Application of bulbospongiosus muscle flap tamponade combined with vaginal occlusion in the repair of complex urinary fistula following radiotherapy: a surgical technique

Introduction

Vesicovaginal fistula (VVF) is an abnormal fistula between bladder and vagina, causing continuous, involuntary leakage of urine into the vaginal fornix (1). VVF after radiotherapy refers to a serious complication that occurs after radiotherapy for pelvic malignant tumors, which is a challenge faced by urologists. The patient needs to wear diapers for a long time, causing severe psychological, physiological, and social stress, while seriously impacting the quality of their sexual life. However, patients with radiotherapy-induced VVF often experience bladder mucosal congestion and edema, reduced flexibility, and impaired bladder wall blood supply. Once ulceration occurs, it can extend through the bladder wall, resulting in urine leakage; surgical repair frequently fails, and leakage symptoms often recur (2).

Current treatment options have significant limitations. Traditional nephrostomy greatly affects patients’ quality of life, restricting their daily activities. They need to clean the skin around the stoma, fix the stoma tube, and change the dressing regularly. The patient often experiences feelings of low self-esteem, anxiety, and depression, and their social activities are limited; meanwhile, pedicled greater omentum, peritoneal flap, full-thickness labial flap, gracilis muscle flap and gluteal muscle flap may cause side injuries and bleeding due to large surgical trauma, especially dense adhesion of pelvic and abdominal organs after radiotherapy, and hence, the widespread adoption of this surgery method is difficult. Therefore, there is an urgent need for a surgical method that is simple to operate, carries low surgical risks and delivers satisfactory therapeutic outcomes to solve such complex problems.

In this case, we successfully treated a patient with complicated bladder vaginal fistula after radiotherapy by using a modified surgical protocol of pedicle bulbospongiosus muscle flap vaginal tamponade combined with vaginal closure. A 56-year-old female patient underwent full-dose chemotherapy and radiotherapy for stage IIIB cervical squamous cell carcinoma. Two years post-treatment, she developed increased vaginal discharge, which significantly worsened with changes in body position. The patient has a large amount of vaginal discharge, needs to wear diapers for a long time, has vulvar eczema, has a distinct body odor. The patient has poor nutritional status, is emaciated, and shows no obvious abnormalities in blood routine or liver and kidney functions. The patient has anxiety symptoms, refusal to go out, and reduced interaction with friends and family. After ruling out tumor recurrence via computed tomography urography (CTU) cystoscopy and cystography, bulbospongiosus muscle flap tamponade combined with vaginal block was performed smoothly following thorough preoperative preparation. The operation lasted 96 minutes with a blood loss of 69 mL. The catheter was retained for two weeks after operation. A follow-up cystoscopy at three months showed well-healed bladder fistula. Six months after the operation, cystoscopy was reexamined. The necrotic bladder mucosa was completely repaired, with no vaginal leakage, and no hydronephrosis in either kidney. Follow-up for 18 months showed no vaginal leakage. This procedure is a good choice for complicated vesicovaginal fistula after radiotherapy. We present this article in accordance with the SUPER reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-24/rc).

Preoperative preparations and requirements

All procedures performed in this study were in accordance with the ethical standards of the ethics committee (2021) GSFY Ethics Review [54] and the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images and videos. A copy of the written consent is available for review by the editorial office of this journal.

Comprehensive preoperative evaluation and preparation were conducted to ensure patient safety and optimize surgical outcomes. Tumor markers and imaging examinations were performed to rule out tumor recurrence. Cystoscopy was conducted to determine the fistula location, size, and its relationship to the ureters. The vagina was rinsed with light iodophor water twice daily for three days prior to surgery to reduce bacterial colonization. Preoperative urine culture revealed Escherichia coli infection, and antimicrobial susceptibility testing demonstrated sensitivity to cefuroxime sodium. Accordingly, intravenous cefuroxime sodium was administered at 0.75 g three times daily for infection control. Antimicrobial therapy was continued until urine culture turned negative, ensuring adequate preoperative infection management.

Surgical environment

This procedure was performed in a Grade-A tertiary teaching hospital (Gansu Provincial Maternal and Child Health Hospital) in a Class I laminar flow operating room to ensure sterile conditions.

Team composition

The surgical team consisted of a surgeon with more than 10 years of experience in urologic surgery who had completed more than 10 similar cases, an anesthesiologist, a scrub nurse, and a circulating nurse. The lead surgeon has passed the learning curve in this specific operation, and the surgical team works in perfect harmony.

Specific information about patients with fistula

For patients with single vesicovaginal fistula, the fistula was located in the trigone area, measuring 1.5 cm in diameter. The bilateral ureteral openings are located approximately 1.0cm from the edge of the fistula. Special attention should be paid to protection during the operation. Regarding anesthesia management, the patient received general anesthesia.

Anesthesia management

The patient received combined intravenous-inhalation general anesthesia. Sufentanil is used for anesthesia induction. Sevoflurane is used to maintain anesthesia during the operation, and mechanical ventilation is implemented. During the operation, the patient’s vital signs were continuously monitored, including electrocardiogram, non-invasive blood pressure, pulse oxygen saturation and end-expiratory partial pressure of carbon dioxide. The anesthesiology team worked closely with the surgical team to ensure the patient’s vital signs were stable.

Step-by-step description

• Perform cystoscopy before the operation to assess the degree of bladder injury and identify fistula location, size and number (Figure 1).
  

  Figure 1 Preoperative cystoscopy demonstrating the fistula location, size, and relationship to the ureteral orifices.
• Expose fistula: The patient was in the lithotomy position before the operation, with a catheter in place. The vagina was exposed with a hook. Significant vaginal wall fibrosis and cervical atrophy were observed. A fistula measuring approximately 1 cm × 1 cm was visible on the right side of the anterior vaginal fornix (Figure 2).
  

  Figure 2 The top of the vagina was exposed, revealing a vesicovaginal fistula.
• A circumferential incision was made in the vaginal mucosa tissue around the fistula, around 1 cm from its margin. Free the vaginal mucosa surrounding the fistula tract and the vaginal-bladder space. During the separation process, the scar tissue around the fistula tract was brittle. Liberate as much mucosal tissue as possible from the anterior and posterior aspects of the vaginal wall apex to develop fresh tissue (Figure 3).
  

  Figure 3 Circumferential incision of the vaginal mucosa approximately 1 cm from the fistula margin.
• The middle third of the vaginal mucosa was cauterized using electrocautery to create a roughened surface.
• Close the fistula tract: The vaginal mucosa of the anterior and posterior walls around the fistula was approximated and closed with interrupted sutures using 2-0 absorbable suture. Diluted methylene blue was instilled into the bladder through the catheter to test for leakage; minimal leakage was observed. The anterior and posterior vaginal walls were reinforced and closed with an additional layer using 2-0 absorbable suture.
• Free the bulbospongiosus muscle flap: A longitudinal skin incision was made on the right labium majus, approximately 8 cm in length. The bulbospongiosus muscle flap was dissected, with its vascular supply preserved during the dissection. The superior edge of the bulbospongiosus muscle flap was transected at the level of the clitoral plane. The dissected muscle flap measured approximately 7 cm in length and 2 cm in width (Figure 4). A subcutaneous tunnel approximately 3 cm wide was created on the medial aspect of the right labium majus and connected to the vaginal canal.
  

  Figure 4 Dissection and exposure of the bulbospongiosus muscle flap.
• Fix the bulbospongiosus muscle flap and cover the fistula: The bulbospongiosus muscle flap was sutured with 3-0 absorbable suture, then passed through the subcutaneous tunnel to the vaginal area. It was subsequently sutured and secured to the vaginal apex to cover the fistula.
• Free the outer one-third of the vaginal mucosa and close the vagina: The mucosal tissue of the anterior, posterior, and lateral walls of the outer one-third of the vagina were freed to create fresh tissues. The mucosal tissue of the outer one-third of the vagina and the surgical wound on the medial aspect of the labia minora were approximated and closed with interrupted sutures using 2-0 absorbable suture, thus closing the vaginal canal completely (Figure 5).
  

  Figure 5 Postoperative pictures.
• Close surgical wound on the labium majus: The wound on the right labium majus was approximated with 1-0 absorbable suture, and the skin was closed with 3-0 absorbable suture.

The procedure proceeded smoothly with effective anesthesia. The operative time was 96 minutes, and the estimated blood loss was 69 mL. The complete surgical procedure is provided in Video 1.

Postoperative considerations and tasks

A three-lumen Foley catheter was maintained for two weeks postoperatively, with careful monitoring to ensure its normal function. The surgical wounds were kept dry and clean to prevent infection.

Cystoscopic examination performed at 3 months postoperatively showed satisfactory healing of the vesicovaginal fistula with vaginal dryness, no abnormal discharge, no low back pain, fever, or discomfort, and no significant lower urinary tract symptoms (Figure 6A). A follow-up cystoscopy conducted 6 months after the procedure revealed complete regeneration of the previously necrotic bladder mucosa with no evidence of vaginal leakage (Figure 6B). Follow-ups at 12 and 18 months all showed good recovery: no vaginal leakage, no hydronephrosis in either kidney, bladder capacity of 300 mL, and well-healed incision at the right labia majora.

Figure 6 The results of cystoscopy (A) three months and (B) six months after the operation.

Tips and pearls

Our team classifies the vagina into three segments based on the extent of radiation damage: the vaginal apex, the mid-vagina, and the distal vaginal segment (near the introitus). The apex is managed using a traditional vaginal repair technique, as detailed in the surgical procedure description. The vaginal mucosa is cauterized with an electrocautery device to create a roughened surface, which promotes adhesion of the bulbospongiosus muscle flap and helps prevent the formation of dead space within the vagina. The mucosal layer at the vaginal introitus is dissected and sutured to achieve complete vaginal closure.

Discussion

VVF refers to an abnormal tract between the bladder and vagina, which severely impacts the patient’s quality of life (3). The causes of VVF include obstetric trauma, physical injury, iatrogenic injury, and pelvic radiotherapy (4). The incidence of radiation-induced VVF is relatively low; however, extensive scarring around the fistula tract and compromised local microcirculation make treatment challenging and result in low surgical success rates. The main mechanisms involve the proliferation of radiation-induced fibroblasts in the bladder, vagina, and surrounding tissues under radiation exposure, as well as progressive tissue fibrosis (5). Conventional treatment involved mostly percutaneous nephrostomy, requiring patients to wear stoma bags for a long time, which seriously affected their quality of life (6). In recent years, with the rising incidence of cervical cancer and the wide application of pelvic radiotherapy, the incidence of post-radiation VVF has been on the rise, thus calling for heightened attention to treatment strategy selection (7).

Treating radiotherapy-induced bladder vaginal fistula is challenging, and surgery is an option (8). Surgical approaches include transabdominal, laparoscopic and vaginal approaches (9). Literature indicates satisfactory outcomes with these various surgical methods, but postoperative bladder dysfunction rates were 36.4%, 28.6% and 20% for transabdominal, transvaginal and laparoscopic transabdominal procedures, respectively (10). The choice of surgical approach is closely related to fistula type, size, urethra or ureter involvement, the patient condition, and the surgeon’s experience (9).

The abdominal approach requires a longer hospital stay and causes more significant postoperative pain. Additionally, prior surgical history and radiotherapy may lead to pelvic adhesions, thus increasing surgical difficulty and the risk of iatrogenic injuries. The vaginal approach may reduce the risk of complications, and vaginal approach combined with the implantation of a pedicled tissue flap can improve the success rate. The implanted bulbospongiosus muscle flap is an interstitial tissue flap that utilizes the bulbospongiosus muscle and labial fibrofatty tissue. It is placed between the two structures involved in the fistula to maximize the chances of success. The reason for using interstitial flaps in fistula repair lies in establishing a mechanical barrier at the sutures site and enhancing blood supply to poorly vascularized tissues (2). Guijarro-Campillo et al. successfully repaired a complex vesicovaginal fistula that developed as a postoperative complication of early-stage endometrial cancer using a bulbospongiosus muscle flap (11). Carlos et al. used bulbospongiosus muscle flap to repair vesicovaginal fistula of the new bladder after bladder cancer surgery (12). Brändstedt et al. successfully repaired a vesicovaginal fistula after gynecological surgery using a transvaginal bulbospongiosus muscle flap approach. They found this surgical procedure simple, safe and replicable with good long-term functional and aesthetic effects (13). Kapriniotis et al. reviewed all studies on transvaginal VVF repair reported in MEDLINE, Embase and the Cochrane Central Controlled Trials Registry. The results show that for obstetric fistulas and most simple, non-irradiated iatrogenic fistulas, successful closure can be achieved with or without tissue intervention. However, in most radiotherapy cases, the bulbospongiosus muscle transplantation is crucial for successful repairs (14).

The bulbospongiosus muscle flap has achieved satisfactory outcomes in complex VVF repair. It receives arterial supply from the perineal branches of the internal and external pudendal arteries (2). Its advantages include high mobility, ease of tunneling, medial rotation capability, and the feasibility of opening an adequately sized flap. The following are the advantages of this procedure: (I) it allows repair of the vaginal wall around the fistula, leaving the bladder fistula open, avoiding injury to the ureteral orifice and eliminating the need for ureteral stenting; (II) the vaginal mucosa is everted and sutured, preventing direct contact with the bladder mucosa, thereby promoting fistula healing; (III) the bulbospongiosus muscle flap is easy to expose and to obtain, close to the fistula, long with pedicle suitable for transposition, providing vital nutrition support to enhance fistula healing; (IV) the procedure causes minimal surgical trauma, low blood loss, and mild postoperative pain, resulting in high patient acceptance and satisfaction. As a disadvantage of the procedure, the surgery results in vaginal closure, preventing the patient from engaging in sexual intercourse after surgery.

The criteria for successful VVF repair are re-evaluation of urinary leakage at 6 and 12 weeks after the operation, vaginal dryness in the patient, and no contrast agent in the vagina as detected by cystography, which are considered successful surgical repair (10). All the samples taken from this patient were from the right bulbospongiosus muscle flap, which is related to the surgeon’s habits. The first stage of the operation healed without any complications

The literature reports that most VVF repairs are performed following hysterectomy or hysterectomy combined with radiotherapy. These cases are typically characterized by a shortened vagina and a fistula located relatively close to the vaginal introitus, facilitating intraoperative exposure of the fistula and reducing the difficulty of repairing. In contrast, this patient in our series developed VVF after radiotherapy. They exhibited an elongated and narrow vagina with a deeply situated fistula, making transvaginal repair technically challenging and significantly increasing the surgical difficulty.

For such complex post-radiation vesicovaginal fistulas, we have achieved success by employing bulbospongiosus muscle flap interposition combined with colpocleisis. The advantages of this procedure are as follows: (I) the vaginal approach is selected, avoiding the visceral injuries associated with abdominal procedures; (II) the pedicled bulbospongiosus muscle flap is easily exposed and harvested, located close to the fistula, providing essential nutritional support to promote fistula healing; (III) this technique is highly safe, minimally invasive, results in minimal blood loss, and causes only mild postoperative pain. However, this technique also has limitations: (I) the surgical procedure is complex and requires the surgeon to have extensive anatomical knowledge and surgical skills; (II) sexual intercourse is not possible due to vaginal closure; (III) the donor site may affect aesthetics. Therefore, this procedure should be regarded as an effective yet specialized approach for treating complex, refractory vesicovaginal fistulas, particularly in post-radiation cases, rather than a first-line solution for all types of fistulas.

The management of post-radiation vesicovaginal fistula poses significant challenges. A comprehensive preoperative assessment of bladder and ureteral function, fistula characteristics, and the health of surrounding tissues is essential. This surgical technique represents an important advancement in the treatment of complex radiation-induced vesicovaginal fistulas. By incorporating innovative surgical principles, it offers a successful solution for the most challenging cases. Moving forward, through stringent patient selection, specialized training for healthcare professionals, and ongoing technical development and research, this procedure will provide treatment options for a greater number of patients, profoundly influencing treatment approaches and patient outcomes for this condition.

Conclusions

Transvaginal bulb-spongy muscle flap packing combined with vaginal closure is a good choice for the treatment of VVF after radiotherapy, especially for patients with a long and narrow vagina and a deep fistula, which can increase the success rate of the surgery. The adipose tissue on the surface of the globular spongiform muscle flap may provide nutrients for tissue repair. Therefore, when separating the globular spongiform muscle during the operation, it is necessary to retain the adipose tissue on the surface of the globular spongiform muscle as much as possible, which can better promote wound repair. This method is simple to operate, has high surgical safety, causes little trauma to the donor site and has a high success rate.

Acknowledgments

The video was awarded the third prize in the Fifth International Elite Gynecologic Surgery Competition (2025 Masters of Gynecologic Surgery).

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine for the series “Award-Winning Videos from the Fifth International Elite Gynecologic Surgery Competition (2025 Masters of Gynecologic Surgery)”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-24/rc

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-24/prf

Funding: This study was supported by Lanzhou Science and Technology Plan Project (No. 2022-ZD-59).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-24/coif). The series “Award-Winning Videos from the Fifth International Elite Gynecologic Surgery Competition (2025 Masters of Gynecologic Surgery)” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the ethics committee (2021) GSFY Ethics Review [54] and the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images and videos. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Duan XH, Li FY, Han XW, et al. Clinical Observation of Double Percutaneous Nephrostomy Combined with Ureter Occlusion Stent for Treating Cervical Cancer Complicated with Vesicovaginal Fistula. Cancer Biother Radiopharm 2022;37:759-65. [Crossref] [PubMed]
2. Gupta P, Kalra S, Dorairajan LN, et al. Labia Majora Fasciocutaneous Flap Reconstruction in Complex Urogynecological Fistulas With Vaginal Deficit - A Versatile Approach Urology 2022;167:241-6. [Crossref] [PubMed]
3. Imantika E, Sasotya RMS, Armawan E, et al. Enhanced Proliferation and Adhesion Marker Gene Expression in Fibroblast Cells: Evaluating the Efficacy of a Non-Surgical Treatment for Urogenital Fistula. Med Sci Monit 2023;29:e941641. [Crossref] [PubMed]
4. Hillary CJ, Osman NI, Hilton P, Chapple CR. The Aetiology, Treatment, and Outcome of Urogenital Fistulae Managed in Well- and Low-resourced Countries: A Systematic Review. Eur Urol 2016;70:478-92. [Crossref] [PubMed]
5. Breen M, Ingber M. Controversies in the management of vesicovaginal fistula. Best Pract Res Clin Obstet Gynaecol 2019;54:61-72. [Crossref] [PubMed]
6. Kołodyńska A, Streit-Ciećkiewicz D, Kot A, et al. Radiation-Induced Recurrent Vesicovaginal Fistula-Treatment with Adjuvant Platelet-Rich Plasma Injection and Martius Flap Placement-Case Report and Review of Literature. Int J Environ Res Public Health 2021;18:4867. [Crossref] [PubMed]
7. Arbyn M, Weiderpass E, Bruni L, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. Lancet Glob Health 2020;8:e191-203. Erratum in: Lancet Glob Health 2022;10:e41. [Crossref] [PubMed]
8. Malik MA, Sohail M, Malik MT, et al. Changing trends in the etiology and management of vesicovaginal fistula. Int J Urol 2018;25:25-9. [Crossref] [PubMed]
9. Lo TS, Chua S, Wijaya T, et al. Clinical relevance and treatment outcomes of vesicovaginal fistula (VVF) after obstetric and gynecologic surgery. Taiwan J Obstet Gynecol 2019;58:111-6. [Crossref] [PubMed]
10. Anand M, Kumar M, Jain M, et al. Early bladder dysfunction after vesicovaginal fistula repair: A prospective comparative analysis of transvaginal, open, and laparoscopic abdominal approaches. Neurourol Urodyn 2024;43:2101-9. [Crossref] [PubMed]
11. Guijarro-Campillo AR, Kumar V, Patil J, et al. Modified Martius technique for complex vesicovaginal fistula repair. Int J Gynecol Cancer 2023;33:1152-3. [Crossref] [PubMed]
12. Carlos D, Abraham N, Zhou TC, et al. Transvaginal repair of Neobladder Vaginal Fistula with Martius Flap. Int Braz J Urol 2020;46:864-6. [Crossref] [PubMed]
13. Brändstedt J, Abrahamsson J, Baseckas G, et al. Urosymphyseal fistula after pelvic radiotherapy in a tertial referral centre - a rare entity with significant comorbidity requiring multidisciplinary management. Scand J Urol 2023;58:4-10. [Crossref] [PubMed]
14. Kapriniotis K, Loufopoulos I, Gresty HCM, et al. The utility of Martius fat pad in the repair of urogenital fistulae: review of current evidence. BJU Int 2024;134:365-74. [Crossref] [PubMed]