Bladder Operations
Kenneth D. Hatch
GENERAL PRINCIPLES
Definition
A vesicovaginal fistula is an abnormal connection between the bladder and the vagina.
It occurs most often after pelvic surgery but may be a complication of radiation or a result of invading cancer.
Postoperative vesicovaginal fistulas generally develop within the first 10 days following hysterectomy. The majority occur after abdominal hysterectomy.
Urinary diversion techniques for radiation or cancer-related fistulas are discussed in Chapter 24.
This chapter will discuss repair of uncomplicated fistulas.
Differential Diagnosis
Lymph drainage from the vaginal cuff after radical hysterectomy and pelvic node dissection may reach as high as 500 cc/day and be mistaken for urine. Obtain a sample of the fluid from the vagina and perform a creatinine level. Lymph fluid will have a creatinine similar to the patient’s serum creatinine level. Urine will have a creatinine more than three times higher.
Ureterovaginal fistula should also be considered. Place a Foley catheter into the bladder and instill sterile water while watching the vaginal apex. I use a colposcope to view the vaginal cuff, as it is easier to see small amounts of fluid and a small fistula. If no water is seen, then empty the bladder and instill water that is stained with blue dye. Place a tampon and let the patient walk around for 30 minutes. If the tampon is stained with blue dye, there is likely to be a small vesicovaginal fistula. Be sure the patient is not having urinary incontinence and leaking dyed urine from the urethra.
If it is uncertain whether there is a ureteric fistula, a CT urogram should be ordered. This will also help to define whether a complex fistula involving both the ureter and the bladder is present.
Anatomic Considerations
Vesicovaginal fistulas that occur after simple hysterectomy are usually above the trigone and small and can be repaired without interfering with ureteral function.
In developed countries, obstetrical injuries from obstructed labor are very rare. More common is a postcesarean section fistula, especially if the pregnancy was complicated by a placenta previa with significant bleeding.
The fistulas developing from radical hysterectomy are more difficult. The bladder has been dissected to the trigone in most patients during the operation, leading to fistulas in the trigone area.
The patient who has had previous radiation therapy and then undergoes a hysterectomy will have up to a 50% risk of vesicovaginal fistula. The fistulas will be a result of radiation fibrosis with very poor vascularization. These fistulas are very difficult to correct, leading to a urinary diversion as the only option.
Nonoperative Management
Vesicovaginal fistulas following simple hysterectomy will heal with simple bladder drainage in 11.7% to 39% of the cases.
Catheters inserted within 3 weeks of the causative surgery will heal in a higher percentage than after 6 weeks.
IMAGING AND OTHER DIAGNOSTICS
CT urogram is the preferred imaging to determine whether the fistula is complex or simple.
PREOPERATIVE PLANNING
Complete evaluation of the urogram will allow one to counsel the patient concerning the type of surgery, length of catheter drainage, complications, and time of recovery.
The timing of the surgical intervention has been a subject of debate. The historical standard was to wait several months to allow tissue to heal and infection to subside. More recent experience is to repair the fistula after a conservative trial of catheter drainage which may be 3 to 6 weeks.
If one or both ureters are involved in the fistula, then a percutaneous nephrostomy will need to be performed while acute inflammation is resolved.
SURGICAL MANAGEMENT
An abdominal repair is indicated if the patient has failed previous vaginal repairs, needs to have a ureter reimplanted, needs debridement of necrotic tissue, or has poor access to the vagina (see Video 31.1
).
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