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Vesicovaginal and Ureterovaginal Fistula Treatment & Management

  • Author: Sandip P Vasavada, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
 
Updated: Dec 01, 2015
 

Medical Therapy

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.[5]

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. Small fistulas have a higher likelihood of healing with catheterization. Furthermore, in the rare series of patients who were successfully managed with fulguration, optimal success was achieved in patients who had longer and narrower fistulas, as opposed to short and wide ones.

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Surgical Therapy

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. Increasingly, this is being done now with minimally invasive techniques laparoscopically or robotically.[6]

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.

This patient developed a supratrigonal vesicovagin This patient developed a supratrigonal vesicovaginal fistula immediately over the right ureteral orifice after transabdominal hysterectomy for uterine fibroids. The right ureteral orifice has been cannulated with a ureteral catheter to prevent injury to the ureteral orifice during the fistula repair. A Foley catheter has been inserted into the bladder. A transvaginal repair was performed.
Percutaneous suprapubic tube is placed prior to re Percutaneous suprapubic tube is placed prior to repair of a supratrigonal vesicovaginal fistula.
The supratrigonal vesicovaginal fistula site is ma The supratrigonal vesicovaginal fistula site is marked out.
Supratrigonal vesicovaginal fistula. Isotonic sodi Supratrigonal vesicovaginal fistula. Isotonic sodium chloride is injected into the anterior vaginal wall to facilitate hydrodissection.
Supratrigonal vesicovaginal fistula. A J-shaped in Supratrigonal vesicovaginal fistula. A J-shaped incision is made, and the anterior vaginal wall is dissected off proximally and distally to the fistula. The fistula site is not excised. A generous flap is created anteriorly and posteriorly to the fistula site. Surgical sutures have been placed in the fistula to close the site.
Supratrigonal vesicovaginal fistula. Surgical sutu Supratrigonal vesicovaginal fistula. Surgical sutures are tied, and the fistula is closed.
Supratrigonal vesicovaginal fistula. Reinforcing t Supratrigonal vesicovaginal fistula. Reinforcing tissue layers are used to cover up the fistula site in a nonoverlapping fashion. In this case, peritoneum followed by pubocervical fascia was used.
Supratrigonal vesicovaginal fistula. Vaginal wall Supratrigonal vesicovaginal fistula. Vaginal wall is closed.
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Preoperative Details

Informed consent discussions should include potential risks, including, but not limited to, ureteral injury, bladder injury, bowel 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.

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Intraoperative Details

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 [7, 8]

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.

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Postoperative Details

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.

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Follow-up

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, see eMedicineHealth's patient education articles Intravenous Pyelogram, Cystoscopy, and Foley Catheter.

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Complications

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.

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Outcome and Prognosis

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.

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Future and Controversies

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.[9]

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Contributor Information and Disclosures
Author

Sandip P Vasavada, MD Physician, Associate Professor of Surgery, Cleveland Clinic Lerner College of Medicine, Center for Female Urology and Genitourinary Reconstructive Surgery, The Glickman Urological and Kidney Institute; Joint Appointment with Women's Institute, Cleveland Clinic

Sandip P Vasavada, MD is a member of the following medical societies: American Urological Association, Engineering and Urology Society, American Urogynecologic Society, International Continence Society, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic, Allergan and Axonics<br/>Received ownership interest from NDI Medical, LLC for review panel membership; Received consulting fee from allergan for speaking and teaching; Received consulting fee from medtronic for speaking and teaching; Received consulting fee from boston scientific for consulting.

Coauthor(s)

Raymond R Rackley, MD Professor of Surgery, Cleveland Clinic Lerner College of Medicine; Staff Physician, Center for Neurourology, Female Pelvic Health and Female Reconstructive Surgery, Glickman Urological Institute, Cleveland Clinic, Beachwood Family Health Center, and Willoughby Hills Family Health Center; Director, The Urothelial Biology Laboratory, Lerner Research Institute, Cleveland Clinic

Raymond R Rackley, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Mark Jeffrey Noble, MD Consulting Staff, Urologic Institute, Cleveland Clinic Foundation

Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, SWOG

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Additional Contributors

Michael Grasso, III, MD Professor and Vice Chairman, Department of Urology, New York Medical College; Director, Living Related Kidney Transplantation, Westchester Medical Center; Director of Endourology, Lenox Hill Hospital

Michael Grasso, III, MD is a member of the following medical societies: Medical Society of the State of New York, National Kidney Foundation, Society of Laparoendoscopic Surgeons, Societe Internationale d'Urologie (International Society of Urology), American Medical Association, American Urological Association, Endourological Society

Disclosure: Received consulting fee from Karl Storz Endoscopy for consulting.

References
  1. Hodges AM. Vesico-vaginal fistula associated with uterine prolapse. Br J Obstet Gynaecol. 1999 Nov. 106(11):1227-8. [Medline].

  2. Kim JH, Moore C, Jones JS, et al. Management of ureteral injuries associated with vaginal surgery for pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2006 Sep. 17(5):531-5. [Medline].

  3. Hampel C, Neisius A, Thomas C, Thüroff JW, Roos F. [Vesicovaginal fistula. Incidence, etiology and phenomenology in Germany]. Urologe A. 2015 Mar. 54 (3):349-58. [Medline].

  4. Binstock MA, Semrad N, Dubow L, Watring W. Combined vesicovaginal-ureterovaginal fistulas associated with a vaginal foreign body. Obstet Gynecol. 1990 Nov. 76(5 Pt 2):918-21. [Medline].

  5. Ghoniem GM, Warda HA. The management of genitourinary fistula in the third millennium. Arab J Urol. 2014 Jun. 12 (2):97-105. [Medline].

  6. Sharma S, Rizvi SJ, Bethur SS, Bansal J, Qadri SJ, Modi P. Laparoscopic repair of urogenital fistulae: A single centre experience. J Minim Access Surg. 2014 Oct. 10 (4):180-4. [Medline].

  7. Abdel-Karim AM, Moussa A, Elsalmy S. Laparoendoscopic Single-site Surgery Extravesical Repair of Vesicovaginal Fistula: Early Experience. Urology. 2011 Sep. 78(3):567-71. [Medline].

  8. Gupta NP, Mishra S, Hemal AK, Mishra A, Seth A, Dogra PN. Comparative analysis of outcome between open and robotic surgical repair of recurrent supra-trigonal vesico-vaginal fistula. J Endourol. 2010 Nov. 24(11):1779-82. [Medline].

  9. Morita T, Tokue A. Successful endoscopic closure of radiation induced vesicovaginal fistula with fibrin glue and bovine collagen. J Urol. 1999 Nov. 162(5):1689. [Medline].

  10. Akman RY, Sargin S, Ozdemir G, Yazicioglu A, Cetin S. Vesicovaginal and ureterovaginal fistulas: a review of 39 cases. Int Urol Nephrol. 1999. 31(3):321-6. [Medline].

  11. Cohen BL, Gousse AE. Current techniques for vesicovaginal fistula repair: surgical pearls to optimize cure rate. Curr Urol Rep. 2007 Sep. 8(5):413-8. [Medline].

  12. Comiter CV, Vasavada SP, Raz S. Repair of Vesico-Vaginal Fistula. Atlas of the Urologic Clinics of North America. 2000. 8(1):133-139.

  13. Demirel A, Polat O, Bayraktar Y, Gül O, Okyar G. Transvesical and transvaginal reparation in urinary vaginal fistulas. Int Urol Nephrol. 1993. 25(5):439-44. [Medline].

  14. Elkins TE. Fistula surgery: past, present and future directions. Int Urogynecol J Pelvic Floor Dysfunct. 1997. 8(1):30-5. [Medline].

  15. Hsu TH, Rackley RR, Abdelmalak JB, Madjar S, Vasavada SP. Novel technique for combined repair of postirradiation vesicovaginal fistula and augmentation ileocystoplasty. Urology. 2002 Apr. 59(4):597-9. [Medline].

  16. Iselin CE, Aslan P, Webster GD. Transvaginal repair of vesicovaginal fistulas after hysterectomy by vaginal cuff excision. J Urol. 1998 Sep. 160(3 Pt 1):728-30. [Medline].

  17. Nesrallah LJ, Srougi M, Gittes RF. The O'Conor technique: the gold standard for supratrigonal vesicovaginal fistula repair. J Urol. 1999 Feb. 161(2):566-8. [Medline].

  18. Rackley RR, Appell RA. Vesicovaginal Fistula: Current Approach. American Urological Association: Update Series. 1998. 17(21):162-7.

  19. Sims JM. On the treatment of vesico-vaginal fistula. 1852. Int Urogynecol J Pelvic Floor Dysfunct. 1998. 9(4):236-48. [Medline].

  20. Smith GL, Williams G. Vesicovaginal fistula. BJU Int. 1999 Mar. 83(5):564-9; quiz 569-70. [Medline].

  21. Soong Y, Lim PH. Urological injuries in gynaecological practice--when is the optimal time for repair?. Singapore Med J. 1997 Nov. 38(11):475-8. [Medline].

 
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Vaginal view of vesicovaginal fistula.
Cystoscopic view of vesicovaginal fistula.
Cystogram of vesicovaginal fistula. Note the contrast extravasating from the bladder into the vaginal canal.
This patient developed a supratrigonal vesicovaginal fistula immediately over the right ureteral orifice after transabdominal hysterectomy for uterine fibroids. The right ureteral orifice has been cannulated with a ureteral catheter to prevent injury to the ureteral orifice during the fistula repair. A Foley catheter has been inserted into the bladder. A transvaginal repair was performed.
Percutaneous suprapubic tube is placed prior to repair of a supratrigonal vesicovaginal fistula.
The supratrigonal vesicovaginal fistula site is marked out.
Supratrigonal vesicovaginal fistula. Isotonic sodium chloride is injected into the anterior vaginal wall to facilitate hydrodissection.
Supratrigonal vesicovaginal fistula. A J-shaped incision is made, and the anterior vaginal wall is dissected off proximally and distally to the fistula. The fistula site is not excised. A generous flap is created anteriorly and posteriorly to the fistula site. Surgical sutures have been placed in the fistula to close the site.
Supratrigonal vesicovaginal fistula. Surgical sutures are tied, and the fistula is closed.
Supratrigonal vesicovaginal fistula. Reinforcing tissue layers are used to cover up the fistula site in a nonoverlapping fashion. In this case, peritoneum followed by pubocervical fascia was used.
Supratrigonal vesicovaginal fistula. Vaginal wall is closed.
 
 
 
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