Presentation and Investigation
Vaginal Repair of Vesicovaginal Fistula
Repair of Urethrovaginal Fistula and Urethral Reconstruction
Abdominal Repair of Vesicovaginal or Ureterovaginal Fistulas
Laparoscopic and Robotic Repair of Vesicovaginal Fistula
Postoperative Bladder Drainage
The earliest evidence of a vesicovaginal fistula was reported by in the mummified remains of Queen Henhenit, one of the wives of King Mentuhotep II of Egypt (11th Dynasty, c. 2050 BC). In his dissection of the mummy at the Cairo School of Medicine in 1923, Derry noted a large vesicovaginal fistula in the presence of a severely contracted pelvis; he concluded that the fistula was a consequence of obstructed labor. Hippocrates (460-377 BC) recognized the problem of urinary incontinence after confinement but offered no clue as to its cause. In his textbook, Al Kanoun , the celebrated Persian physician Avicenna (980-1037) was the first to recognize that urinary incontinence after difficult labor was caused by communication between the bladder and vagina.
No further reference to vesicovaginal fistula appeared until 1597, when both Felix Platter of Basle and Luiz de Mercado of Valladolid separately reviewed the problem but offered no constructive therapeutic advice. states that de Mercado first used the term fistula instead of the usual term ruptura .
In 1663, van Roonhuyse of Amsterdam published Medico-Chirurgical Observations About the Infirmities of Women . Commonly thought of as the first textbook on operative gynecology, this text was translated into English in 1676. The fourth chapter is titled, “Rupture of the Bladder: The Signs, Causes, Prognostics and Cure Thereof.” van Roonhuyse proposed a revolutionary surgical technique for the closure of vesicovaginal fistulae based on the following principles: lithotomy position, good exposure of the fistula with a vaginal speculum, marginal denudation of the fistula edge, use of a fine scissors or knife, and approximation of the denuded edges with “stitching needles of stiff swans’ quills.” No record has been found that van Roonhuyse operated on patients using this technique. In 1752, a medical text by Swiss physician Fatio was published. In it were recorded two successful fistula repairs performed by Fatio in 1675 and 1684, using van Roonhuyse’s technique.
In 1687, Volter suggested that sutures should be interrupted, and he introduced the use of a retention urinary catheter. During this same period, claimed complete cures, using cautery. In later years, Monteggia, Dupuytren, and others also recommended cautery.
The nineteenth century was the dawn of a new era in the surgical treatment of vesicovaginal fistulas. In 1834, successfully repaired a small number of fistulas using pedicled skin flaps ( autoplastie vaginale par la methode indienne ). A second technique ( autoplastie par glissment ou par locomotion ) later enabled him to close a greater number of fistulas. This technique involved dissecting the bladder from the cervix and vagina with the additional use of curved releasing incisions in the vagina to facilitate mobilization and closure without tension.
In a letter to the Boston Medical and Surgical Journal in August 1838, of Virginia stated that he had repaired a vesicovaginal fistula about the size of a half-dollar piece using lead wire, with good results. This was the first successful repair in the United States.
On June 21, 1849, in an eight-bed infirmary on Perry Street in Montgomery, Alabama, operated on a young slave woman named Anarcha for the thirtieth time. Using the genupectoral position, a bent pewter spoon as a vaginal speculum, and reflected light from a mirror, Sims denuded the fistula edge, closing the defect in one layer with fine silver wire applied with leaden bars and perforated shot. On the eighth day, Sims reexamined the patient and noted that the wound was well healed. In 1852, he published his classic paper “On the Treatment of Vesicovaginal Fistula” in the American Journal of Medical Sciences . He deprecated both cautery as advocated by Dupuytren for small fistulas and obturation of the vulva as practiced by Vidal de Cassis (whereby the bladder and vagina are converted into a common reservoir for urinary and menstrual discharge). Sims insisted on the liberal use of opium for perioperative analgesia and stressed the importance of postoperative bladder drainage with a urethral catheter. He later designed a silver sigmoid-shaped, self-retaining catheter for this purpose. In 1853, Sims moved to New York and, 2 years later, became chief surgeon in the newly built Woman’s Hospital, where he was later joined by a brilliant young assistant, Thomas Addis Emmet. Sims and Emmet worked closely together, with Emmet perfecting many of his mentor’s techniques.
In his text, Vesico-Vaginal Fistula from Parturition and Other Causes with Cases of Recto-Vaginal Fistula (1868), dedicated to Sims, Emmet reported on 270 consecutive patients treated in the Woman’s Hospital: 200 were cured, 65 were improved, and 5 were considered incurable. Emmet eventually succeeded Sims at the Woman’s Hospital. His greatest contribution to obstetric care was arguably his insistence that frequent catheterization of the bladder in labor, together with the judicious use of forceps for second-stage delay, would prevent the majority of labor-related vesicovaginal fistulas.
In 1861, Collis of Dublin advocated the flap-splitting technique, whereby the anterior vaginal wall is widely dissected from the bladder with separate closure of the two defects. This method was later popularized by in Berlin.
In the 1880 and 1890s, Trendelenburg and von Dittel reported failed attempts at fistula repair, using extraperitoneal and suprapubic approaches, respectively. also devised a parasacral incision, which permitted better access to high fistulas, particularly when associated with vaginal stenosis.
The discovery of antibiotics and the development of general and regional anesthesia contributed significantly to the surgical treatment of vesicovaginal fistulas in the twentieth century. Other notable milestones included urethral reconstruction using lateral vaginal flaps and labium minus grafts ( ); suprapubic intraperitoneal repair of posthysterectomy, high vesicovaginal and rectovaginal fistulas ( ); partial colpocleisis for posthysterectomy vesicovaginal fistulas ( ); urethral reinforcement using pelvic floor muscles ( ); pedicled gracilis muscle flap ( ); bulbocavernosus flaps ( ); abdominal repair technique of vesicovaginal fistulas involving bisection of the bladder (O’Conor and Sokol, 1951); pubococcygeus, bulbocavernosus, rectus abdominis, and gracilis flaps ( ); the use of pedicled omental flaps in the repair of extensive vesicovaginal fistulas ( ); and urethral reconstruction ( ). Knowledge of effective repair of genitourinary fistulas became more widely disseminated with the publication of The Vesico-Vaginal Fistula ( ). Greater international attention was brought to the immense problem of genitourinary fistulas in developing countries with the foundation of the Second Fistula Hospital in Addis Ababa, Ethiopia, in 1975, and the report of 1789 fistulas repaired during an 11-year period from Nigeria ( ).
Epidemiology and Etiology
Most of the literature on the etiology, diagnosis, management, and prevention of lower urinary tract fistulas consist of expert opinions, case series, or cohort studies, with few randomized controlled trials. Many of the studies are based on experiences with obstetric fistulas, which primarily occur in women in developing countries. Research in these environments is often limited by resource scarcity and plagued with short-term follow-up periods. It is important to review the information presented in this chapter with these limitations in mind.
Lower urinary tract fistulas occur secondary to a defect or vulnerability in the wound-healing process. Wounded tissue undergoes four phases of healing: coagulation, inflammation, fibroplasia, and remodeling. These phases do not occur independently but overlap one another. During the fibroplastic phase, collagen is laid down, reaching its peak on the seventh day after injury and continuing for 3 weeks. Between the first and third weeks, healing is most vulnerable to hypoxia, ischemia, malnutrition, radiation, and chemotherapy, so this is the time when most fistulas present. Conditions known to interfere with wound healing are associated with an increased risk of fistula formation, including diabetes mellitus, smoking, infection, peripheral vascular disease, chronic steroid use, malignancy, and previous tissue injury.
The vast majority of vesicovaginal fistulas that occur in women in developing countries are caused by obstetric trauma. Obstetric fistula occurs when women experience prolonged, obstructed labor without access to emergency obstetric care allowing cesarean section. Prolonged pressure of the fetal head within the maternal pelvis results in necrosis of the pelvic tissue trapped between the fetal head and the maternal bony pelvis, which leads to tissue breakdown and eventual fistula formation. Of 377 cases reported by from Ibadan, Nigeria, 369 (97.9%) were obstetric and 343 were a consequence of obstructed labor.
Obstetric fistula is estimated to affect 2–3.5 million women in the developing world including Sub-Saharan Africa and South Asia. Prevalence estimates of obstetric fistula from demographic health surveys and other population-based surveys range widely from 0.16% to 4.7% in Sub-Sahara Africa and 0.08% to 2.7% in South Asia. However, the accuracy of these figures is unknown as they are based on expert opinions or extrapolation of expert experiences from hospital-based settings. Additionally, many of the population-based surveys are limited by the use of different, unvalidated, case-defining questions without confirmatory examinations.
Women at risk for and with obstetric fistula commonly live in rural areas, deliver at home without access to established medical care, and may go unnoticed by public health officials or health care providers. Many women are unaware that the condition is treatable and thus lack appropriate care due to social isolation as a result of their urine leakage symptoms. Poverty, lack of knowledge, long travel distances, and waiting lists deter women from traveling to major centers and undergoing care. As a result, many of these women live with fistula symptoms for many years and face abandonment by their families and isolation from society. A study of five countries in Southeast Asia found that 62% to 92% of afflicted women were divorced from their husbands and rejected from society. Studies from Africa also demonstrated high divorce rates, with a high prevalence (73%-90%) of psychological conditions such as depression.
The risk factors that lead to obstetric fistula development are incompletely understood. Most of the published studies are from Africa, from hospital-based descriptive case series, and may have limited generalizability. The commonly accepted prototype of the fistula patient is a poor and malnourished young woman of limited formal education from a rural area, who attempts a home delivery without a trained birth attendant, which results in prolonged, obstructed labor and delivery of a stillbirth infant. In various hospital-based case series, the mean age of women with obstetric fistula ranges from 19 to 35 years,and in approximately half (31%-81%) of women, the fistula developed during their first delivery. Although traditional practices such as female circumcision have not been shown to be associated with an increased risk for fistula development, other traditional practices such as Gishiri cutting (i.e., longitudinal cuts in the vagina, made for various obstetric and gynecologic disorders) and the use of traditional postpartum vaginal caustic agents, may also be associated with fistula development. Several case series have documented short stature in women with fistulas, with average heights of 149 to 156 cm, and smaller foot sizes. Other possible anthropomorphic risk factors include reduced pelvic dimensions (caused by early childbearing, chronic disease, malnutrition, and rickets). Even after presenting to a hospital, a woman may still develop a fistula caused by trauma from forceps or other instruments used to deliver stillborn infants or perform surgical abortion. Vesicovaginal fistulas can follow cesarean delivery or peripartum hysterectomy, particularly in the presence of distorted anatomy (e.g., large fibroids with massive hemorrhage) or if the procedure is being performed by an inexperienced surgeon.
In developed countries, the major cause of genitourinary fistulas is abdominal surgery and, more recently, laparoscopic and robotic surgery, especially when hysterectomy is performed. In the United States, vesicovaginal fistulas are caused by benign gynecologic surgery (80%); obstetric events (10%); surgery for malignancies of the cervix, uterus, or ovary (5%); and pelvic radiotherapy (5%). Four-fifths of postsurgical fistulas in the developing world are the result of operations performed by obstetrician-gynecologists, and the remaining fifth is divided among urologists, colorectal, vascular, or general surgeons.
Predisposing risk factors for lower urinary tract fistulas include intraoperative cystotomies that extend into the trigone or bladder neck, hysterectomy for a large uterus, intraoperative blood loss greater than 1000 mL, and tobacco use ( ). Other risk factors include prior pelvic irradiation, pelvic adhesions, endometriosis, previous pelvic operations including cesarean section, history of pelvic inflammatory disease, diabetes mellitus, and concurrent infection. reviewed 303 cases of genitourinary fistulas in women treated at the Mayo Clinic. Gynecologic surgery was responsible for 82% of the fistulas, obstetric events for 8%, radiation therapy for 6%, and trauma or fulguration for 4%. Seventy-four percent of fistulas resulted from gynecologic surgery for benign conditions such as fibroids, dysfunctional uterine bleeding, prolapse, incontinence, and endometriosis. Fistulas occurred after surgery for malignancy in 42 patients (14%). This review included 53 patients with urethrovaginal fistulas, of whom 10 also had a vesicovaginal fistula. Antecedent events included vaginal surgery for incontinence or cystocele, urethral diverticulum repair, treatments for gynecologic cancer, and the use of forceps.
The reported incidence of vesicovaginal fistula after hysterectomy is approximately 1 in 1300 surgeries. In a study in Finland, reviewed the incidence of urinary tract injury on a national scale. During the study period, 62,379 hysterectomies were performed and 142 urinary tract injuries wer reported. The incidence of bladder injury was 1.3 per 1000 hysterectomies. The incidence of vesicovaginal fistula was 1 in 1200 procedures: 1 in 455 after laparoscopic hysterectomy, 1 in 958 after total abdominal hysterectomy, and 1 in 5636 after vaginal hysterectomy. The risk of ureteral injury was greater with laparoscopic procedures than with open or vaginal procedures.
Bladder and urethral injury are also known complications of anti-incontinence procedures and repair of pelvic organ prolapse. A recent increase has occurred in these types of fistulas, mirroring the increased popularity of numerous synthetic materials used during such procedures. reviewed cases in which sling removal is required after placement of a woven polyester sling treated with pressure-injected bovine collagen (ProteGen, Boston Scientific, Neddick, MA). Thirty-four women in a 2-year period required sling removal, and six had developed urethrovaginal fistulas. There are also case reports of urethrovaginal fistula development after urethral diverticulectomy and periurethral injection of a bulking agent.
Radiation therapy, used for carcinoma of the cervix or other pelvic malignancies, may rarely result in fistula formation. Healthy tissues of the anterior vaginal wall tolerate radiation doses as high as 8000 rad. Fistulas may first appear during the course of radiotherapy, usually from necrosis of the tumor itself, or after treatment is completed. Late fistulas arise secondary to endarteritis obliterans, usually within the first 2 years, but they can occur anytime from 6 months to 5 years after treatment completion. In planning a repair of a fistula after radiotherapy, ruling out recurrent malignancy with biopsy of the fistula margins is essential. Because of decreased vascularity of the adjacent tissue, there is usually extensive fibrosis, making primary surgical closure extremely difficult with a high failure rate. For this reason, many of these patients will have their fistula addressed temporarily with percutaneous nephrostomy tubes, followed by a urinary diversion procedure.
Most genitourinary fistulas that result from gynecologic surgery occur secondary to urinary tract injuries. This underscores the need to strongly consider routine cystoscopy to assess for bladder and ureteral integrity after hysterectomy, prolapse, or incontinence surgeries, as well as any other pelvic surgery in which the lower urinary tract may be at risk. Bladder injuries resulting from total abdominal hysterectomy occur primarily during blunt dissection of the bladder off the lower uterine segment. Devascularization or an unrecognized tear in the posterior bladder wall subsequently results in tissue ischemia, necrosis, and fistula formation.
Vesicouterine and vesicocervical fistulas are rare and are usually complications of obstetrical surgery, occurring most frequently after a cesarean section.
Vesicovaginal and urethrovaginal fistulas are best classified as being either simple or complicated. Complicated urethrovaginal fistulas are those that involve the proximal urethra and bladder neck and/or are radiation induced. Complicated vesicovaginal fistulas include previous radiation, pelvic malignancy, compromised vaginal length, larger than 3 cm, and involving the trigone.
Presentation and Investigation
Patients with genitourinary fistulas present in many ways. Gross hematuria or abnormal intraperitoneal fluid accumulation (urinoma) noted during or after surgery should raise suspicion of an unrecognized urinary tract injury and dictates immediate investigation. In the postoperative period, symptoms may develop after an interval of days, weeks (surgical and obstetric fistulas), months, or even years (radiotherapy-related fistulas). Postsurgical fistulas usually present 7 to 30 days after surgery. Most patients have continuous urinary leakage or persistent watery vaginal discharge, which is leakage of urine from the vagina. If the fistula is very small, leakage may be intermittent, occurring only at maximal bladder capacity or with particular body positions. Other signs and symptoms include unexplained fever, hematuria, recurrent cystitis or pyelonephritis, vaginal pain, suprapubic pain, flank pain, and abnormal urinary stream.
The initial evaluation of all patients with symptoms of genitourinary fistulas starts with a complete physical examination. A thorough speculum examination of the vagina may reveal the source of fluid, which can then be collected; measurement of its urea concentration may identify it as urine. Urine should be examined microscopically and cultured, and appropriate treatment should be instituted for infection. If leakage is not demonstrated, the bladder is filled to maximum capacity and provocative maneuvers, such as Valsalva or manual pressure over the bladder, are used to reproduce and confirm the patient’s symptoms. Urethrovaginal fistulas are usually easily diagnosed on physical examination. Further office evaluation, cystourethroscopy, and imaging studies such as intravenous urography permit the physician to localize the fistula and exclude or identify other types of urinary tract injury.
In all cases of suspected urinary tract fistula, it is important to evaluate for both bladder and ureteral involvement, as ureteral compromise has been reported in up to 12% of vesicovaginal fistula. This can usually be accomplished using basic office tests. Although the sensitivity and specificity of the tampon test are unknown, instillation of methylene blue or indigo carmine into the bladder typically stains vaginal swabs or tampons in the presence of a vesicovaginal fistula. If this test is not diagnostic, a transurethral Foley catheter should be placed to prevent any staining of the distal tampon from leakage of fluid through the external urethral meatus. Unstained but wet swabs may indicate a ureterovaginal fistula. Once a vesicovaginal fistula has been excluded, intravenous indigo carmine can be given and the tampon observed for blue staining to evaluate for a ureterovaginal fistula. Intravenous methylene blue must be used with caution because of the risk of methemoglobinemia, a rare but serious complication. Alternatively, if there is no intravenous access, oral phenazopyridine can be administered, which will cause orange-colored urine, and the tampon is observed for orange staining.
There is no clear consensus on the optimal imaging modality that should be performed to diagnose and determine the extent of a urinary tract fistula. In developed countries, radiologic studies are recommended in most cases and usually include intravenous urography, cystoscopic retrograde urography, or voiding cystourethrography. Renal ultrasound may miss up to 20% of ureteral injuries. A Tratner catheter may be useful in cases of suspected urethrovaginal fistula. Hysterosalpingography may be useful in cases of vesicouterine fistula. Helical computed tomography scanning and magnetic resonance imaging may be useful in cases where the fistulas are not clearly identified with other imaging studies.
Cystourethroscopy is not always necessary but is helpful to further characterize the fistula size, number, and location within the bladder; associated lesions; and condition of surrounding tissue. Key observations include the fistula’s proximity to the bladder neck, urethral sphincter, and ureteral orifices, as well as the presence of tissue edema, slough, infection, induration, stones, foreign material (sutures, mesh), and scarring. Water or normal saline cystoscopy may be impossible with large fistulas; in such cases, a Foley catheter may be placed within the fistula tract to decrease leakage. Bladder biopsy should be performed as needed if there is a suspicion of malignancy or lesions suspicious for infectious agents such as tuberculosis, contributing to the development of fistula. Bladder calculi and nonabsorbable sutures should be removed.
Various conservative or minimally invasive therapies are available for vesicovaginal and ureterovaginal fistulas, although the true viability and success of these treatment modalities are unknown. The most conservative treatment of a vesicovaginal fistula is simply prolonged bladder drainage with a Foley catheter. In a retrospective analysis of 1716 women with obstetric vesicovaginal fistula, continuous catheter drainage resulted in spontaneous fistula closure in 15% of patients. Spontaneous closure occurred in 50% to 60% of patients with fistulas that were ≤2 cm and who presented for care no later than 4 to 6 weeks after delivery ( ). Because it may be logistically difficult to repair a vesicovaginal fistula immediately and/or there may be tissue factors such as necrosis preventing immediate repair, it is reasonable to proceed with a trial of continuous bladder drainage for 4 weeks in fistulas that are <1 cm in diameter and unrelated to malignancy or radiation, as these fistulas may spontaneously resolve in 12% to 80% of cases.
Other less invasive options include curetting, electrofulguration, and laser ablation to deepithelialize the fistula tract and allow it to spontaneously heal while the bladder is continuously drained. Once the fistula tract has been deepithelialized, agents such as fibrin glue and collagen have been successfully injected into the fistula tract to promote closure. Most of these studies report successful treatment in fistulas that are small (≤5 mm), resulting from gynecologic surgery. There have also been reports of using these methods to successfully close radiation-induced fistula. More recently, agents such as cyanoacrylic glue administered percutaneously, endoscopically, or vaginally have been used in a series of 13 urinary tract fistulas of differing etiology with 85% success rates after a mean follow-up period of 35 months ( ). The failures were in fistulas that were larger (>1 cm). Nonsurgical attempts at fistula closure should always be attempted in a patient who has a small fistula, who is a poor surgical candidate, or who desires to first try less invasive options.
The recommended initial management of a ureterovaginal fistula is ureteral stenting. Stenting is more successful when performed sooner rather than later; in one study, 82% of attempts in patients whose fistulas were <1 month old were successful, compared with 33% of attempts with older fistulas.
Stents are usually made of Silastic, with the length measured in centimeters and the diameter measured in French units, with single-J or double-J ends. Double-J stents are preferred because of reduced risk of migration out of the renal pelvis, and the distal J tip in the bladder is atraumatic. Ureteral stenting is best accomplished in a suite that can accommodate anesthesia, fluoroscopy, and cystoscopy. Epidural anesthesia is ideal. A guidewire can be passed from the kidney to the bladder (antegrade) through a percutaneous nephrostomy, allowing antegrade stent placement to be attempted. If this fails, cystoscopic passage of a guidewire and stenting (retrograde) should be attempted. Occasionally, a guidewire can be passed but a stent cannot. This may be caused by a stricture, which can be dilated with increasing size stents or with balloon dilation. Ureteroscopy may also aid in stent placement.
If a stent is placed successfully, it should be left in for 6 to 8 weeks. The risk of infection, stone formation, and ureteral occlusion increases with time. After 4 to 6 weeks, an intravenous or retrograde pyelogram can be performed to evaluate for persistence of the fistula. If the fistula has healed, the stent may be removed via cystoscopy, and a computed tomography urogram performed after ≈4 weeks to rule out subsequent stricture formation. If the fistula has not healed at 6 weeks, a repeat examination may be performed at 8 weeks, with preparation to proceed with surgical repair if the fistula persists.
If stenting is not possible, interval management with percutaneous nephrostomy should be used until inflammation has subsided and the patient can safely undergo surgery. Surgery for ureterovaginal fistula depends on the site of involvement of the ureter and how best a repair can be accomplished with minimal tension. Typically, to address fistulas involving the distal third of the ureter, the ureter can be reimplanted into the bladder (ureteroneocystostomy). If there is tension at the reimplantation site, a psoas hitch or Boari-Ockerblad flap can be performed. Fistulas that involve more proximal parts of the ureter usually require resection and reanastomoses to the unilateral or contralateral ureter. See Chapter 29 for further discussion of ureteral injuries and their management.
Timing of Surgical Repair
Ideally, early repair of vesicovaginal fistula requires diagnosis of the fistula within 72 hours of the injury. During this period, the tissues are often supple and normal in appearance and can be dissected and closed without tension. Early repair can be performed either transvaginally or transabdominally. In addition to the technical advantages, early detection and repair of the fistula spare the patient the potentially devastating physical, psychological, and social impacts on their quality of life ( ). Unfortunately, early repair is not always an option because many fistulas are not detected until days or weeks after the initial injury. Fistulas identified during this time may be complicated by infection and induration, making closure difficult. Once these changes have occurred, traditionally, a 3- to 6-month waiting period has been recommended to allow for maturation of the fistula. During this waiting period, vaginal examination should be performed every 3 to 4 weeks to monitor the inflammation and infection. However, many authors have shown that many of these fistulas can be closed in a timely fashion, foregoing the 3- to 6-month waiting period. (Blaivas 1995) recommended that the timing of repair be individualized and based on endoscopic evidence of healing. When the fistula site and adjacent tissue are pliable, noninflamed, epithelialized, and free of granulation tissue and necrosis, little is gained by waiting longer. Corticosteroids and nonsteroidal anti-inflammatory drugs have been used by some to facilitate early surgery, but their efficacy has not been proved. As mentioned earlier, it is reasonable to place a Foley catheter for continuous bladder drainage during this time as the fistula may spontaneously close. Studies have shown successful repair rates of 91% to 100% in posthysterectomy vesicovaginal fistulas that were closed within 35 days of surgery ( ). In a large series of obstetric vesicovaginal fistulas where 88% of the fistulas were repaired within 60 days, >90% of fistulas were successfully closed ( ).
Once the decision has been made to proceed with surgical correction of the fistula, patients awaiting surgical repair should be given perineal and urinary care instructions. Leakage from small fistulas may be controlled by frequent voiding and the use of tampons, perineal pads, or silica-impregnated incontinence pants. A vaginal diaphragm with a watertight attachment to a urinary catheter can collect urine from larger fistulas in a leg bag. Perineal care is important and makes the patient more comfortable and tolerant of delayed closure. Frequent pad changes are required to minimize inflammatory edema and vulvar irritation. The dermatitis that can result from the constant urinary leakage can be treated with sitz baths and zinc oxide barrier ointments. Inventive collection and drainage systems have been described for this purpose as well. Before surgical repair, vaginal or oral estrogen can be given to women who are surgically or naturally postmenopausal to improve urogenital tissue integrity. In malnourished patients, a high-protein diet, vitamin and trace elements supplements, and correction of anemia are essential before surgical repair. Many experts recommend that surgery not be performed during menstruation because of the increased tissue vascularity.
We recommend one dose of antibiotic prophylaxis administered at the time of surgical repair. In a placebo-controlled randomized trial of 79 obstetric fistula patients who underwent repair via the abdominal, vaginal, or combined routes, antibiotic prophylaxis (ampicillin 500 mg) administered intraoperatively did not improve repair success or decrease incontinence; however, fewer patients who received antibiotics developed a urinary tract infection on postoperative day 10 (40% versus 90%, odds ratio 0.07 [95%, confidence interval 0.01-0.55]) ( ). More recently, another randomized trial compared one dose of intraoperative antibiotics (gentamicin 80 mg) with extended use of antibiotics started 2 to 3 hours after completion of surgery and continued for 7 days in 722 obstetric fistula patients. No differences were found in repair success (95% for the gentamicin group versus 89% for the extended antibiotic group), length of hospital stay, rates of incontinence, fever, or postoperative infection ( ).
Lower urinary tract fistulas can be repaired vaginally, abdominally, laparoscopically, or robotically. Most of the literature on surgical outcomes is based on large case series of obstetric fistulas with success rates ranging from 40% to 100%. Many of these retrospective case series are plagued with either short-term follow-up periods of a few weeks or large loss of follow-up rates. Most studies report high fistula closure rates with highest success after the first attempt (83%) and decreased success with subsequent attempts (65%). There is limited Level I evidence recommending one surgical technique over another with very little information on topics such as the optimal technique, route of surgery, or suture type or size. Therefore, much of what is presented regarding techniques for surgical repair is based on the experiences of the authors, expert opinions, and published study findings. Common principles of repair include adequate mobilization of the fistula, tension-free closure, locating and protecting the ureters, ensuring water-tight closure after the repair, and prolonged postoperative continuous bladder drainage. Risk factors for failure include complete loss of posterior wall of the urethra, severe vaginal scarring, small bladder size (large fistula), circumferential fistula, and irradiated tissue. Other factors that may contribute to repair failure include the surgeon’s experience, availability of health facility, patient’s general health, and number of attempted repairs.
Vaginal Repair of Vesicovaginal Fistula
The majority of vesicovaginal fistulas can be closed transvaginally, although examination under anesthesia may be necessary to identify tissue edges and to plan surgical approaches in certain situations such as large fistulas or patients with a very long vagina. In the series of 303 cases reported by , 80% were repaired transvaginally, regardless of fistula size or number or history of previous repairs. Advantages of vaginal repair include decreased operative time, blood loss, and postoperative pain, as well as shorter hospital stays. Additionally, because many of these procedures are performed in developing countries under regional anesthesia, patients are able to better tolerate vaginal surgery.
To evert the fistula edges and improve descent and stability for dissection, a Foley catheter (6 French-30 French) is typically placed through the fistula tract into the bladder, and gentle traction is applied during dissection. Stay sutures can also be placed through the vaginal epithelium on the margins of the fistula to allow traction on the tissue and make the fistula more accessible. Very small fistulas may require gentle dilation, using lacrimal duct probes and small dilators to allow insertion of the Foley catheter through the fistula tract ( Fig. 41.1 ). Alternatively, small-caliber vascular catheters such as the Fogarty Arterial Embolectomy Catheter (Edwards Lifesciences, Irvine, CA), which range from 2 to 7 French with an inflatable catheter balloon at the tip, can be placed within the fistula tract to improve descent and stability for dissection. Infiltration of tissues with normal saline or dilute solution of epinephrine (1:200,000) or vasopressin may aid in dissection in the appropriate plane and maintaining local hemostasis. Some concern has been expressed about increased infection rates after epinephrine use in vaginal surgery, so many surgeons use saline only.
If the fistula encroaches on one or both ureteral orifices, stents can be placed in the ureters at the outset of surgery. Simple vesicovaginal fistulas near the vaginal apex can usually be repaired with use of the Latzko technique ( Fig. 41.2 ), whereas more complex fistulas may require more extensive dissection with possible excision of the tract and a layered closure of the defect ( Fig. 41.3 ).