Management of Urological

Fistulae
Brendan Dias
Etiology
• Obstetric
• Iatrogenic
• Congenital
• Malignancy
• Inflammation / Infection
• Radiation
• Trauma
Vesicovaginal fistula
• MC acquired fistula of the urinary tract
• First surgical repair – 1663 Hendrik von Roonhuyse
• First successful repair – 1675 Johann Fatio
• James Marion Sims described a transvaginal approach with silver wire
to close VVFs. He achieved success at his 30th attempt. 1852
• Latzko technique. 1942
• Hayward, Collis and Lawson Tait – Flap splitting technique. 2005
• Martius. 1928
Epidemiology
• Developing world – 75% Obstetric injury complex
• Industrialized world – 75% gynecologic, urologic, pelvic surgery
(Iatrogenic)
Obstetric Injury Complex
• VVF • Cause
• Urethral loss • Prolonged labour
• SUI • Cephalopelvic disproportion
• Hydro-uretero-nephrosis
• Pressure Necrosis to anterior
• Renal failure vaginal wall, bladder, bladder neck
• Rectovaginal fistula and proximal urethra
• Amenorrhoea
• Pelvic Inflammatory disease
• Secondary infertility
• Vaginal stenosis
• Osteitis pubis
• Foot drop
Intraoperative risk factors
• Bladder injury • Prevention (Hutch caveats)
• Endometriosis • Immediate detection of bladder
injury
• Infection • Watertight closure
• Radiation • Adequate drainage (IDC +/- SPC
• Arteriosclerosis +/- perivesicle drain)
• Avoidance of a vaginal incision if
• Diabetes possible after recognition of
• Pelvic inflammatory disease bladder injury
• Prolonged uninterrupted
• Obesity postoperative drainage
• Approach (abdominal vs vaginal)
Evaluation and diagnosis
• Focused history (Incontinence) • 3 swab test
• Details of prior surgery • Double dye test / tampon test
• Obstetric fistulae (7-10 days post
partum); Iatrogenic fistulae (1 – 3
• Cystoscopy +/- biopsy +/- B/L
weeks later); usually months after RGP
radiation • Imaging – Contrast CT / MRI
• Physical examination – enhanced with
• VCUG +/- IVU
dye in bladder
• Identify location, size and number of VVF • Fluid for creatinine
• Assessment of inflammation and timing
of repair
• Vaginal anatomy, introital size, atrophy
Classification
• Goh classification
• Waaldijk classification
• Other classification systems
• Lawson
• Tafesse
• WHO
Treatment
• Trial of conservative management
• Indewelling catheter
• Anticholinergics
• Factors contributing to success:
• Size < 1 cms
• Time between insult and drainage < 3 weeks
• Oblique tract
• Absence of inflammation
• Adequate vesicovaginal septum thickness
• Overall success rate 8% to 28%
• Cauterisation +/- Fibrin Sealant
• Laser welding
Surgical Management
Considerations
• Timing: early vs delayed
• Approach: abdominal vs vaginal
• Handling of the fistula tract: excision vs no excision
• Adjuvant flaps or grafts
• Other considerations
Early vs delayed
• Controversial
• Obstetric VVF – preferable to wait for 3 to 6 months for the area of
ischemia to demarcate
• Radiation induced VVF – longer wait 6-12 months with a strong
consideration for diversion
• No consensus in literature to the definition of ‘early’
• In contemporary practice, iatrogenic fistulae can be repaired as soon as
‘deemed feasible’ after excluding sepsis and ensuring adequate drainage
and nutrition. Some authors recommend a ‘window’ 2-3 weeks after
fistula formation and waiting for 3 months if that ‘window’ has passed
Approach
Excision vs no excision
• RCT (Shaker et al. 2011)
• No difference in success rates
• However, trimming of the fistula tract in unsuccessful repairs tends to leave
larger defects
• There are potential disadvantages to excision
• Larger defect
• Bleeding – if diathermy used can impair success rates
• If adjacent to ureter, might need reimplantation
Adjuvant flaps or grafts
• Usually used to improve success rates
• No RCT comparing outcomes with and without interposition
• Indications for interposition
• Radiation
• Obstetric fistulae
• Failed prior repairs
• Large fistulae
• Difficult repair
• Martius, Gracilis, Labial myocutaneous, seromuscular intestinal flaps, rectus
abdominis
• Peritoneum, greater omentum
• Grafts – bladder mucosa, BMG
Surgical options for VVF repair
• Vaginal
• Flap Splitting procedure
• Saucerisation – Sims procedure
• Latzko procedure – partial colpocleisis
• Webster procedure
• Abdominal procedure
• Classical O’Connor technique (Transvesicle / Intravesicle) – Open or Lap
• Gil Vernet technique (Transvesicle) – Open or Lap
• Extravesicle approach – Open or Lap
• Urinary diversion – Ileal conduit vs cutaneous continent reservoir
• Unfit patients – Ureteral occlusion with permanent nephrostomies (IR)
Ureteric fistulae
Vesicouterine Fistula
• MC cause is an injury during lower segment caesarean section
• Youssef syndrome describes the presenting symptom complex of vesicouterine
fistula:
• Menouria
• Cyclic hematuria with associated apparent amenorrhea,
• Infertility, and urinary continence
• In a patient who has undergone prior low-segment cesarean section
• Management
• Bladder drainage with fulgration
• Hormonal induction of menopause
• Surgical fistula repair in patients desiring fertility preservation
• Hysterectomy if there is no desire for childbearing