. The calculus and suture were easily removed per urethra, and the patient had no further trouble.

I find that these silkworm-gut sutures are

encapsulated and give rise to no future trouble. If the operation breaks down and the sutures are-

exposed to the urine, they soon become encrusted and must be removed. I have tried silk, linen, chromicized catgut, and kangaroo tendon, but

have gone back to using fine silkworm-gut for

the bladder sutures. As soon as all the sutures

are in place they are securely, but not too

tightly, tied and cut. A glass catheter is passed and sterilized milk is injected into the bladder and any leakage carefully looked for. If there

should be a leak, the sutures on either side should be removed, and that portion re-sutured. This

saves time and is much better than trying to

close the tiny opening by suturing over it. The

angles of the fistula, especially if near any bony structure, are the most difficult to close, but if

the dissection has been free, the bladder mov- able, and the site of the fistula within easy reach (through the extensive dissection), this also will become a simple matter. A second layer of

buried catgut sutures may now be put in to avoid any dead space and to cover and reinforce the

bladder closure.

The vaginal mucous membrane is now sutured (witli silk or silkworm-gut), trying to draw the line of incision in a different plane from that of the bladder if possible. In large fistulae with extensive loss of tissue this is sometimes im-

possible. In such cases I cover the opening with fascia taken from the abdominal wall. The fascia is dissected out and cut a little larger than one thinks is necessary (as it contracts slightly). It is then lifted with two pairs of forceps and placed at once over the bladder sutures. A few fixation sutures are taken, and this fascia is covered over with as much tissue as can be drawn from the

sides. We have to depend upon granulation for the rest.

Our next step is to repair the incisions made in the vagina during the early part of the operation. The vagina is now carefully cleansed, painted

with iodine, and packed lightly with iodine

gauze. A rubber catheter is inserted and the milk

washed out of the bladder. A long rubber tube with a connecting glass tube is attached to the

catheter, and after the patient is put to bed, the end of the rubber tube is placed in a bottle hung from the edge of the bed.

I do not use a self-retaining catheter, and think it inadvisable, especially in cases where the urethra has been sutured. I sometimes steady the catheter by attaching it with adhesive plaster over the

pubic bone. 5. After-treatment.?This 1 consider very

important. The patient must be kept very quiet. I do not allow patients to move if it can be

prevented, and I use hypodermic injections of morphia freely for three or four days if they are at all restless. The patients are not allowed to turn for six days or more.

Once daily I re-dress the case., The patient is brought to the table and given

a hot sponge-bath and oil-rub. I find this quiets and relieves patients very much, for they get tired of lying so still. I then wash the bladder

thoroughly and put in a fresh, sterile catheter. A vaginal douche is given, the vagina wiped dry and dusted with boric powder. The stitches are

lightly touched with iodine, and then an oleum santali dressing is placed over them and the

vagina lightly packed as before. A large abdominal binder is put on, reaching below the knees.

Medicinal Treatment:

Urotropine is continued three times a day. Stimulants, if necessary. If the patient is very weak I prefer the Murphy drip method jby rectum. The bladder is washed three or four times during the 24 hours with a mild boric solution. This is

done by a reliable nurse. The catheter is not

removed nor is the patient disturbed by this

procedure.

Oct., 1918.] THE TEETH OF SEPOYS. 375

We remove the catheter on the eighth or ninth day. After the catheter is removed the patient is made to void her urine (without straining) every third hour. It is sometimes necessary to pass the

catheter occasionally. The stitches are removed on the tenth day. Patient is allowed to sit up on the twelfth day, and to move about on the day following. As soon as she is strong she is advised to go to her mother's home for a couple of months.

Diet consists of barley and rice conjee, milk, weak coffee, and plenty of water for the first few days. I keep my patients on bland diet until the stitches are removed, when they are allowed to have usual diet.

6. Complications.?The most serious and

discouraging complications are: (a) when the urethra, though present, is torn from the bladder at its base; and (b) when the urethra is entirely missing.

If the urethra is separated from the bladder at its base only, I freshen the edges and fasten it to the bladder as I am closing the fistula. The first stitch is taken posteriorly, and is often very difficult, as it is so inaccessible. I then take one or two stitches at either side, and the last or

anterior stitch is included in the final fistula suture. The after-treatment in these cases is

difficult, and the catheter should be most carefully and gently removed and re-inserted, or there is sure to be a leakage at this point later.

Absence of Urethra :

I must confess to more failures here than

anywhere else, but we have had a few successes. An incision is made as far from the centre of the

urethra as possible. I then dissect the mucous and submucous tissue free. A slim glass catheter is now placed in the position of the urethra and the mucous membrane is sutured over it. The

ligatures must be of very fine catgut and be placed closed together. I next place an oblong piece of fascia taken from the abdominal wall, or from the leg, over these sutures, and draw over this

any tissue I can dissect from the sides.

I do not operate on the fistula until after the urethra is healed, and then I do a secondary operation.

Summary.

The points to be emphasized are:? 1- Free incision of cicatricial bands in vagina,

giving the maximum amount of space to obtain free access to the fistula.

-? Free mobilization of the bladder is essen- tial to the successful closure of the fistulse.

3- Care in suturing to avoid penetrating the bladder mucous membrane.

4. Use of fascia when necessary. After treatment of absolute rest.