Vesicovaginal and Ureterovaginal Fistula Treatment & Management

No medical therapy is available for the management of vesicovaginal and ureterovaginal fistula. However, conjugated estrogen (oral or transvaginal) helps vaginal tissues become softer and more pliable for upcoming fistula repair. This is especially important for postmenopausal women and women with atrophic vaginitis.

For personal hygiene and skin care, sitz baths with a solution of permanganate or baking soda douches may be helpful.

For a small fistula, an initial trial of urethral catheter drainage may be attempted for 4-6 weeks. However, catheter drainage and/or fulguration of the edges of the fistula tract less often results in a cure.

The main factor in correcting vesicovaginal fistula is to separate the fistulous communication between the bladder and the vagina. This can be accomplished by inserting interposing tissue between the 2 organs and obtaining a watertight tension-free closure.

Pinpoint fistulas may respond to conservative management with urethral catheter drainage and fulguration of the fistulous tract, but success rates may be low. Persistent incontinence after an adequate period of watchful waiting requires open exploration and formal fistula repair.

Historically, the site of the fistula often dictated the surgical approach. Supratrigonal fistulas (fistulas above the interureteric ridge) were typically approached transabdominally. Infratrigonal fistulas (fistulas below the interureteric ridge) were corrected transvaginally.

The transvaginal approach is the safest and most comfortable for the patient. A history of previous failed repairs does not preclude transvaginal reconstruction. Fistulas located in the infratrigonal area, fistulas near the bladder neck, and those occurring after hysterectomy are usually amenable to transvaginal reconstruction. Transvaginal repairs do not require excision of the fistula tract.

In corrections of extensive fistulas after radiation therapy, a combined transvaginal and transabdominal approach with fixation of the omentum in the space between the vagina and urinary bladder is often useful.

Ureterovaginal fistulas may be treated with an internal stent. However, persistent fistulas despite stent placement warrant surgical exploration and ureteral reimplantation.

Important: The basic rule for fistula repair is that the first operation has the best chance of success, and surgeons should use the approach with which they feel most comfortable. All adjuncts should be included to ensure successful closure of the fistula.

Images of repair techniques are depicted below.

Informed consent discussions should include potential risks, including, but not limited to, ureteral injury, bladder injury, rectal injury, recurrence of fistula, persistent fistula, bleeding, and infection. Inform the patient if a Martius fat pad or gracilis muscle flap will be used.

Preexisting urinary tract infection should be cleared, and preoperative conjugated estrogen therapy is helpful. Broad-spectrum intravenous antibiotics are administered preoperatively.

Transvaginal approach

Place the patient in a dorsal lithotomy position. Insert a percutaneous suprapubic tube and urethral catheter. Insert a posterior-weighted vaginal speculum and place a self-retaining vaginal retractor.

Identify the fistula and place traction sutures on the vaginal mucosa next to the fistula site. For traction, a small urethral catheter (8F) is inserted into the fistula. If the tract is very small, dilate the fistula to an acceptable size for urethral catheter insertion. The use of Fogarty balloon catheters and expensive catheters is unwarranted and adds unnecessarily to the expense of the procedure, as a regular (albeit smaller) Foley catheter usually suffices.

Using an inverted J-shaped incision, circumscribe the fistula site. Dissect the anterior vaginal wall off the underlying pubocervical fascia. Close the fistula tract (bladder mucosa) vertically using 2-0 or 3-0 absorbable sutures in a watertight fashion. Close the pubocervical fascia using 2-0 or 3-0 absorbable sutures horizontally. An additional layer of peritoneal-based flap from the posterior incision can be placed as a third layer. Excise the redundant vaginal mucosa. Approximate the vaginal incision using 2-0 absorbable sutures, without causing an overlapping suture line. Place Betadine-soaked packing in the vagina.

Alternatively, a Latzko partial colpocleisis technique can be used. In this technique, 2 concentric circular incisions around the fistula tract are made. The vaginal mucosa is excised in quadrants. The fistulous tract, pubocervical fascia, and vaginal mucosa are closed in layers, without overlapping suture lines.

When closure is difficult or tenuous, a Martius fat pad (pedicle flap) may be harvested from the labia majora and interposed. A cylindrical bundle of bulbocavernosus and pedicled fat are developed carefully, preserving the superior external pudendal artery. A capacious tunnel under the vaginal mucosa between the labia majora and the fistula site is then developed. The labial pedicle flap is brought through the vaginal mucosal tunnel and sutured to the edges of the fistula repair. The vaginal mucosa then is closed over the fat pad.

Transabdominal approach

Place the patient in a modified lithotomy position. Insert a urethral catheter. Make an infraumbilical incision and carry it down into the peritoneal cavity. Expose the pouch of Douglas. Completely mobilize the bladder and bivalve it at the dome. Identify the ureteral orifices and the fistula tract.

Cannulate both ureteral orifices with pediatric feeding tubes for easy identification. Circumscribe and excise the fistula. Separate the bladder from the vagina. Close the bladder with sequential 2-0 absorbable sutures after the vaginal closure is completed.

If omental interposition is performed, the abdominal incision should be carried to the epigastrium, with mobilization of the omentum. Separate avascular adhesions to the transverse colon. Divide and ligate the left gastroepiploic and short gastric vessels. Mobilize the omentum using the right gastroepiploic pedicle. Medially mobilize the ascending colon and hepatic flexure. Pass the omentum, which is hinged on the right gastroepiploic artery, behind the ascending colon and into the pelvis.

Close the vagina using 2-0 absorbable sutures. Suture the distal aspect of the omentum to the distal limits of the space between the vagina and the bladder. Complete the bladder closure in 1-2 layers. Put the suprapubic tube and pelvic drains in place.

If ureteral reimplantation is necessary, dissect out the ureter prior to fistulectomy. Reimplant the ureter in the upper bladder wall after the fistula is closed. The ureter should be stented postoperatively.

Laparoscopic and robotic approaches ^{[4, 5]}

In the era of more minimally invasive management (MIS), increasing experience in the use of robotic and laparoscopic technologies has yielded successes with vesicovaginal fistulae repairs. Adherence to similar principles as in open abdominal repair with use of interposition grafts and layered closures has helped patients do well. Still, no randomized trials are available to make true comparisons (perhaps none should be), but, as stated earlier, the first repair is often the best repair. so whichever route is chosen, it should be the surgeons best in his or her hands. Often, there is a fair amount of scarring and extravasation in the area of the fistula, so that may affect the quality of the repair. Nonetheless, MIS technology has worked in several authors hands in this type of repair.

Continue intravenous antibiotics until the patient is able to tolerate an oral diet. To prevent bladder spasms, prescribe anticholinergics. Remove pelvic drains when the output becomes minimal, usually prior to discharge.

Remove the urethral catheter and perform cystography 10-14 days following surgery. Alternatively, intravesical methylene blue may be used. If extravasation is not evident, the suprapubic tube may also be removed. If a persistent leak is present, leave the suprapubic tube in place and perform cystography 2 weeks later. When the cystogram does not define extravasation, the suprapubic tube may be removed.

For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center and Procedures Center. Also, see eMedicine's patient education articles Intravenous Pyelogram, Cystoscopy, and Foley Catheter.

Potential complications associated with repairing large vesicovaginal fistulas include the development of transient vesicoureteral reflux or de novo detrusor instability. Reflux and bladder spasms resolve spontaneously with anticholinergic therapy.

If a large fistula is present, the nearby ureteral orifice is at risk of becoming obstructed during the repair. If this is the case, the ureter must be reimplanted during the initial operation. The most feared complication is the recurrence of fistula. If this occurs, a proper waiting period is advised. The subsequent repair should be performed with a Martius flap, peritoneal interposition, or gracilis muscle flap.

Complications associated with ureterovaginal fistula repair include urinary extravasation and ureteral stricture formation. Persistent urinary leak can be treated with percutaneous nephrostomy drainage, ureteral stent(s), and/or Foley catheter drainage. For short ureteral strictures, minimally invasive endoscopic treatments can be used.

The success rate of vesicovaginal and ureterovaginal fistula repair approaches 90% at first attempt and approaches 100% after a second attempt. However, realize that the second operation is more extensive and more complex than the first operation. Often, the surgical approach must be changed, and additional procedures, such as Martius flap, peritoneal flap, omental flap, or gracilis muscle flap, must be performed in combination with the fistula repair. For complex repairs involving radiated tissues, the success rate is less than 90%, but, for experienced surgeons, the outcome remains highly successful.

Keep in mind that the first operation is the best one. Any attempts at further surgical repair after an initial failed approach may yield unsatisfactory results. It is highly recommended to seek out a surgeon who is adept at this type of reconstruction and performs this in a high volume in an attempt to maximize outcomes and to minimize further potential morbidity.

The following factors remain controversial: (1) the timing of operative repair, ie, early versus delayed; (2) the surgical approach, ie, transvaginal versus transabdominal; (3) the excision of the fistula, ie, to excise versus not to excise; and (4) the use of local tissue flaps, ie, Martius flap, gracilis muscle, or other.

Resolution of these controversies depends on the preference and clinical experience of the surgeon. For uncomplicated fistulas, early repair using a transvaginal approach without excision of the fistulous tract is recommended. Local tissue flaps or myocutaneous flaps are not routinely used, except in situations of complex or recurrent fistula formation.

As an alternative to open surgical repair, some authors have reported encouraging results using fibrin glue as an effective sealant for vesicovaginal fistulas. Thus, endoscopic injection of fibrin glue may be a minimally invasive treatment alternative for correction of selected vesicovaginal fistulas.^[6]