Laparoscopic and Robotic Techniques for Repair of Female Genitourinary Fistulas

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Laparoscopic and Robotic Techniques for Repair of Female Genitourinary Fistulas

Chad Baxter¹ & Vishnukamal Golla²

¹ David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

² Department of Urology, University of California, Los Angeles, CA, USA

Introduction

Female genitourinary fistulas are abnormal communications that may occur between the ureter, bladder, or urethra and the uterus, cervix, or vagina. A genitourinary fistula can have devastating effects on the woman. Typically, they present with continual incontinence of varying degree; in some cultures the patient may be ostracized from their family and society, they may suffer depression, loss of employment, and become impoverished. In developed and developing nations alike there is often shame associated with incontinence. Women with fistulas often also develop dermatitis, recurrent urinary tract infections, infertility, and amenorrhea.

The most common cause of female genitourinary fistula in poorer communities is neglected, obstructed labor. Obstructed labor may lead to pressure necrosis of the anterior vagina and posterior bladder, with or without ureteral impingement, from compression between the baby’s head and the mother’s pubis. Obstructed labor rarely causes ureterovaginal fistula via the same compressive mechanism [1]. In contrast, genitourinary fistulas in developed countries are typically iatrogenic secondary to urologic or gynecologic surgeries for a variety of benign and malignant conditions, or radiation for pelvic malignancies. Iatrogenic fistulas include ureterovaginal, vesicovaginal, urethrovaginal, or vesicouterine fistulas. Rarely, fistulas may occur secondary to a granulomatous infectious process.

Urethrovaginal fistulas are increasing in prevalence due to increasing recognition and surgical treatment of urethral diverticula and the increasing use of midurethral slings [2]. Urethrovaginal fistulas are treated via a transvaginal approach and do not lend themselves to a transabdominal laparoscopic repair. Because of this, they will not be reviewed here.

Most vesicovaginal fistulas are successfully treated via a minimally invasive transvaginal surgery [3]. Vesicovaginal fistulas that have failed prior transvaginal repair, involve a fixed, fibrotic vagina, or are located high in the vaginal vault lend themselves readily to a transabdominal repair. Ureterovaginal fistulas and vesicouterine fistulas are most easily addressed transabdominally and, when appropriate, it is best to use a minimally invasive laparoscopic approach.

Indications are listed in Box 107.1.

Incidence and prevalence of female genitourinary fistulas

Although the true incidence of vesicovaginal fistulas is unknown, they are estimated to occur in approximately 1/5636 of transvaginal hysterectomies, 1/958 of open hysterectomies, and 1/455 of laparoscopic hysterectomies [4]. Radiation‐induced fistula can be divided into early postradiation fistulas caused by tumor necrosis and delayed fistulas secondary to capillary damage with subsequent tissue necrosis and sloughing [5].

Clinical presentation

Genitourinary fistulas most commonly cause persistent urinary incontinence with an obvious inciting event such as recent obstructed delivery, pelvic surgery, or radiation.

Ureterovaginal fistulas typically present with continual incontinence as urine passes directly from the ureter to the vagina. They may be associated with partial ureteral obstruction, which may give the patient hydronephrosis and flank pain. Vesicouterine fistulas may present with cyclical hematuria, infertility, or amenorrhea (Youssef’s syndrome). In the presence of a competent cervix, vesicouterine fistula may also present only with cyclical incontinence of urine during menses [6].

Vesicovaginal fistulas present with incontinence. Urine may pool in the vagina and periodically pass via the vaginal introitus with change in position or increasing abdominal pressure, thus mimicking stress urinary incontinence. Incontinence may be episodic as the fistula may be compressed and obstructed at low bladder volume and pressure and only open with evident incontinence at high pressure or volume. Patients may also develop urinary tract infections, pelvic pain with concomitant urinoma, flank pain if there is hydronephrosis, and perineal dermatitis due to constant moisture on the skin.

Clinical diagnosis and evaluation

Typical preoperative evaluation at a minimum includes vaginal speculum exam to identify the location of the fistula and the health and viability of the affected portion of adjacent bladder and vaginal tissue. It is important to note during the visual inspection and bimanual exam the relevant vaginal anatomy, including a thorough assessment of vaginal length, signs of inflammation/infection, masses, atrophy, or prior scars. All of these can help aid in surgical planning. If the fistula location is uncertain and not clearly identified on vaginal speculum examination and cystoscopy there are a variety of imaging modalities and bedside tests to employ.

Vesicovaginal fistulas may be identified by instillation of methylene blue dye via a catheter into the bladder, compressing the urethra around the catheter and simultaneously observing for effluent into the vagina.

Ureterovaginal fistulas may also be detected by the double‐dye tampon test. This test is performed by administering oral phenazopyridine, placing a tampon into the vagina, and filling the bladder with methylene blue dye. The apical portion of the tampon will reveal orange dye in the presence of a ureterovaginal fistula and blue dye in the presence of a vesicovaginal fistula.

Genitourinary fistulas are also readily identified on contrast‐enhanced cross‐sectional imaging. Ureterovaginal and ureterouterine fistulas may be identified on images in the pyelographic phase of an intravenously enhanced abdominal and pelvic CT scan or CT urogram. Importantly, the incomplete filling of the bladder as occurs with delayed images of the CT urogram is inadequate to exclude the presence of a vesicovaginal fistula.

A CT cystogram will appropriately distend the bladder and is highly sensitive for vesicovaginal fistula. Cross‐sectional imaging may also reveal additional pathology such as urinoma, allow accurate lateralization of ureterovaginal fistula, identify congenital ureteral duplication, presence of hydroureteronephrosis, and thus significantly inform operative planning.

Endoscopic evaluation is also critical. Cystoscopy allows direct visualization of a vesicovaginal fistula, the health of surrounding tissue, and the proximity to the ureters and bladder neck. Cystoscopy may also reveal the presence of foreign material, such as suture, brachytherapy seeds, titanium vascular clips, or calculus. If patient history or clinical suspicions suggest carcinoma, fistula biopsy should be performed at time of cystoscopy. Retrograde pyelography may also reveal the location of ureterovaginal and ureterouterine fistulas.

Some tests for fistula evaluation are summarized in Table 107.1.

Table 107.1 Summary of tests for fistula evaluation.

Fistula type	Test	Diagnostic findings
Vesicovaginal	Bladder backfill	Bladder is filled retrograde with dilute methylene blue or sterile milk while visualizing the anterior vaginal wall with the posterior speculum blade in place. If no fistula visualized, the catheter is removed and the patient is asked to Valsalva to evalute for stress incontinence
Vesicovaginal or urethrovaginal	Double‐dye tampon test	Oral phenazopyridine is given and a tampon is placed in the vagina; bladder filled retrograde with methylene blue. Tampon inspected after 10 min: if orange dye is present on tampon, fistula likely urethrovaginal; if blue dye is present likely vesicovaginal. Both colors is combination of both fistulas
Urethrovaginal	Trattner double balloon catheter	The upper balloon is inserted through the urethra into the bladder and both balloons are inflated; one balloon is located at the urethrovesical junction and the second at the urethral meatus. Downward traction is placed on the internal balloon which occludes the urethrovaginal junction while the external balloon is pressed snugly against the external urethral meatus; methylene blue or sterile milk is then instilled into the catheter to identify a fistula between the vagina and urethra
Vesicovaginal, urethrovaginal, rectovaginal, or colovesical	Direct visualization or imaging	Cystoscopy, CT urogram, or retrograde pyelogram, colonoscopy, proctoscopy, endoanal or transperineal ultrasound, MRI

Nonsurgical management

Small, benign, nonirradiated ureterovaginal fistulas may be initially managed by ureteral stent. If retrograde ureteral stent placement is not achieved due to associated stricture, percutaneous nephrostomy with antegrade ureteral stenting may be attempted. If successfully cannulated and stented, an initial trial of ureteral stent may be undertaken for perhaps 6–10 weeks prior to stent removal. If the fistula closes, serial imaging of the upper tract is necessary to observe for delayed stricture formation and need for subsequent endoscopic, laparoscopic, or open repair of the stricture or ureteroneocystotomy. Quality evidence supporting conservative management is poor and limited to case series and expert opinion. Irradiated, large, or malignant ureterovaginal fistulas are unlikely to close with conservative management and are best managed with surgical intervention.

Ureterouterine fistulas may close with hormone therapy to prevent endometrial proliferation and maintain an amenorrheic state [7]. Typically, however, ureterouterine fistulas require transabdominal surgical intervention.

Small, benign, nonirradiated vesicovaginal fistulas may respond to prolonged Foley catheterization that diverts urine and prevents bladder distension. Success with this method ranges from 7% to 15% in case series. Fulguration of a fistula less than 3 mm in diameter is reported as successful in 73–100% of patients in two small series. Fibrin glue injection into the fistula tract has been reported, as has, more recently, fibrin glue combined with platelets and plasma. High cure rates of small fistulas with short‐term follow‐up are reported [8].

Goals of surgery

Regardless of etiology, vesicovaginal fistulas can have a devastating impact on quality of life, sexual function, psychological well‐being, physical discomfort from incontinence, and increase the risk for recurrent urinary tract infections and therefore damage to the upper tract urothelium. As is the case in most surgery, the first attempt at a surgical repair will be most likely to succeed. Therefore the goal with the surgical repair of vesicovaginal fistulas should be to minimize the number of surgeries, avoid complications and utilize precise surgical techniques to prevent recurrence.

Timing of surgery for vesicovaginal fistula repairs

Optimal timing of fistula repair is unknown. Formerly, delayed fistula repair was advocated by many [9], but many now advocate for early surgical intervention [10]. Timing of fistula repair is determined by considering several factors, including the benign or malignant nature of the fistula, health and vitality of surrounding tissue, presence of concomitant abdominal or vaginal pathology, and the surgeon’s experience and success with varying techniques and approaches. Surgical treatment of large or small, benign, nonirradiated fistula may be pursued without delay. Irradiated, large, or malignant fistula will not close with conservative management, delaying only long enough to optimize tissue health. The surrounding tissue may be optimized by treating any active infection, diverting urine as best as possible with Foley catheter and/or bilateral nephrostomy tubes, waiting for resolution of hematoma or edema, and (in the absence of a contraindication, such as hormonally sensitive cancer or thromboembolic disease) topical estrogen therapy in a low‐estrogen state [11].