Complications of Female Incontinence and Pelvic Reconstructive Surgery (Current Clinical Urology) 2nd ed.

14. Vesicovaginal and Urethrovaginal Fistula Repair

Michael Ingber1, 2   and Ray Rackley3

(1)

Department of Urogynecology, Saint Clare’s Health System, Denville, NJ 07834, USA

(2)

Department of Urology, Weill Cornell Medical College, New York, NY, USA

(3)

Department of Urology, Cleveland Clinic, Cleveland, OH, USA

Michael Ingber

Email: ingbermd@aol.com

Abstract

A urogenital fistula is an abnormal communication between two structures which causes urine to leak into a space other than through the urethral meatus. Vesicovaginal fistulae represent the most common type of fistula encountered by pelvic surgeons today. In developed countries, the more common etiologies include pelvic surgeries for hysterectomy, incontinence, or pelvic reconstructive procedures [1]. In developing countries, pregnancy-related complications from obstructed labor result in ischemic injury to the bladder and vagina and can lead to very large fistulae that can be difficult to treat [2] (Table 14.1).

Introduction

A urogenital fistula is an abnormal communication between two structures which causes urine to leak into a space other than through the urethral meatus. Vesicovaginal fistulae represent the most common type of fistula encountered by pelvic surgeons today. In developed countries, the more common etiologies include pelvic surgeries for hysterectomy, incontinence, or pelvic reconstructive procedures [1]. In developing countries, pregnancy-related complications from obstructed labor result in ischemic injury to the bladder and vagina and can lead to very large fistulae that can be difficult to treat [2] (Table 14.1).

Table 14.1

Causes of urogenital fistulae

Congenital

Acquired

Iatrogenic

Postoperative

Hysterectomy

Abdominal

Transvaginal

Laparoscopic

Incontinence procedures

Transvaginal slings

Retropubic

Laparoscopic

Prolapse procedures

Anterior colporrhaphy

Mesh kits

Sacrospinous/uterosacral fixation

Urethral diverticulectomy

Endoscopic procedures

Bowel and vascular surgeries

Radiation injury

Noniatrogenic

Pelvic malignancy

Obstructed labor

Trauma

Sexual injury

Infection

Foreign body

Regardless of the etiology, repair of vesicovaginal fistulae can be challenging, and complications can occur even when performed by expert surgeons. Patients with fistulae by their nature often have significant comorbidities that make them more prone to having complications. Furthermore, not only do tissue ischemia, inflammation, and devitalized tissue cause fistulae, but they also can be a limiting factor in proper management and cure. Controversies ­continue to exist with respect to the proper timing of treatment, route and method of surgery, and use of any adjuvant flaps. Nevertheless, several steps may be performed in order to minimize such perioperative issues. Herein we describe complications related to vesicovaginal and urethrovaginal fistulae and ways to prevent adverse outcomes from surgical repair.

Preoperative Considerations

Timing of Repair

Obstetrical fistulae typically have significant tissue ischemia due to prolonged pressure from the fetal head on the bladder wall. As such, most experts agree that waiting several months to fix such fistulae increases likelihood of success (Fig. 14.1). However, when to fix an iatrogenic fistula has been a subject of controversy for many years [3]. Each case should be managed individually, as both early repair and delayed repair may be successful in the appropriate circumstance [47]. In general, fistulae which are recognized within several days of injury should be immediately repaired. Delaying in cases of immediate recognition only causes additional psychological suffering, given the significant amount of leakage that patients will experience while waiting for repair. In cases where tissue edema and inflammation prevent successful repair, a waiting period of ­several weeks to months may be appropriate.

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Fig. 14.1

Obstetric vesicovaginal fistulae are typically larger, due to prolonged tissue ischemia

Diagnostic Studies

Determining the location of severe vaginal urinary leakage is often the most challenging part of an incontinence evaluation. While voiding cystourethrograms and plain cystograms can often demonstrate the presence of a fistula, they often fail to demonstrate the exact location of vesicovaginal fistulae, as well as the presence of multiple fistulae (Fig. 14.2). Additionally, ureteral injury can be present in up to 12% of cases of vesicovaginal fistulae, and recognition of this preoperatively is essential [8]. CT Urography has largely replaced intravenous pyelography as a diagnostic modality of choice when evaluating upper tract damage or fistula. Cystoscopy is an essential component in the evaluation of any woman with unexplained or continuous incontinence. Typically, cystoscopy can show a fistulous tract, or at least suggest fistula due to severe inflammatory changes (Fig. 14.3). Retrograde pyelogram at the time of cystoscopy can usually demonstrate ureteral extravasation of contrast (Fig. 14.4). Alternatively, CT Urography can show locations of urinary extravasation and often be diagnostic of ureterovaginal fistula (Fig. 14.5).

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Fig. 14.2

Performing a careful examination is essential, as many patients have multiple fistulae which should all be addressed simultaneously during surgical repair. This patient had both a vesicovaginal and a urethrovaginal fistula

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Fig. 14.3

Cystoscopic examination will often show a fistulous tract, or area of inflammation suspicious for vesicovaginal fistula

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Fig. 14.4

Retrograde pyelogram demonstrating ureteral extravasation of contrast into vagina. With ureterovaginal fistulae, early ureteral stenting may avert need for ureteral reimplantation

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Fig. 14.5

CT Urography can be an excellent imaging modality when evaluating for presence of fistula. Here, a communication can be seen (arrow) between the distal ureter and vagina

Approaches to Fistula Repair

Determining which route to perform fistula repair is of utmost importance in order to prevent untoward complications. Most fistula experts agree that the first attempt at repair is the most important surgery which can provide the surgeon with the opportunity to definitively repair the defect. Therefore, the first attempt should be the route in which the surgeon feels most comfortable with. There are some benefits, however, to choosing specific methods based on the type of fistula.

Open Abdominal Repair

The abdominal route may be preferred in women who have poor vaginal access, ischemic tissue from radiation, or those in whom a laparoscopic approach is contraindicated. Women with multiple fistulae including other organs (i.e., enterovaginal fistulae) are often better served with an open abdominal approach. Large, well-vascularized adjuvant tissue flaps are a major advantage to open abdominal approaches and may decrease recurrence risk in such cases. Complications related to open repair include wound infection, incisional hernia, and increased bleeding risk.

Transvaginal Repair

Choosing a transvaginal route and avoiding intraperitoneal access is often a preferred method in most fistulae, provided that the surgeon has access to the site. Specifically, for distally located fistulae, the transvaginal route is recommended, as fistula repair can be performed in an outpatient setting. Some practitioners prefer the Latzko partial colpocleisis to repair apical fistulae, as this method has rather high success rates [911]. Most women handle postoperative pain well with the transvaginal route. Complications specific to the transvaginal route include vaginal shortening and vaginal stenosis which may lead to dyspareunia.

Laparoscopic and Robotic-Assisted Laparoscopic Repair

Several authors have described laparoscopic and robotic-assisted laparoscopic repair of vesicovaginal fistulae [12]. The advantage of utilizing robotic technology is the ability to have excellent magnified views of the repair, along with the ability to suture for those surgeons not experienced in laparoscopic suturing techniques. Robotic and laparoscopic repairs are often a preferred route in apical fistulae that are unable to be reached vaginally, as they provide superior visualization to defects in this area when compared to the open route. One potential disadvantage that could lead to increased risk for recurrence is the difficulty in obtaining an interposed omental flap, although peritoneal flaps are typically easy to obtain during laparoscopic repair.

In a recent report, authors compared intraoperative data and outcomes of 12 robotic-assisted repairs to 20 open surgical repairs [13]. All subjects in the robotic group and 90% of those in the open cohort were managed successfully. Not surprising, mean blood loss was significantly less in the robotic group (88 mL vs. 170 mL, p  <  0.05). Mean hospital stay was also shorter in the robotic group (3.1 vs. 5.6 days, p  <  0.05). In the authors’ experience, laparoscopic and robotic-assisted repairs can typically be discharged home after a 23 h stay. Neither group had a significant difference in complication rate. Complications relevant to laparoscopic repair include port-site hernias, bowel injury, and adjacent organ injury.

Intraoperative Considerations

Because of the already present poor tissue conditions that led to development of a fistula in the first place, intraoperative complications can be relatively common during fistula surgery.

Complications During Dissection

Many fistulae are surrounded by significant inflammation, which can lead to excessive bleeding and poor visualization intraoperatively. Careful dissection is of utmost importance when performing repair, as the surgeon must obtain several layers of closure to prevent recurrence. Complications may occur if the initial dissection of the vaginal epithelium is too deep, and additional layers of closure are unattainable. Excess bleeding may result when improper tissue planes are entered. In cases where flaps are too thin for a good watertight closure, adjuvant tissue flaps utilizing omentum (in abdominal repair) or a Martius flap (in vaginal repair) are crucial.

The authors do not routinely excise the entire fistula tract. Nevertheless, in cases of prior malignancy or in postradiation fistulae, one should obtain a biopsy to ensure that there is no malignancy at the site of the fistula. Any nonviable tissue should always be removed in order to obtain better healing. Avoidance of cautery is important, as excess cautery can compromise blood supply to tissue flaps and jeopardize healing. Hence, significant bleeding should be controlled with interrupted suture.

Complications related to adjacent organ injury are relatively uncommon. If the ureters are close to the repair, they should be stented initially. Ureteral injury may be a result of cautery injury or sharp dissection and should be recognized immediately. A small ureteral defect may be repaired primarily. However, extensive cautery injury, or full transection, typically requires reimplantation in order to prevent ureteral leak or stricture formation. Injury to the bowel may occur during transperitoneal repair, either immediately from dissection injury, or 1–2 weeks following repair due to cautery injury. Patients with prior pelvic radiation may have more inflammation, resulting in additional adhesions, and can be more prone to such injuries.

Closure

Choosing the proper suture is extremely important in minimizing complications. Closure of the bladder or urethral defect should be performed with absorbable suture such as 3-0 polygalactin or 3-0 chromic. If knots are tied on the intravesical side, a patient may be predisposed to developing calcifications or infections due to delayed absorption when exposed to urine. Nonabsorbable suture should never be used during fistula repair, as permanent suture material can lead to infections and stone formation within the bladder (Fig. 14.6). Additional layers such as a pubocervical fascial layer should also be closed with absorbable suture so that suture lines are nonoverlapping. Once fully closed, the repair should be tested for water-tightness by instilling saline. Any sites of leakage along the suture line should be oversewn with additional suture to ensure complete closure.

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Fig. 14.6

Permanent sutures should never be used during fistula repair. Similarly, absorbable suture knots should be tied external to the bladder mucosa, in order to prevent fistula recurrence and stone formation, as in this patient

Adjuvant Flaps

Providing an additional layer of closure should be considered when a three-layer closure is not able to be performed, or when tissue quality may compromise proper healing. Interposed tissue flaps should be secured with absorbable suture at least 1–2 cm beyond the site of repair. Complications related to harvesting flaps are relatively minimal and are typically limited to bleeding from the site of where the flap was obtained. One study evaluated eight women who underwent Martius flap surgery and questioned subjects on appearance of the harvest site and any postoperative complications [14]. Three (38%) women felt the appearance of the flap site was different from the contralateral labia. At 1 year after the procedure, one patient (13%) complained of dyspareunia, three (38%) patients had intermittent discomfort in the harvest area, and five patients (62%) complained of permanently decreased sensation or numbness at the harvest site. Another study evaluating mostly obstetrical urethrovaginal and vesicovaginal fistulae, however, showed decreased incidence of dyspareunia as well as recurrence after Martius interposition [15].

Omental flaps are an excellent source of adjuvant tissue during transabdominal repair and can occasionally be accessible during transvaginal repair in posthysterectomy vesicovaginal fistulae. The blood supply to omental flaps are based upon the right or left gastroepiploic artery, although the right gastroepiploic is both larger and more caudal, allowing for better reach distally during intra-abdominal fistula repair. Regardless, tissue interposition should be determined based on the quality of repair. All patients should be counseled about potential use of flaps and the complications specific to the site of tissue interposition.

Postoperative Complications

Not unexpectedly, the most common complication encountered after vesicovaginal and urethrovaginal fistula repair is recurrence of the fistula. With a complete preoperative workup, attention to basic fistula principles, and careful surgical repair, recurrence rates can be minimal. Should a recurrence occur, management can be via any route.

To a woman suffering from continuous incontinence from a fistula, persistence of urinary incontinence despite a properly repaired fistula can be devastating. Stress incontinence may occur after both transvaginal and transabdominal fistula repair if the dissection disrupts the ligamentous support of the urethra or the sphincteric mechanism. In several series, the rate of stress incontinence after fistula repair ranges from 4 to 33% after surgery and are likely higher in obstetrical fistula [1617]. Risk factors of stress incontinence after fistula surgery include involvement of the urethra, small bladder capacity, large fistula, and need for extensive vaginal reconstruction [18]. In women with vesicovaginal fistula and concomitant stress incontinence, a simple midurethral sling may be performed provided that the urethral dissection is well away from any fistula repair. However, in the setting of any periurethral dissection during fistula repair, it is the authors’ preference that any therapy for stress incontinence wait until after total healing occurs after fistula surgery.

Urinary tract infection is a relatively common complication of fistula repair postoperatively, as instrumentation of the urinary bladder itself can predispose a woman to infection. Studies evaluating antibiotic use during and after fistula repair are limited to obstetric fistula. In a review of single-dose gentamicin vs. extended postoperative antibiotics during 722 obstetric fistula repairs in Ethiopia, Muleta et al. showed no difference in rates of postoperative infection [19]. Regardless of postoperative antibiotic use, sterilization of the urine prior to repair is of utmost importance, as preoperative urinary tract infection may increase the likelihood of fistula recurrence [20]. The authors occasionally use a low-dose antibiotic such as nitrofurantoin while patients await repair not only to prevent perioperative urinary tract infection, but also to decrease tissue edema and inflammation which allows for easier repair.

Urinary urgency may occur after any vaginal surgery which involves dissection around the urethra and the bladder. Rates of postoperative urinary urgency are difficult to determine due to the few studies that have used urinary urgency as an outcome. However, in one small study evaluating 20 genitourinary fistulae, seven (35%) developed urinary urgency postoperatively. Because de novo urgency can be an irritative complication, it should be discussed preoperatively with patients. It is the authors’ preference to offer patients anticholinergic therapy during the healing phase when catheters are present to minimize uninhibited detrusor contractions. Rarely, patients may have persistent urinary urgency even several months after repair. When such a complication occurs, urodynamic investigation to ensure no evidence for bladder outlet obstruction is essential. Long-term treatment of the urgency may be required in some patients.

Vaginal shortening is more common with apical fistulae when the Latzko partial colpocleisis is utilized. However, when done appropriately, only 1–2 cm of vaginal length is compromised, and this should not be an issue. Typically, women can remain sexually active without major problems with dyspareunia even when significant vaginal shortening occurs [21]. Nevertheless, vaginal shortening should be mentioned when counseling women who are sexually active, as women may recognize the change in anatomy with deep penetration of their partner.

Urethrovaginal Fistula

In developed countries, urethrovaginal fistulae are most commonly a result of previous vaginal surgery. Symptoms are variable as are techniques for repair. Like vesicovaginal fistula, complications specific to urethrovaginal fistula most ­commonly involve recurrence, with 10% of ­primary repairs recurring in a recent series [22]. Knowing the location and number of the fistulae are extremely important.

Because of the proximity of the urethral sphincter, patients with urethrovaginal fistula that occur within the proximal and/or middle urethra are prone to development or worsening of stress urinary incontinence after repair (Fig. 14.7). In the aforementioned study, of 71 subjects undergoing repair, 37 (52.1%) developed stress incontinence after repair [22]. Some surgeons advocate the use of autologous fascia in order to correct stress incontinence during urethrovaginal fistula repair [2324], but the authors typically prefer to wait until any fistula repair is complete. Once several months of healing has occurred, if the incontinence remains, it may be assessed, and a synthetic or autologous sling may be placed if necessary.

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Fig. 14.7

Urethrovaginal fistula can affect the external sphincter and simple repair of the defect may still result in chronic incontinence. This patient required autologous fascial sling to correct the resulting stress incontinence after fistula repair (courtesy Howard B. Goldman, MD)

Conclusion

Vesicovaginal and urethrovaginal fistulae are conditions which require extensive preoperative planning, experience-driven intraoperative judgment, and close outpatient follow-up. When basic principles of fistula repair are followed, complications may be minimized, and subsequently, chances of a successful repair can be maximized.

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