Vesicovaginal fistula repair

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• fistula not closing or coming back, needing another operation
• catheter for 2 to 3 weeks, with bladder spasms
• new stress incontinence or urgency after repair
• painful intercourse or narrowing of the vagina
• injury to a ureter, or need for ureteric stent or reimplantation
• bleeding
• a labial or other tissue flap, with a scar at the donor site
• change to an abdominal operation if the fistula cannot be reached from below

Pre-operative details for this operation

1. Cause of fistulaAfter abdominal hysterectomyAfter vaginal or laparoscopic hysterectomyObstetric (prolonged labour)After caesarean sectionAfter radiotherapyOther (state)date of the causative event, weeks since then
2. Previous repair attemptsnumber, route, date of last attempt
3. Dye testintravesical dye result; oral / IV test for ureteric leak
4. Upper tract imagingCT urographyIVPRetrograde pyelogramhydronephrosis, ureterovaginal fistula
5. Cystoscopy and vaginoscopynumber, size, site of fistula; distance from ureteric orifices and bladder neck; tissue quality; biopsy if previous cancer
6. Planned routeTransvaginalTransabdominal (transperitoneal)Transvesical (extraperitoneal)Laparoscopic / roboticreason for the route chosen
7. Urine cultureresult and date

Anaesthesia and position

1. AnaesthesiaSpinalGeneralCombined spinal-epidural
2. PositionDorsal lithotomy with moderate TrendelenburgLow lithotomyProne jack-knife
3. Exposurering retractor with hooks, labial stay sutures, weighted speculum, Breisky retractors, relaxing (Schuchardt) incision if used
4. Ureteric cathetersNot neededPlaced on both sidesPlaced on one side (state)size; placed if the fistula is close to a ureteric orifice
5. Mechanical VTE prophylaxisSequential compression devices

Operative findings

1. Vaginal opening of the fistulasite (vault / anterior wall / near bladder neck), size in mm, scarring
2. Bladder opening of the fistulasupratrigonal / trigonal, distance from each ureteric orifice
3. Number of fistulaeSingleMultiple (state)
4. Tissue qualityHealthy, pliableScarredInflamed / oedematousIrradiated
5. Vaginal capacity and accesslength, laxity, whether the fistula could be brought down
6. Leak test after repairWatertightLeak, repaired further

Procedure (steps)

1. Cystoscopyfistula and ureteric orifices seen; ureteric catheters placed if needed
2. Cathetersurethral Foley size; suprapubic catheter if placed and how (Lowsley retractor)
3. Traction on the fistulasmall Foley (8 Fr) passed through the tract from the vagina, tract dilated if needed; stay sutures either side
4. InfiltrationNormal salineLignocaine with adrenalineDilute vasopressinstrength and volume
5. Vaginal incisionCircumferential around the fistulaCircumferential plus inverted U flapU flap (fistula deep in the vault)Excision of vault scarLatzko (partial colpocleisis)
6. Dissectionvaginal wall separated from perivesical fascia; bladder mobilised well beyond the fistula
7. Fistula tractLeft in placeEdges trimmedExcised with vault scar
8. First layer (bladder)suture, size, interrupted / running; direction of the suture line
9. Second layer (perivesical fascia / detrusor)suture, size; perpendicular to the first layer, tension-free
10. Leak testdye and volume instilled into the bladder, result
11. Interposition flapNonePeritoneal flapLabial fat pad (Martius)GracilisOmental flap (abdominal route)reason; how secured
12. Vaginal flap advanced and closedsuture, size, technique; suture lines not overlapping

Closure, drains and dressing

1. Vaginal wallsuture and technique
2. Vaginal packPovidone-iodine soaked packPlain packNone
3. Bladder drainageUrethral Foley onlyUrethral Foley and suprapubic catheterMalecot suprapubic without balloonsizes, balloon volume
4. Labial or abdominal wound (if flap or abdominal route)closure, Penrose or pelvic drain
5. Ureteric cathetersRemoved at endLeft in, to be removed on day (state)

Specimens and implants

1. Fistula tract / vault scar sent for HPEYesNo tissue excisedalways send if there is a history of cancer

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Catheter carefree drainage, catheter must not block or kink; watch urine colour and output
2. Anticholinergic for bladder spasmdrug, dose, duration while catheter is in
3. Antibioticssingle prophylactic IV dose at surgery (drug, dose, time); no extended course unless there is infection. If the unit gives low-dose daily prophylaxis until the cystogram, write drug, dose and stop date
4. Vaginal packremove on POD 1
5. Duration of drainage2 to 3 weeks; do not remove catheters early
6. Before catheter removalcystogram / VCUG to confirm no leak; if leak, continue drainage 2 to 3 more weeks and repeat
7. Order of catheter removalif suprapubic catheter present, remove urethral catheter first, then suprapubic after a successful voiding trial
8. Labial drainremove in a few days if Martius flap used
9. Advice at dischargereport any wetness at once; date of cystogram and follow-up

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery