Fistulas of the urinary tract in gynecologic and obstetric surgery

Management of urinary-tract fistulas using reversible balloon nephrostomy: a single-center retrospective analysis of 56 patients

PURPOSE

To evaluate the effectiveness of balloon nephrostomy (BN) for treating urinary tract fistulas.

MATERIALS AND METHODS

In a single-center retrospective analysis, 56 patients were treated using BN between 2003 and 2014. All causes of urinary tract fistula were included. We assessed the effectiveness of drainage, complications, and the types of reconstruction surgery used. Success was defined as fistula closure without surgery.

RESULTS

The cohort consisted of 25 males (54%) and 31 females (55%) with a median age of 63 years who underwent BN for a urinary fistula secondary to surgery, i.e., urologic (40%; n = 22), gynecologic (34%; n = 19), or digestive (20%; n = 11). Of these patients, 48 (86%) had a history of cancer (49% had a tumor progression). Median drainage time was 90 days (10-583), with an average of three successive readjustments needed per patient. We obtained a 21% success rate (n = 12), morbidity was 6.5% (urinary sepsis, renal abscess, ureteral stricture), and 7% of patients developed ureteral stricture after balloon removal. There was no recurrence of any fistula within a median follow-up time of 15.2 months.

CONCLUSION

This minimally invasive procedure can be used for selected urinary tract fistulas with few complications. It can also be used safely in populations that have several comorbidities.

Successful conservative management of a large iatrogenic vesicovaginal fistula after loop electrosurgical excision procedure

A 40-year-old G3P3 woman with grade 3 cervical intraepithelial neoplasia underwent loop electrosurgical excision procedure complicated by a large vesicovaginal fistula. She was initially managed with an indwelling Foley catheter to allow for fistula maturation. During planned surgical repair it was discovered that the fistula had closed spontaneously.

Urogenital fistulae: changing trends and personal experience of 46 cases

A retrospective study of 46 patients with different types of urogenital fistulae treated by the author during the period from January 1997 to December 2006 is presented. Twenty-two (48%) cases had a vesicovaginal fistula of which 16 (73%) were repaired vaginally and 6 (27%) were repaired abdominally. The remaining fistulae were as follows: 14 (30%) unilateral ureterovaginal fistulae, 6 (13%) ureterovesicovaginal fistulae (one bilateral), and 4 (9%) vesicouterine fistulae. All were repaired abdominally except for one patient with ureterovesicovaginal fistula needing continent urinary diversion using Mainz type II pouch. All fistulae were iatrogenic except one case (2%) which was due to neglected obstructed labor. The iatrogenic causes were gynecologically related in 26 (57%) patients and obstetrically related in 19 (41%) cases. There were two (9%) failed repairs in the vesicovaginal cases, one in each group, and both were salvaged by a secondary surgery. In view of this selected retrospective study and in association with other reports, it seems that with the improvement in the basic health-care services in Egypt, there is a change in the etiology of urogenital fistulae with the vast majority being physician related and no more related to neglected obstructed labor. Such shortcoming should be addressed in the current gynecological surgery training and residency programs.

Spontaneous closure of vesicovaginal fistulas after bladder drainage alone: review of the evidence

A vesicovaginal fistula may occur as a surgical complication, the result of obstructed labor, or a late manifestation of radiotherapy. Surgical treatment includes many routes and techniques, with a success rate reaching 100%. The spontaneous closure of vesicovaginal fistulae following [corrected] bladder drainage alone for varying periods has been reported by many. The factors favoring the success of this conservative method have not been well examined [corrected] In this investigation [corrected] all articles referring [corrected] to this modality were reviewed [corrected] The parameters studied included etiology, size, interval from [corrected] causative insult to drainage, and duration of drainage. The incidence of spontaneous closure of fistulae [corrected] after bladder drainage alone ranged between [corrected] 0 and 100%. Among all assessed criteria, the interval to drainage seems to have the best correlation with success. This finding [corrected] is most likely explained on the basis of the epithelialization of the fistulous tract with time, preventing spontaneous healing. In the view of the retrospective nature of the reviewed articles, the absence of a detailed classification system, and the heterogeneity of the treatment in question, no solid conclusion regarding management recommendations can be drawn.

Fistulas of the Lower Urinary Tract: Percutaneous Approaches for the Management of a Difficult Clinical Entity

Fistulas of the lower urinary tract are uncommon conditions that may occur spontaneously or after therapy in patients with various pelvic abnormalities. When present, these fistulas are associated with urine leakage, which is often socially distressing and disabling. Unfortunately, factors that lead to the formation of genitourinary fistulas often increase their complexity or preclude surgical repair. A high failure rate is associated with surgical repair, and many patients are not optimal surgical candidates. For such patients, a percutaneous treatment approach is highly desirable. Percutaneous ureteral occlusion combined with insertion of a functioning nephrostomy tube allows complete diversion of urine in those patients in whom nephrostomy alone does not provide adequate relief. Many approaches to percutaneous ureteral occlusion have been used with variable success, including coils and gelatin sponge, isobutyl-2-cyanoacrylate, detachable balloons, radiofrequency electrocautery, ureteral clipping, and solid and soft polymer agents. Furthermore, percutaneous or retrograde ureteral stents may be used to preserve antegrade urine flow, and surgical options are also available. It is essential that the interventional radiologist involved in the care of these patients be familiar with these different techniques as well as with the limitations, pitfalls, and possible complications of their use.

Functional outcomes of primary and secondary repairs of vesicovaginal fistulae via vaginal cuff scar excision

Hospital and office charts of patients who underwent vaginal cuff scar excision for vesicovaginal fistula (VVF) repair from February 1998 to December 2002 at our institution were reviewed. Preoperative demographics and fistula characteristics were gathered. Intraoperative data included use of tissue flaps, blood loss, OR time and anesthetic type. Postoperative review included time to discharge, successful repair and postoperative urinary or sexual dysfunction. Forty fistula repairs were identified. Ninety-three percent occurred after a hysterectomy and no subjects had a history of radiation. Forty-two percent had failed at least one surgical repair of their fistula and 12% had failed two or more attempted repairs. Twenty percent of the fistulae measured 1 cm or more in diameter and the remaining 80% were 5 mm or less. Peritoneal flaps and martius flaps were performed in 32% and 5%, respectively. Postoperatively, 100% of subjects were evaluated at 3 weeks when the suprapubic catheter was removed and 93% were evaluated at 3 months or later. All subjects were cured of their fistulae at last contact. At 3 months postoperatively, 94% percent denied any urinary dysfunction and 85% had resumed sexual intercourse. Two sexually active subjects reported mild deep dyspareunia. Transvaginal cuff scar excision is an effective method for the primary and secondary repair of vesicovaginal fistulae and does not appear to cause postoperative irritative voiding symptoms or dyspareunia.

Delayed presentation and successful repair of a recurrent vesicovaginal fistula after hysterectomy and primary abdominal repair

Urogenital fistulae are an uncommon consequence of gynecologic surgery. Vesicovaginal fistulae due to gynecologic surgery generally appear 1-6 weeks after surgery and recurrent fistulae within 3 months of their repair. The pathogenesis of vesicovaginal fistula formation remains unclear. We present the case of a 36-year-old woman with a spontaneously recurring vesicovaginal fistula 21 months after abdominal repair of a vesicovaginal fistula caused by a laparoscopic-assisted vaginal hysterectomy. During the repair of the fistula and excision of the vaginal cuff, two small fluid-filled cysts between the bladder mucosa and the vaginal epithelium were encountered. Vesicovaginal fistulae can occur spontaneously and remote from surgery. The finding of small fluid-filled cysts in the cuff suggests that rupture of a similar cyst may have led to the formation of the fistula.