Vesicovaginal and Ureterovaginal Fistula Treatment & Management

Updated: Dec 18, 2018
  • Author: Sandip P Vasavada, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Treatment

Approach Considerations

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. [7]

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.

Vesicovaginal and ureterovaginal fistulas recognized within 3-7 days after the causative operation may be repaired immediately via a transabdominal or transvaginal approach. Fistulas identified after 7-10 days postoperatively should be monitored periodically until all signs of inflammation and induration have resolved. Before embarking on fistula repair, the fistula tract should be well epithelialized and the vaginal wall should be soft and supple.

The traditional approach has been to wait at least 3-4 months before attempting fistula closure. However, this philosophy has been challenged. Some surgeons have successfully closed the fistula with or without using a tissue interposition, such as Martius flap or peritoneal flap, without waiting 3-4 months. The main issue being that satisfactory tissue quality and healing must be evident or the operative intervention may not be satisfactory.

Patients with a history of multiple failed repairs, patients with associated enteric fistula with pelvic phlegmon, or patients with a history of pelvic radiation should not undergo fistula repair for at least 6-8 months.

The presence of an active vaginal infection or persistent inflammatory or malignant process at the fistula site is a contraindication to surgical repair. Historically, the transvaginal approach has been contraindicated for supratrigonal fistulas. However, this is no longer an absolute contraindication. Whether to use a transabdominal or transvaginal approach is now dictated by the surgeon's experience and preference and ease of access to the fistula site.

In the past, surgical repair of any vesicovaginal fistula before 3 months was discouraged for fear of recurrence and inadequate healing. However, the principle of delayed repair is no longer absolute. The timing of fistula repair is now dictated by the nature of the local tissues around the fistula site. Surgical repair may commence if no vaginal infection is present and if the inflammatory process at the fistula site has resolved.

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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. [8]

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. [9, 10]  However, there have been no large studies that compare transvaginal repair to minimally invasive transabdominal approaches. [11]

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.

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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

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. [12, 13] Adherence to similar principles as in open abdominal repair with use of interposition grafts and layered closures has produced reports of successful repair. Often, there is a fair amount of scarring and extravasation in the area of the fistula, which may affect the quality of the repair. Nonetheless, the use of MIS technology for this type of repair is increasing. [11]

 

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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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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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Long-Term Monitoring

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.

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