Conservative management of ureterovaginal fistula

Minimally invasive treatment of ureterovaginal fistula: A review and report of a new technique

Background

An iatrogenic ureterovaginal fistula (UVF) can be a consequence of difficult pelvic surgery. The patient must endure a long wait before having major surgery to reconstruct the injured ureter. Reports that address the minimally invasive treatment of UVF are limited, and are reviewed here. We introduce the concept of using a Memokath™ 051 stent (PNN A/S, Hornbaek, Denmark) as a promising minimally invasive approach for UVF.

Methods

We used PubMed, Science Direct, Google and the Cochrane Library to assemble appropriate evidence-based reference reports. The keywords used for the search were: ‘Memokath’, ‘stent’; ‘ureterovaginal fistula’ and ‘ureteral injury’. The review showed 42 relevant articles published up to September 2011.

Results

Ureteric stenting consistently stopped the vaginal leak of urine. The long-term results were not encouraging after removing the JJ stents at 3 months after insertion. Most patients had a recurrence of the vaginal leak of urine. The outcome was different with the Memokath stent, that remained in situ for a duration far exceeding that of the JJ stent. The Memokath stopped the vaginal leak of urine with no episodes of urinary tract infection and no evidence of stent migration.

Conclusion

Long-term ureteric stenting has two advantages, in that it facilitates urine flow through the ureteric strictured segment down to the bladder, and it stops urine leakage along the fistula. It further promotes the resolution of the ureteric stricture and healing of the fistula. A duration of 3 months was inadequate when a JJ stent was used, whereas longer periods are possible with the Memokath stent. The optimum stenting period required for complete healing of a UVF remains to be defined. Long-term Memokath ureteric stenting can be an effective alternative and minimally invasive approach to conventional surgical repair in selected cases.

Use of endoscopy in the management of postoperative ureterovaginal fistula

The aim of the study was to evaluate endourological techniques in the management of iatrogenic ureterovaginal fistula. Seventeen patients referred to us after gynecologic surgery were diagnosed as having iatrogenic ureterovaginal fistula. First, retrograde double-J stenting was tried. If this failed, percutaneous nephrostomy using an antegrade double-J stent was performed. If this also failed, open surgical repair was performed. The retrograde double-J stent bypassed the fistula in 2 patients (11.8%). Percutaneous nephrostomy was performed in the remaining 15. The antegrade double-J stent bypassed the fistula in another 2 of these patients (11.8%). Open surgical repair was performed in the remaining 13 patients (67.5%) (direct ureteroneocystostomy) with nipple valve in 11 patients and Boari flap with psoas hitch in 2 patients). Of all patients, 2 had ureteral stricture, one after antegrade double-J stenting and the other after open repair. It was concluded that early intervention is recommended in the treatment of iatrogenic uretrovaginal fistula, causing minimal morbidity and discomfort, and being less expensive.

The changing management of ureterovaginal fistulas

A retrospective review of 20 ureterovaginal fistulas in 19 patients treated within the last 20 years was done. All fistulas developed after gynecological procedures. The ureterovaginal fistulas resolved in all 7 patients in whom a self-retaining internal stent was placed in either a retrograde (5) or antegrade (2) manner for a minimum of 4 to 8 weeks. In contrast to the literature, it is concluded that modern endourological treatment will result in resolution of a ureterovaginal fistula if passage of a suitable internal stent is feasible. Every effort should be made to treat a ureterovaginal fistula endourologically rather than resort to an open operation.

Female urinary tract fistulas

Urinary tract fistulas in women are an uncommon complication of a variety of surgical procedures. However, such fistulas lead to significant patient and physician distress, and have important medicolegal implications. Successful repair of urinary tract fistulas requires careful preoperative evaluation and adherence to basic surgical principles. A variety of approaches and techniques may be used, and the choice of procedure is less important than achieving adequate resection of fibrosis with watertight, tension-free closure of well vascularized tissues in layers. Interposition grafts of omentum, muscle, peritoneum and labial fat may be used in recurrent, complicated or radiated fistulas, and add significantly to the rate of success. Overall, successful repair of urinary tract fistulas can be achieved in the majority of cases.

Ureteral injury in obstetric and gynecologic operations in Nigeria

Forty-eight cases of ureteral injuries resulting from obstetric gynecologic surgery were treated at the University of Nigeria Teaching Hospital between January 1978 and December 1987. Cesarean sections and cesarean hysterectomies were the leading causes of injury, being responsible for 18 (38%) and 12 (25%) of the cases, respectively. Ureteral transection was the commonest lesion observed, being noted in 29 (60%) of the patients. Attempt was made to reimplant the ureter into the bladder whenever possible, thus ureteroneocystostomy was performed in 27 (56%) cases while only 3 cases of end to end anastomosis were done. There was a case of mortality recorded from one of the referred patients. Forty patients recovered normal renal function after repair. Repair of ureteric injury as soon as the patient is fit for surgery is recommended.

Ureterovaginal fistula: summary of 18 years' experience

Ureterovaginal fistula is an uncommon complication of pelvic operations. We report 31 such cases seen over an 18-year period, all of which followed surgery for benign gynaecological conditions. Most patients had no urinary symptoms until the sudden onset of incontinence 1 to 4 weeks post-operatively. Diagnosis was established by a combination of intravenous urography, cystography, cystoscopy, retrograde ureteropyelography and dye studies. Twenty-nine patients underwent ureteroneocystostomy, 10 with a Boari flap and 19 by a direct method; fistulas healed in 2 patients following conservative treatment. Renal salvage was achieved in all cases.

Ureterovaginal fistula: a report of 12 cases and review of the literature

Ureterovaginal fistula is an uncommon complication of pelvic operations, seen most often after Wertheim's hysterectomy. We report 12 cases of ureterovaginal fistulas seen during a 20-year period, all of which followed operations for benign gynecologic conditions. Most patients had no urinary symptoms until the sudden onset of incontinence 1 to 4 weeks postoperatively. Diagnosis was established readily by a combination of excretory urography, cystography, cystoscopy, retrograde pyeloureterography and dye studies. In our series only 1 patient was treated by primary nephrectomy, while 11 underwent ureteroneocystostomy: 2 with a Boari flap and 9 by a direct method. Reconstruction failed in 2 patients, 1 of whom required a secondary nephrectomy.

Early treatment of ureteral injuries found after gynecological surgery

Five consecutive patients with 7 ureteral injuries found after gynecological operations were treated conservatively. The complications ensuing this type of management are reported briefly. Twenty more consecutive patients with 27 ureteral injuries were treated immediately after diagnosis and definitively. Important points of technique are 1) little attempt to stay extraperitoneally, 2) sacrifice of all abnormal ureter, 3) re-establishment of ureteral continuity between a normal ureter and the bladder by usual means, 4) peritoneal closure only when easy, 5) adequate drainage and 6) use of antibiotics. The results obtained were excellent. Early and definitive treatment of ureteral injuries found after gynecological operations seems to be the safest and easiest type of management in all cases.

Surgical injury to ureter

The incidence of surgical injury to the ureter varies from as low as 0.5% to as high as 30%. By being aware of various pitfalls in prevention, recognition, and treatment, the operating surgeon may perhaps minimize the incidence of surgical injuries to the ureter or their sequelae. The authors' experience with twenty-four surgical ureteral injuries is discussed and 5 cases are reported. In spite of a thorough knowledge of embryology, anatomy, and pathology predisposing to ureteral involvement, the possibility of ureteral injury must always be kept in mind.