Hypothesis / aims of study
Vesicovaginal Fistula (VVF) is the non-physiological communication between bladder and vagina, resulting in uncontrollable urine leakage into the vagina. The most common cause of VVF in developed countries are gynaecological and obstetric procedures. It's estimated that 85% all of VVF appear to be a complication of transabdominal hysterectomy (1,1/800 procedures) or transvaginal hysterectomy (0,2/1000 procedures), and 11% develop after caesarean section. It can also be associated with dilation & curettage, cone biopsy, stress urinary incontinence procedures or laparoscopic hysterectomy. The other, less common, factors are pelvic tumors, pelvic injuries, foreign intrauterine or intravaginal bodies and abscesses. The VVF may be a late consequence of oncological radiotherapy . VVF is a devastating condition with serious negative effect on quality of patients life. Treatment is based on surgical procedures that can be performed transvaginally, transabdominally or laparoscopically. According to the WHO successful closure rate for a first repair is around 85% . However, it is still a challenging surgical procedure, recurrence remains a highly distressing complication for patients and surgeons.
Platelet Rich Plasma (PRP) is an autologous concentrate of thrombocytes in small volume of plasma, which contains five times higher concentration of platelets than physiological, and higher concentration of growth factors localized in thrombocytes, like Platelet-Derived Growth Factor (PDGF), Transforming Growth Factor ß (TGF ß), Vascular Endothelial Growth Factor (VEGF) and Endothelial Growth Factor (EGF). In addition, PRP contains a high level of adhesion proteins like fibrin, fibronectin, vitronectin, that are the components of the extracellular matrix and play important role in wound healing. Autologous character of PRP eliminates the risk of viral infections like viral hepatitis or HIV transmission .
The aim of our study is to evaluate the efficacy of PRP use as a supportive agent in the treatment of recurrent VVF after two previous unsuccessful surgical attempts.
Study design, materials and methods
Between January 2018 and January 2019 10 patients with recurrent VVF were injected with PRP in tertiary gynecological clinic and underwent following surgical Latzko procedure. All patients signed informed consent and agreed to the use of this data for scientific purposes. The Local Ethics Committee approved the study concept. The demographic patients’ data are given in Table 1.
Whole blood (180 ml) was collected from the patients into sodium citrate tubes (ratio 9:1). The tubes were centrifuged with the Arthrex Angel System® kit (Arthrex Inc., Naples, USA), resulting in 4-6ml PRP volume (Table 1).
With the patient in the lithotomy position, the exact location of fistula was determined transvaginally. The edges of the fistula were injected with PRP- in 4 to 5 points. Injections were made without local analgesia in order to avoid tissue pH change.
After the injection, patients were discharged home with ciprofloxacin 500 mg bid for five days. Following surgical procedure for VVF closure was scheduled 8 weeks after the PRP injection allowing proper neovascularization in surrounding tissues.
VVF repair procedure
The Latzko procedure was performed with the patient in the lithotomy position in general anesthesia. Cystoscopy was performed and bladder orifice of the VVF was localized and single J catheters were inserted into the ureters in order to decrease the amount of urine flowing into the bladder. Fistula was visualized from the vagina and Foley catheter 6 or 8 Fr, depending on fistula size, was placed into the bladder via VVF tract and balloon was inflated with 0.9% saline solution. Vaginal wall was then dissected and separated from the VVF tract for approximately 1 cm around the fistula. The scar tissue of the fistulous tract was excised in order to refresh the edges for better healing. Then imbricating, 3 layer, closure of the bladder, vesicovaginal fascia and vagina was performed with 3.0 absorbable sutures. After the first layer tightness of the closure was checked with inflating 150 ml methylene blue dye solution into the bladder. If watertight closure was achieved, next two layers of sutures were applied to secure complete closure. Foley and single J catheters were left for 12 days after surgery with antibiotic prophylaxis. On few postoperative days patients were kept on complete bed rest. Patients were checked up with inflating 150 ml methylene blue dye solution into the bladder before discharge and all catheters were removed. First follow-up visit was scheduled 4 weeks after discharge.
Interpretation of results
Platelet rich plasma is already used in wide range of indication, in orthopedics or aesthetic medicine, with beneficial effects in all types of tendinopathy (tendinopathy of the Achilles tendon, tendinopathy of the lateral humerus- the so-called tennis elbow), degenerative joint diseases, or healing of chronic wounds like diabetic foot. Our results of first few cases are quite encouraging, especially in complicated cases of recurrent VVF, where scar tissue after previous attempts might be overgrown and have negative influence on wound healing, especially in VVF case where urine is present from one side and vaginal flora from the other. Acceleration of tissue healing, because of growth factors and adhesion proteins concentration in PRP, might be crucial for fast and successful VVF closure.