Vaginal stenosis with severe dyspareunia or apareunia often remains following the  repair of a vesicovaginal fistula cal/sed by an obstructed labour. Five patients have undergone vaginoplasty operations using full-thickness labial skin flaps, all with  satisfactory results

Dick, J.S.

English

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5 June 1971 S.A. MEDICAL JOURNAL 617VAGINOPLASTY FOLWWING VESICOVAGINAL FISTULA REPAIR: A PRELIMINARYREPORT*J. S. DICK, M.R.C.O.G., Lecturer in Obstetrics and Gynaecology, University College of Rhodesia, AND R. M. STROYER,ER.C.S., Consultant Plastic Surgeon, Harari Hospital, Salisbury, RhodesiaSUMMARYVaginal stenosis with severe dyspareunia or apareuniaoften remains following the repair of a vesicovaginalfistula cal/sed by an obstructed labour. Five patients haveundergone vaginoplasty operations using full-thicknesslabial skin flaps, all with satisfactory results.A vesicovaginal fistula is an obstetric tragedy too oftenfound in African obstetric practice. We feel it will remaincommon in developing countries until the patient: doctorratio is reduced and all women have access to satisfactorymodern antenatal care.Fibrosis and subsequent stenosis of the vagina is a com-plication of the vesicovaginal fistula resulting fromobstructed labour. Repair of the vesicovaginal fistula doesnot necessarily make the vagina a satisfactory sexual organand may, in fact, make a stenosed vagina worse. Severedyspareunia, if not apareunia, may result. We report a fewcases which have been treated in Harari Hospital, Salis-bury, by a vaginoplasty procedure similar to that men-tioned by Lawson and Stewart.'Apareunia and dyspareunia is frequently seen in patientswho have had vesicovaginal fistulae repaired. The aetiologyof the condition is one of pressure necrosis which occursduring an obstructed labour. A vesicovaginal fistula de-velops on the· anterior vaginal wall, whereas pressure onthe posterior vaginal wall may result in a rectovaginalfistula. However, a fistula may not develop posteriorlyand the rectum remains intact but the damaged area ofFig. 2. The incisions are widened. See text.~ 'a'Fig. 1. Incision of the fibrous band.*Dale receiyed: I4 December I970. Fig. 3. The flap is clos.ed and drained. See text.l8 S.-A. MEDIESE TYDSKRIF 5 Junie 1971-)sterior vaginal wall may subsequently heal by fibrosisId contracture. The resuliant fibrotic bar in the posterior19inal wall is an obstruction to intercourse.It has long been established that if fibrous tissue is'oken down it will reform with greater contraction than:fore. Simple incision even with repeated stretching is no,lution. This is well demonstrated in patients who haveld burns over joints if relieving incisions only are made.owever, if full-thickness skin grafts or flaps are inter-Ised between a divided fibrosed area the contracture doesIt reform. This is the principle employed when correcting.ginal stenosis due to fibrosis following ischaemic necrosisthe posterior vaginal wall.MATER~L AND METHODSuring the years 1968 and 1969, there were 4418 patients>charged from the gynaecological wards of HarariDspital, Salisbury. Of these, 127 patients developed asicovaginal fistula as a result of obstetric trauma, usuallytheir first pregnancy.We performed a vaginoplasty operation on 5 patients torrect their vaginal stenosis. Their ages were 18, 19, 19,24d 35 years. All had had vesicovaginal fistulae repairedeviously except for one patient whose fistula had closedontaneously.ig. 4. Incision lines on flaps marked out with Bonney'sue.The procedure is basically to incise the fibrous band (asin Fig. 1) in the posterolateral vaginal wall at 4-0'clock and8-0'clock (lines 'b' in Fig. 1), allowing the fibrous band tofall backward, and then to place full-thickness flaps oflabia minora into the defects thus produced.Adrenaline 1: 300 000 in saline is injected into theoperative field and 5 minutes are allowed to elapse beforemaking the relieving incisions in the posterolateral vaginalwall. While making these incisions the pudendal vesselsmay be damaged as they hook around the ischial spines-one of our patients had quite severe haemorrhage fromthis site during surgery .The rectum is always pulled forwards by the fibrosisand is immediately behind the fibrous bar. One must becareful to keep the rectum intact by making the relievingincisions well lateral in the vaginal wall. The incisions aredeveloped down to healthy muscle and widened to producewide defects ('a' in Fig. 2).The labia minora are the areas of skin best selected forthe flaps as they are non-hair-bearing and contain someerectile tissue, and have an excellent blood supply. 'Flapsare marked on the labia minora (lines 'b' in Fig. 2). Thebase of each flap should be about 3·8 cm wide and situatedlevel with the fourchette. The lines of incision are in-filtrated with I: 300 000 adrenaline and 5 minutes allowedto elapse before surgery is commenced. The base of theFig. 5. Incision lines on flaps marked out with Bonney'sblue.5 June 1971 S.A. MEDICAL JOURNAL 619flap is not infiltrated with adrenaline. Each flap is raised,taking the full thickness of the skin and ensuring that, asthe base of the flap is approached, its thickness increases.Fig. 6. The fiap raised before insertion of fiap and closureof donor area.Fig. 7. One fiap is in position with a corrugated drain pro-truding from beneath its base and the other fiap raisedand ready for insertion.The flaps are handled carefully with skin hooks and raisedby sharp dissection. Bleeders are tied with fine catgut anddiathermy is never used. The raw surfaces of the clitoralend of the flap are spread out with short scissors.Fig. 8. The 3-month follow-up result. The Sims's speculumis 7·5 cm in length and the cervix can be seen at the vault.'Ibere is some fibrosis on the anterior vaginal wall at thesite of the vesicovaginal fistula repair.The flap is placed Ca' in Fig. 3) in position in theposterolateral fornix using interrupted atraumatic No. 000chromic catgut sutures. A small corrugated rubber drainCb' in Fig. 3) is placed under the flap and held in positionwith a stitch. The donor area is then closed with inter-rupted silk stitches; the labia have usually been removedquite near the clitoris and the small portion remaining canbe usefully used to form a hood for the clitoris by suturingit to the bare area at the upper part of the donor site. ANo. 16 Foley's catheter is inserted into the bladder andan acriflavine emulsion pack is placed in the vagina.Postoperative CareThe patient is given a 10-day course of ampicillin toprevent urinary infection and also to reduce the risk ofinfection under the flaps. The pack is changed every 2 - 3days under anaesthetic for 10 days. After the initial packis removed glycerine and ichthyol 10% is used to soakthe packs. This is hygroscopic and prevents the flapsbecoming soggy.S.-A. MEDIESE TYDSKRIF 5 Junie 1971-The drains are removed on the second postoperative dayt the changing of the pack. The catheter is removed onile 10th postoperative day with the pack and if all is wellile patient is allowed home. Intercourse is forbidden andile patient is requested to attend for review in 2 weeks'ime. If all is well, intercourse is then encouraged.:ollow-Up ExaminationTo date only 4 cases have had a 6-month follow-upxamination. All the grafts have taken satisfactorily. Inach case the vagina has been found to be soft and,liable and of satisfactory calibre and length. Coitus has'een encouraged and has been reported to be satisfactoryilough a long-term follow-up will need to be carried out.'he repaired fistulae have remained intact.DISCUSSION'he advantages of this procedure are: (i) theoreticallybrosis and stenosis should not recur when full-thicknessaps are used; (ii) the vagina is adequate in both widthnd depth; and (iii) the stress on the anterior vaginal walluring intercourse is reduced by the enlarged vagina andle risk of recurrence of the vesicovaginal fistula is re-uced.The disadvantages are: (i) distorted vulva I anatomy-this is visible but perhaps less of a problem than theinvisibly distorted vagina; (ii) haemorrhage-this has notbeen a problem so far (we believe that the use of adrena-line, careful haemostasis and the use of drains under theflaps should prevent serious mishaps; (iii) failure of flaps tosurvive-this has not occurred and should not, providedthe base of the pedicle is adequate and diathermy is notemployed; (iv) hair in the vagina-this could be a problem,especially for the husband, but if it is, elective cauterydepilation of the few hairs could easily be carried out ora depilation cream used; (v) further deliveries must be bycaesarean section; (vi) theoretically complications couldoccur from interference of the drainage of Bartholin'sglands, but our follow-up is not yet long enough to beable to comment on this.We should like to thank Professor Philpott and the Gynae-cological staff of Harari Hospital, Salisbury, for their help,advice and co-operation with these patients. We would like tothank the Hospital Superintendent, Dr D. Goold, and theSecretary for Health, Dr M. Webster, for their permission toreport these cases, and also Mr G. Davies, the Clinical.Photo-grapher, and Miss H. McKenzie, the Secretary, for theirassistance.REFERENCEI. Lawson, J. B. and Stewart, D. B. (1967): Obstetrics and Gynaecologyin the Tropics. London: Edward Arnold.IN MEMORIAMDr VoortmanQueenstown on 29medical practitionerMedical AssociationALEXANDER YOORTMAN, M.B., Ch.B. (Cape Town)Ir R. Schaffer, of Queensrown, writes:Alexander Yoortman, who died inlecember 1970, was a highly respected[Id an active and loyal member of thef South Africa. He was born inouxville 66 years ago. His fatheras a well-known surgeon whoIW active service in the Anglo-oer War and 'Sandy', aslexander Yoortman was known, all his friends, followed in theme tradition, qualifying at theniversity of Cape Town in 1931.During his student days he'oved to be an outstanding ath-te and would certainly have wonJringbok colours had he not beenvolved in an accident whichid him low for over six months.laracteristically, however, heumphed over these adverse cir-mstances and contrived to playicket, bowls, golf and, incredibleit may seem, became a very ableferee of rugby.Professionally he was a highly respected and most able,ysician and was loved by his patients and his colleagueske, despite his forthright attitude and frankness. An extro-rt, blythe spirit who loved an argument, yet who never:med too busy nor too pre-occupied to give a cheery wavea word of encouragement. He was also a keen and shrewdserver of life and his own disability never robbed him of his:-force. Particularly on the bowling greens he was a delight. relaxed, full of humour, larded at times with astute andarming observations. In the clubhouse he was often pro-:ative, at times even profane ... but he was always good,lant company and gay.iandy will be mourned by a large circle of friends, patientsI colleagues. The memory of his loving kindness andlerosity of spirit will surely sustain those who had had theleftt of his friendship.To his widow and his two sons we extend our warmestsympathy.MAURICE ALEXANDER ROBERTSON, M.R.C.S. (Eng.)L.R.C.P. (Lond.) ER.C.S. (Eng.)Dr R. Polakow, of Johannesburg, writes:Maurice Alexander Robertson, whose death occurred inRhodesia in December 1970, was born in Aberdeen, Scotland,in 1906. He was admitted at Sedbury School and commencedhis medical studies at St John's College, Cambridge, where heobtained his M.A., M.B., RCh. He proceeded to the LondonHospital where, after surgical experience, he obtained hisF.R.C.S. (Eng.). He came to South Africa in 1939 as Surgeonto the Admiralty in Port Elizabeth. He started private practicein that area, and obtained a post as Hon. Surgeon to theProvincial Hospital, Port Elizabeth, in which he served withdistinction for many years. As one of his former housemen Ican well remember the kindness to, and interest in his patients,combined with his willingness to come at all hours to adviseand help the interns.He built up a large private general practice, from whichill health forced him to retire in 1964. During his stay in PortElizabeth he was a member of Hospital Board committees,President of the Cape Midland Branch, and a Federal Coun-cillor.Dr Robertson spent the last six years of his life at theCancer Research Unit of the National Cancer Association atthe SAIMR in Johannesburg. where he worked in associationwith the late Dr A. G. Oettle. He was able to develop suchan effective understanding of cancer epidemiology as to com-plete, with the help of colleagues, three major surveys whichwere left uncompleted by Dr OettIe's death in 1968. Thesesurveys showed the changing cancer patterns from region toregion in Southern Africa, and the finding of a high frequencyof liver cancer not previously known of in the Transkei.His death ·came as a great shock to his colleagues and friends.It is sad that his dedicated work is over, but the high standardof the finished product bears testimony to his careful andscrupulous attention.To his wife and his daughter, Dr Bartlett, a paediatrician inSalisbury, the profession extends its sincerest condolences.

Vaginoplasty following vesicovaginal fistula repair: A preliminary report

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Vaginoplasty following vesicovaginal fistula repair: A preliminary report

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