Urethrovaginal fistula repair with or without concurrent fascial sling placement: A retrospective review

Diagnostic and Therapeutic Challenges of Oligosymptomatic Vesicovaginal Fistula in the Complex Case of Endometriosis

Endometriosis is a complex condition causing surgical challenges, sometimes leading to urogynecological complications, the diagnosis and treatment of which are not always obvious. We present a case of a 46-year-old woman with a history of severe endometriosis and adenomyosis who developed an oligosymptomatic vesicovaginal fistula (VVF) as a complication of surgery. The patient's medical history included multiple surgeries for endometriosis, a cesarean section, and a laparoscopic hysterectomy. After the excision of the full-thickness infiltration of the urinary bladder, she experienced postoperative bowel obstruction treated by laparotomy. Subsequent urinary complications of bladder healing were eventually recognized as oligosymptomatic VVF. Symptoms of VVFs may vary, making a diagnosis challenging, especially when the lesion is narrow. Imaging techniques such as cystoscopy and cystography are helpful for diagnosis. The treatment options for VVFs range from surgical repair to conservative methods, like bladder catheterization, hormonal therapy, and platelet-rich plasma (PRP) injections, depending on the lesions' size and location. In this case, the patient's VVF was treated with PRP injections, a low-invasive method in urogynecology. PRP, known for its pleiotropic role, is increasingly used in medicine, including gynecology. The patient's fistula closed after 6 weeks from the PRP session, highlighting the potential of this conservative treatment modality.

Repair of Vesicovaginal Fistulae: A Systematic Review

OBJECTIVE

To assess and compile the current level of evidence regarding successful surgical treatment of vesicovaginal fistulae and how these perioperative interventions affect anatomic, patient-centered, and adverse outcomes.

DATA SOURCES

PubMed and EMBASE were searched from inception through September 9, 2022.

METHODS OF STUDY SELECTION

This review included comparative studies (of any sample size) and single-group studies (1,000 or more participants) of primary or recurrent vesicovaginal fistula (ie, vesicovaginal fistula, urethrovaginal fistula, and bladder neck-vaginal fistula). We evaluated preintervention assessment or management, various techniques for intraoperative management, and postoperative management. Outcomes of interest included anatomic and objective outcomes (such as successful repair, fistula closure, urinary incontinence, recurrent fistula, perioperative complications) and subjective outcomes (such as voiding symptoms and quality of life). Abstracts and full-text articles were screened in duplicate, and study descriptions and findings were extracted into standardized extraction forms. Risk of bias was assessed independently by two investigators and adjudicated by a third. Study quality was summarized with standardized tools. We conducted random-effects model and restricted maximum-likelihood meta-analyses of relative risks when at least three studies compared similar interventions and reported similar outcome measures.

TABULATION, INTEGRATION, AND RESULTS

Forty-six studies met the inclusion criteria. Studies were categorized into 11 domains: 1) preoperative assessment, 2) preoperative and postoperative physical therapy, 3) route of surgery, 4) incorporation of a flap, 5) trimming, 6) layered closure, 7) intraoperative antibiotics, 8) fibrin glue, 9) fascial sling, 10) postoperative Foley catheter duration, and 11) quality of life. Although the strength of the data is insufficient, preoperative phenazopyridine, physical therapy, layered closure, and intraoperative antibiotics seemed to improve the rate of successful fistula repair. Route of surgery (vaginal vs abdominal laparotomy) was determined primarily by surgeon preference and showed no difference in successful fistula repair. In addition, use of interpositional flaps, trimming fistula edges, fibrin glue, and fascial sling did not show significant improvement in rates of fistula cure. Overall, quality-of-life scores improved postoperatively regardless of route of repair and use of interpositional flaps.

CONCLUSION

Our findings highlight the limited information available to guide evidence-based treatment of vesicovaginal fistula repair. Overall, high-quality evidence is lacking to provide guidelines; therefore, expert opinion remains the primary influence for fistula repair recommendations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021214948.