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Key words: Vesicovaginal fistula, vesicle suture, transabdominal hysterectomy, vaginal cuff,
rabbits
From the Division of Gynecology, Department q[ Obstetrics and Gynecology, University of Mississippi Medical Center.
Supported in part by the VicksburgHospital Medical Foundation.
Presidential Member Prize Paper, presented at the Twenty-thirdAnnual
Meeting of the Society of GynecologicSurgeons, New Orleans, Louisiana,
February 24-26, 1997.
Reprints not availablefrom the authors.
Copyright 1997 by Mosby-Year Book, Inc.
0002-9378/97 $5.00 + 0 6/6/85858
1298
Volume 177,Number6
AmJ Obstet Gynecoi
Meeks et al.
1299
Ovary
Tube
Uterus
IX
IRa
Urethra
(
'
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Meeks et al.
Bladde~
December 1997
~nJ Obstet Gynecol
sutured in the rabbits randomized to exclude the bladder (Group 2). A figure of eight suture with two suture
loops were placed approximately 5 mm apart.
The midline incision was closed in a r u n n i n g mass
fashion with 4-0 polypropylene (Prolene, Ethicon). The
skin was closed in a subcuticular fashion with 4-0 polypropylene suture. The rabbits were washed to remove povidone-iodine and blood from skin and fur. They were
dried and then placed u n d e r a warming lamp for at least
30 minutes. The rabbits were monitored postoperatively
until they had recuperated from the effects of anesthesia,
Postoperative pain relief was obtained with 0.2 m g / k g
butorphanol (Stadol, Bristol-Myers Squibb Co., Princeton, NJ.) administered intramuscularly every 4 hours for
a m i n i m u m of two doses.
Each rabbit was examined twice daily for the first
postoperative week. The wound was inspected for evidence of infection, wound dehiscence, and autophagia.
The abdomen was also specifically evaluated for evidence
of intraperitoneal sepsis. General appearance, activity
level, eating and drinking, and weight gain were assessed.
Daily examinations were performed until the wound was
healed, then at least weekly inspections of the incision
site were performed. Apple slices and alfalfa cubes were
given to stimulate appetite and to help provide a balanced diet to aid in recovery. Food and water were
allowed at will.
After ketamine sedation the animals were put to death
by carbon dioxide asphyxiation 28 days after surgery, and
necropsy was performed. The abdomen was examined
for evidence of dehiscence or autophagia, as well as
hernia. The previous midline incision was opened, and
the surgical site was identified. Significant abdominal
abnormality, such as adhesions or active infection, was
noted. The bladder and vagina were harvested en bloc by
dissecting the areolar tissue surrounding them, by
transecting the ureters, and by cutting the vagina caudad
to the junction of the urethra near the pubic symphysis.
The vagina was dissected free from the urethra, and a
Foley catheter was inserted through the urethra into the
bladder. The urethra was tied with a suture to prevent
urethral leakage (Fig. 4).
Hemostats were used to hold the cuff of the vagina
open for observation. The bladder and vagina were
submerged into a basin of water to aid in the detection of
any leakage. Evidence of a fistula between the bladder
and vagina was then determined in three distinct ways.
Formula milk was infused into the bladder via the
urethral catheter, and the vagina was inspected for
leakage. Saline solution colored with methylene blue was
used in the same manner. Last, air was injected into the
bladder through the urethral catheter. The vagina was
filled with and submerged in water. The vagina was
observed for leakage manifest by bubble formation. Each
specimen was placed in formalin for future study.
Meeks et al.
/Ureter
~~#~'f
Ureth~~
1301
Suture
Cuff
Urethra
Previous
attachment
of urethra
FlesuRs
Thirty-two animals were enrolled in the study. Twentyone animals had a figure-of-eight suture placed through the
anterior vaginal wall with each loop of the suture intentionally placed through the bladder (group 1). Eleven animals
had a figure-of-eight suture placed through the anterior
va~nal wall, but care was taken to ensure that the bladder
was not penetrated (group 2). At the time of arrival at tile
1302
Meeks et al.
December 1997
&n J Obstet Gynecol
Delivery
Ligated (n = 20)*
Nonligated
(n = 10)*
2.40 +- 0.03
2.40 0.05
Surge~
2.81 + 0.23
2.93 0.18
Necropsy
3.48 -+ 0.31
3.54 _+ 0.36
Complication
Ruptured bladder
Hemorrhage
Dehiscence
Autophagia
Hernia
Remote adhesions
Site adhesions
Colon adhesions
Small-bowel adhesions
Nonligated
Ligated group group
(n = 20)
(n = 10) Sig~ijfcanee
3
0
1
8
2
8
6
6
5
1
1
0
4
1
1
0
0
0
p
p
p
p
p
p
p
p
p
=
=
=
=
=
=
=
=
0.593
0.333
0.689
0.656
0.749
0.099
0.065
0.065
0.109
F i s h e r ' s e x a c t test.
Comment
T h e o c c u r r e n c e of fistulas that are obstetric in origin
has b e e n greatly r e d u c e d in the U n i t e d States because of
i m p r o v e m e n t in intrapartum care and the liberal use of
cesarean section for p r o l o n g e d labor and obstructed
labor. However, no change in the overall incidence of
vesicovaginal fistula formation after gynecologic operations has b e e n d o c u m e n t e d . Prevention has b e c o m e the
watchword. Whereas n u m e r o u s clinical opinions have
b e e n espoused regarding prevention of vesicovaginal
fistulas, no major controlled study has focused on this
issue. This study evaluated p l a c e m e n t of suture into the
bladder as an isolated occurrence.
T h e m e a n weight for each group of animals was similar
at arrival in the U M M C animal facilities, immediately
before surgery, and at necropsy. This confirms that the
groups were comparable. Also, the m e a n weight for each
group increased over the duration of the study. The
steady growth of the rabbits indicates that they were
generally healthy and tolerated the surgery well.
Intraoperative surgical complications, postoperative
complications, and postoperative a b d o m i n a l abnormality.
did n o t differ significantly between the groups. Whereas
no statistically different rate of adhesion f o r m a t i o n was
found, adhesion f o r m a t i o n deserves a special c o m m e n t .
Many m o r e adhesions were n o t e d in the "ligated" group
than in the "nonligated" group. P l a c e m e n t of a suture
t h r o u g h tile bladder may p r o d u c e transient leakage of
urine into the p e r i t o n e u m . If urine leaked even for a
short p e r i o d of time and collected at a r e m o t e site, it
could stinmlate adhesions. Also, it may p r o d u c e a m o r e
intense inflammatory response locally, causing m o r e
adhesions at the surgical site.
Use of sterile milk, m e t h y l e n e blue, a n d air p r o v i d e d
t h r e e alternative m e t h o d s to r e c o g n i z e the p r e s e n c e of
a fistula. By c a t h e t e r i z i n g the b l a d d e r a n d s u b m e r g i n g
it in water, we e n h a n c e d o u r ability to d e t e c t leakage if
present. T h e t e c h n i q u e s for identifying leakage s e e m
Meeks et ai.
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Meeks et al,
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,'MnJ Obstet G)aaecol