Djordjević M, Stanojević D, Perović S
Univerzitetska decja klinika, Beograd.
Acta Chir Iugosl. 2004;51(3):101-3. doi: 10.2298/aci0403101d.
Sometimes after delivery, gynecological or other surgeries, radiological therapy, or destructions of vesico-vaginal septum due to the tumor or trauma, the unnatural communication between the bladder and vagina occurs. Those are fistulas that occur after the delivery (tocogenic) caused by the prolonged delivery or some obstetrics operations. Some fistulas are high, coming from the fundus of the bladder, medium, if they come just behind the trigonum of the bladder, and low, if they are in the level of trigonum and the neck of the bladder. The purpose of this paper is to show the operative technique of elimination of medium and low vesicovaginal fistula and the results of the treatment. Material and method The elimination of the vesicovaginal fistula by original Martius technique is done through vagina. The catheter is inserted through the fistula (figure 1). Than the mucosis of the vagina is cut around the fistula and the vaginal wall is separated from the bladder. The catheter is pulled out and the fistula on the bladder is sown with resorptive stitches. Than the labia maiora nearer to the fistula is cut along from Mons Veneris to the middle and the lipoid tissue is taken with vascular pedicle (figure 2). This tissue is put between the bladder and the vagina and fixed with resorptive stitches. After that the vagina is sown by single stitches. The labia maiora that was cut is also sown by single stitches (figure 3). Than the catheter is inserted in the bladder that should stay there for four weeks. This is the method we used to make surgery in twenty patients with vesicovaginal fistula. The first one had the fistula as the result of the Caesarean section. She was operated twice through the bladder without success. The second patient was a fourteen years old girl that cut herself on the glass and damaged anal sfincter, rectum, vagina and the bladder. The fistula appeared later in the level of trigonum of the bladder. The other eighteen patients got fistula after hysterectomy. All patients were treated as described above and fistulas disappeared. The first patient had another baby a year after the operation by Caesarean section. The other patients have regular miction (figure 4 and 5). Discussion and the conclusion Vesicovaginal fistula are serous complications, for the patients and for the doctors. The only treatment of the vesicovaginal fistula is surgical. If any damage of the bladder occurs during any operation it should be treated immediately, otherwise the fistula will appear. The treatment depends of the localization of the fistula. Low fistulas and some medium and urethrovaginal fistulas should be approached through vagina and according to our experience Martius's method is very efficient. The only important thing is when the fistula is detected to wait at least for two or three months for the fistula to "consolidate" and also to cure the infection.
有时在分娩、妇科或其他手术、放射治疗后，或因肿瘤或创伤导致膀胱阴道隔破坏后，膀胱与阴道之间会出现异常通道。这些是分娩后（产伤性）因分娩时间过长或一些产科手术导致的瘘管。有些瘘管位置较高，来自膀胱底部；中等位置的瘘管，若位于膀胱三角后方；位置较低的瘘管，则在膀胱三角和膀胱颈部水平。本文旨在展示消除中等和低位膀胱阴道瘘的手术技术及治疗结果。
材料与方法
采用原始的马蒂乌斯技术经阴道消除膀胱阴道瘘。将导管经瘘管插入（图1）。然后在瘘管周围切开阴道黏膜，将阴道壁与膀胱分离。拔出导管，用可吸收缝线缝合膀胱上的瘘口。接着从阴阜至中部沿靠近瘘管的大阴唇切开，带血管蒂取下脂肪组织（图2）。将该组织置于膀胱与阴道之间，用可吸收缝线固定。之后用单针缝合阴道。切开的大阴唇也用单针缝合（图3）。然后将导管插入膀胱，应留置四周。这就是我们对20例膀胱阴道瘘患者进行手术所采用的方法。第一例患者因剖宫产导致瘘管形成。她曾两次经膀胱手术，但均未成功。第二例患者是一名14岁女孩，被玻璃划伤，肛门括约肌、直肠、阴道和膀胱均受损。瘘管后来出现在膀胱三角水平。其他18例患者在子宫切除术后出现瘘管。所有患者均按上述方法治疗，瘘管均消失。第一例患者术后一年经剖宫产又生了一个孩子。其他患者排尿正常（图4和5）。
讨论与结论
膀胱阴道瘘对患者和医生来说都是严重的并发症。膀胱阴道瘘唯一的治疗方法是手术。如果在任何手术中膀胱发生任何损伤，应立即进行治疗，否则会出现瘘管。治疗方法取决于瘘管的位置。低位瘘管以及一些中等位置的瘘管和尿道阴道瘘应经阴道处理，根据我们的经验，马蒂乌斯方法非常有效。唯一重要的是，当发现瘘管时，至少要等待两三个月，让瘘管“愈合”，同时治愈感染。
