Female Lower Urinary Tract Symptoms (LUTS) / Voiding Dysfunction
The Latzko repair is a classical technique for vesicovaginal fistula repair using a vaginal approach. As an outpatient procedure with minimal morbidity and low cost, the Latzko is a high value procedure. The Latzko is likely underutilized due to prevailing myths. These myths include that it cannot be used for fistulae at the apex or complex fistulae, that it cannot be performed with a uterus in place, and that it shortens the vagina.
The objective of this video is to review the basic steps of the Latzko technique, provide tips and tricks for ensuring a successful procedure and illustrate variations in use for this adaptable technique.
Optimal exposure is key and can be achieved with the use of a vaginal self retaining retractor and a posterior weighted speculum. A pediatric foley in the fistula is important to allow for downward traction. Vasopressin injection through a small needle is essential to hydro-dissect the epithelium off of the underlying layers. A circumscribing incision is made around the fistula. The incision should be 2-3 cm in diameter. The epithelium is then completely denuded. Leaving the fistula tract in situ as opposed to excising it prevents fistula enlargement and postoperative hematuria. The first step of fistula closure is to place a purse string suture just outside the epithelialized tract. This is done using a fine suture and needle. As the purse string suture is tied down, the foley is removed. Imbricating sutures are then placed as a second layer taking care to close any dead space at the base of the defect. One to two subsequent imbricating suture layers are placed. The vaginal epithelium is closed in a running fashion.
We subsequently present the versatility of the Latzko technique. In the first variation we present a case of a large vaginal vault prolapse with vesicovaginal fistula following hysterectomy. The same Latzko steps as described previously are completed. The apical suspension procedure can then commence. In this case a Michigan 4 wall sacrospinous ligament suspension was performed. A diamond shaped incision is used in this operation and positioned medial to the fistula repair in order to avoid tension on the closure. In the second variation a 54 year old woman had undergone a nephro-ureterectomy for urothelial malignancy complicated by vaginotomy repaired with an omental flap. She developed urinary leakage several days after surgery and was found to have a 1.5cm vesicovaginal fistula lateral to the cervix. In this case, the closure technique varies from the standard. Given the size of the defect, a series of imbricating interrupted stitches were used for the first layer instead of a pursestring. In the third variation a woman presented with a complex fistula between a bladder diverticulum and vagina following an emergency cesarean section complicated by cystotomy and bilateral ureteral injuries. She had undergone two ureteral reimplantation surgeries before the fistula repair. Fluoroscopy demonstrates the large bladder diverticulum formed by a previous urinoma and contrast extravasation into the vagina. Her complex anatomy was difficult to discern, but imaging confirmed that the ureter was not involved in the fistula, so plan was made to proceed with Latzko repair. After Latzko repair and repair of a chronic cervical laceration, she had complete resolution of her urinary leakage.
In summary, the Latzko vesico-vaginal fistula repair is a versatile minimally invasive procedure that allows patients to have an outpatient surgery with minimal postoperative pain and low complication rate.