Introduction
The Latzko repair is a traditional vaginal procedure for repairing vesicovaginal fistulas. The Latzko is a high-value surgery since it is performed as an outpatient with minimal morbidity and expense. The Latzko is likely underutilized due to common misconceptions. These misconceptions include that it cannot be utilized for fistulae at the apex or complex fistulae, that it cannot be performed with a uterus in place, and that it shortens the vagina.
What Is Vesicovaginal Fistula?
A fistula is an unintended opening that forms between two regions of the body. Infections, trauma, and inflammation are all possible causes of fistulas. They can appear in a variety of body parts. A vesicovaginal fistula is a hole that forms between the bladder and the wall of the vagina. As a result, urine leaks out of the vagina, sometimes softly but sometimes steadily, depending on the size of the fistula. This illness is not only a major medical problem, but it is also extremely upsetting. The leak is humiliating and can smell foul.
What Is Latzko Procedure for Vulvovaginal Fistula?
The Latzko transvaginal vesicovaginal fistula repair is an extremely effective treatment for even the most difficult fistulas. The procedure's technique differs just a little across different situations. The basic processes involve hydro-dissecting the epithelium from the underlying fascia surrounding the fistula tract and then denuding the epithelium within a circumscribing incision around the fistula. The fistula is subsequently closed with a purse-string suture placed immediately outside the epithelialized tract. Next, numerous layers of imbricating sutures are used to seal the defect. Finally, the vaginal epithelium has closed.
What Causes Vesicovaginal Fistulas?
Vesicovaginal fistulas are a common complication following bladder or vaginal surgery. They can also be associated with gynecological cancer, either directly from the disease or as a side effect of radiation therapy or surgery to treat the malignancy. Fistulas can occur as a result of particularly severe or repeated urinary tract infections, but this is unusual.
How Are Vesicovaginal Fistulas Diagnosed?
Most vesicovaginal fistulas occur shortly after surgery, and patients have a lot of new urine leakage.
To understand more, the provider will most likely perform a thorough physical examination of the area. Depending on their findings, imaging tests may be required. The most common tests are an X-ray of the pelvis or a computed tomography (CT scan), which utilizes dye (also known as contrast) to highlight the tissues in that section of the body, making it simpler to pinpoint the source of the problem. The dye is administered by a vein or a catheter put into the bladder. doctor will most likely use a scope to examine the bladder as well.
What Is the Treatment?
Conservative Management.
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If vulvovaginal fistula is identified within the first few days of surgery, a transurethral or suprapubic catheter should be inserted and kept in place for up to 30 days. Small fistulas (< 0.39 inches) can dissolve or shrink over this period, provided the catheter is properly drained continuously.
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If the fistula is small and the patient's vaginal loss of urine is treated by implantation, the fistula will spontaneously heal after a three-week trial of drainage. One also mentioned that if the fistula has shrunk in size after 30 days of catheter implantation, a trial of ongoing catheter draining for another two to three weeks may be advantageous.
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Finally, a VVF is unlikely to resolve spontaneously if no improvement is noted after 30 days. Under these conditions, extended catheterization raises the risk of infection while providing no further benefit to the fistula cure.
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The complete resolution of four vulvovaginal fistulas with continuous bladder drainage over 19 to 54 days. These three patients received continuous bladder catheterization within three weeks of the index hysterectomy; none had an epithelialized fistula tract, and two had transvesical sutures removed during the initial cystoscopic examination.
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There has been some success with continuous bladder draining. Unfortunately, the rate of success was uncertain for each patient, ranging from 12 to 80 %. Successful patients met the following criteria: continuous bladder drainage for up to four weeks, vulvovaginal fistula detected and treated within seven days of index surgery, vulvovaginal fistula measuring less than 0.3 inches, and no association with cancer or radiation.
Surgical Goals or Principles
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The intraoperative guidelines for minimizing vulvovaginal fistula formation are the same as those for preventing fistula complications during index surgery.
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Adequate exposure to the operation field is required to avoid unintentional organ harm and to ensure timely diagnosis of any injuries sustained.
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Reduce bleeding and hematoma development. After an anterior colporrhaphy, the dead space at the anterior vaginal wall is closed, preventing the formation of hematomas. This technique involves occasionally integrating pubocervicovaginal fascia into the vaginal mucosal layer while suturing the vaginal wall.
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During a hysterectomy, move the bladder from the vagina to reduce the danger of suture insertion into the bladder wall. Before cuff closure, leave a one to two inches margin of dissection of the bladder from the vaginal cuff.
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Dissect the pubocervicovaginal endopelvic fascia between the vagina and the bladder on the proper plane. A sharp technique may make dissection easier than a blunt one; the aim is to avoid trauma and separation of bladder wall fibers while the bladder is moved away from the anterior vaginal wall. The traction and counter-traction concept of the bladder and uterus is effective for achieving a bloodless dissection at the areolar pubocervicovaginal fascial plane.
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If scarring is present at the pubocervicovaginal fascia and dissection is difficult, consider performing an intentional anterior extraperitoneal cystotomy. This technique enables the surgeon to assess the anatomic boundaries of the bladder wall with digital palpation. If scarring is present at the pubocervicovaginal fascia and dissection is difficult, consider employing an interfacial technique of hysterectomy to best dissect the endopelvic fascial plane.
Intraoperative retrograde filling and emptying of the bladder or mild traction on a temporarily placed small Foley catheter inserted into the fistula itself are helpful to optimally identify anatomical planes and reveal intraoperative bladder lacerations. Consider a supracervical abdominal hysterectomy instead of a total abdominal hysterectomy. The incidence of urinary gonadotropin fragment formation is lower for supracervical versus total hysterectomy.
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If an intraoperative bladder injury occurs, Tancer strongly advocates for widespread mobilization of the bladder from the underlying structures (fascia, vagina, cervix, or uterus). In doing so, the surgeon can do a VVF closure with no strain.
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A transverse closure is superior to a vertical one when mending a trigonal cystotomy. Vertical closure is more likely to cause ureteral obstruction because the ureteral orifices are drawn inward toward one other. Ureteral catheters should be explored in repairing a cystotomy that involves or encroaches on ureteric orifices.
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Consider cystourethroscopy when doing pelvic surgery. Some authors recommend cystourethroscopy as a norm for all pelvic surgery to ensure bilateral ureteral patency and the absence of suture insertion in the bladder or urethra.
What Are the Complications?
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Infection, hemorrhage, harm to other organs, particularly the ureters, surgical failure of fistula repair, the possibility of new fistula formation, thrombosis, and mortality are all inherent hazards of major surgery. Before surgery, patients should be warned of the possibility of sexual dysfunction or dissatisfaction, new-onset incontinence, and the advancement of preexisting urge and stress incontinence symptoms. The authors also made recommendations for cesarean delivery in subsequent pregnancies.
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Abdominal approach procedures carry an increased risk of abdominal and pelvic adhesions. Vaginal approach procedures are associated with an increased risk of dyspareunia.
Conclusion
The Latzko vesicovaginal fistula repair is a flexible minimally invasive method that enables patients to have outpatient surgery with minimum postoperative pain and a low complication rate. Adequate exposure of the fistular site is critical to effective repair. The Latzko approach is a minimally invasive procedure for vulvovaginal fistula repair. This procedure may be considered as a first-line treatment for vulvovaginal fistula.
