The Latzko: A High-Value, Versatile Vesicovaginal Fistula Repair

Abstract

The Latzko transvaginal vesicovaginal fistula repair is a highly effective treatment for even complex fistulae. Our video demonstrates the Latzko technique and its application in a variety of circumstances including fistula management concurrent with treatment of uterovaginal prolapse, following complex urologic surgery, and in the postpartum setting after urologic injury. The technique of the procedure varies only slightly in these diverse conditions. The basic steps begin with hydro-dissecting the epithelium from the underlying fascia surrounding the fistula tract, followed by denuding the epithelium within a circumscribing incision around the fistula (Figure 1A). The fistula is then closed with a purse-string suture placed just outside the epithelialized tract. Next, several layers of imbricating sutures are placed to close the defect (Figure 1B). Finally, the vaginal epithelium is closed (Figure 1C).

Problem:

A post-hysterectomy vesicovaginal fistula is a devastating complication for both patient and surgeon. The Latzko repair has several advantages over other techniques. This high-value procedure minimizes pain, morbidity, and cost. Reported success rates for this vaginal approach range from 93-100%,^1,2 similar to abdominal repair success rates.^3,4 The Latzko is likely underutilized due to prevailing myths, including that it cannot be used for complex fistulae, cannot be performed with a uterus in place, and that it shortens the vagina.

Our Solution:

We developed a video to review the steps of the Latzko, provide tips and tricks for successful repair, and illustrate its adaptability (Video). Optimal exposure is achieved by utilizing a Lone Star™ retractor and a posterior weighted speculum (Figure 1A). A pediatric Foley catheter in the fistula allows for downward traction. This exposure reliably makes even a “high” fistula accessible. Vasopressin injection through a small needle to hydro-dissect the epithelium off of the underlying fascia greatly simplifies de-epithelization.

Figure 1. Basic Latzko steps.

A) The epithelium is denuded within the circumscribed area. B) Several imbricating suture layers are placed. C) Vaginal epithelium is closed.

Briefly, a circumscribing incision is made 2 to 3 cm around the fistula. The epithelium is completely denuded (Figure 1A). The fistula tract is left in situ to prevent fistula enlargement and postoperative hematuria. A purse-string suture is placed just outside the epithelialized tract using a fine absorbable suture. As the suture is tied down, the Foley is removed. Imbricating interrupted sutures are then placed, taking care not to leave a channel at the base of the defect. One to two subsequent imbricating suture layers are placed (Figure 1B). The vaginal epithelium is closed with running 4-0 suture (Figure 1C).

The Latzko is more versatile than often considered. For example, we previously published a case of a large vaginal vault prolapse with vesicovaginal fistula following hysterectomy (Figure 2A).⁵ The same Latzko steps described above were completed. In this case, a Michigan 4-wall sacrospinous ligament suspension was then performed. The diamond-shaped incision used in this operation was positioned medial to the fistula repair in order to avoid tension on the closure (Figure 2B).

Figure 2. Large vaginal vault prolapse with vesicovaginal fistula following hysterectomy.

A) The fistula is easily visualized after instilling methylene blue into the bladder. B) The diamond-shaped incision for Michigan 4-wall sacrospinous ligament suspension is outlined medial to the fistula repair site.

In the second variation, a 54-year-old woman had undergone a nephro-ureterectomy for urothelial malignancy. This surgery was complicated by vaginotomy, which was repaired with an omental flap. She developed urinary leakage several days after surgery due to a 1.5 cm vesicovaginal fistula lateral to the cervix (Figure 3A). Given the size of the defect, the closure technique varied from the standard, with a series of imbricating interrupted stitches used for the first layer instead of a purse-string. Imbricating and epithelial closure sutures were then placed, sewing the side of the cervix to the lateral vaginal wall (Figure 3B).

Figure 3. Vesicovaginal fistula lateral to the cervix.

A) Preoperative: vesicovaginal fistula following hysterectomy is located lateral to the cervix. B) Postoperative: Latzko fistula repair is completed.

In the third variation, the patient had a complex fistula between a bladder diverticulum and the vagina following an emergency cesarean section complicated by cystotomy and bilateral ureteral injuries. She had previously undergone two ureteral reimplantation surgeries. Fluoroscopy demonstrated the large bladder diverticulum formed by a previous urinoma and contrast extravasation into the vagina (Figure 4). Imaging confirmed that the ureter was not involved in the fistula, and a Latzko repair with cervical laceration closure was planned (Figure 5). After this operation, she had complete resolution of her urinary leakage and no hydronephrosis.

Figure 4. Complex fistula between a bladder diverticulum and the vagina (fluoroscopy).

Figure 5. Complex fistula before and after Latzko repair.

A) Preoperative: Pediatric Foley catheter is placed though the vesicovaginal fistula, and there is a chronic cervical laceration at 12 o’clock. B) Postoperative: Latzko vesicovaginal fistula repair and cervical laceration closure are completed.

In summary, the Latzko vesicovaginal fistula repair is a versatile, minimally invasive outpatient procedure. With its low complication and high success rates, it should be considered as a first-line treatment to minimize the morbidity associated with an abdominal approach. Even in seemingly complex cases and with the uterus in situ, the Latzko can be used successfully.

Supplementary Material

1

The video reviews the steps of the Latzko procedure, provides tips and tricks for performing a successful vesicovaginal fistula repair, and illustrates the procedure’s adaptability.