Etiology

Vesicovaginal fistulas (VVFs) occur when there is an injury to the bladder, creating a communicating tract with the vagina eventually leading to seepage of urine. There are several implicating factors including infection, inflammation, and radiation as well as malignancies of the pelvic organs including colon, uterus, ovaries, and cervix. Surgical misadventure during routine operative interventions remains the most prominent perpetrator of urinary tract fistula. In the United States 90% of VVFs ensue after surgery. The occurrence of trauma to the lower urinary tract during surgery for benign gynecologic conditions has been classically reported as high as 76% in some series; however, more recent studies have suggested this number is much lower and <1%. There are approximately 240,000 hysterectomies performed in the United States on a yearly basis, although this trend is decreasing. Systematic reviews on laparoscopic hysterectomies have shown the rate of injury to the genitourinary system to be 0.73%. Untoward harm to the genitourinary tract may also occur during colorectal surgeries. The rate of injury to the genitourinary tract during colorectal surgeries is 0.18%. Patients with preoperative exposure to radiation have been shown to have a higher incidence of surgical complications and worse prognoses. In a study by Fujikawa et al. following 271 females receiving radiotherapy for cervical cancer, the authors noted that 8% of patients receiving pelvic radiation had a genitourinary complication arising from the treatment, and an additional 13.7% suffered complications associated with the rectum including fistula and bleeding. The reported rate of iatrogenic injury to the urinary tract is likely under-reported, particularly in cases where routine intraoperative cystoscopy is not employed.

There are over 300,000 procedures for pelvic organ prolapse (POP) and over 100,000 procedures for stress urinary incontinence (SUI) performed across the world every year. A third of those patients with POP will require re-intervention for recurrence of the prolapse. Cases where the surgeon elects to use synthetic mesh material can present a risk for fistula formation and have been reported with both midurethral slings for SUI and slings used during sacrocolpopexy to correct POP. The incidence of fistula formation from synthetic sling material used to correct SUI is low and reported across the medical literature as occurring in 0.1% of cases. Erosion of foreign bodies into the vagina can occur after placement of synthetic mesh for POP or SUI as well as from retained objects introduced into the vagina such as pessaries or tampons that may find their way into the bladder over time ( Fig. 12.2 ).

Urethrovaginal fistula associated with a midurethral synthetic sling. The urethra is exposed directly underneath the vaginal epithelium with no obvious periurethral fascia. The actual fistula (not seen) is located at the proximal border of the area where the vaginal epithelium meets the urethra.

(From Nitti VW, Rosenblum N, Brucker BM. Vaginal Surgery for the Urologist. 1st ed. Philadelphia: Elsevier/Saunders; 2012:xvi.)

Meta-analysis of the global medical literature has suggested that the worldwide prevalence of urinary tract fistula is lower than suspected and reported to truly occur in 0.3% of all women. This value rises in women of reproductive age. There are regions of the world where the incidence is distinctly higher, including sub-Saharan Africa and South Asia where the prevalence is 1.5% and 1.6% respectively. The pooled incidence of vesicovaginal fistula in these countries in women that had recently given birth was 0.09%.

Pathophysiology

Iatrogenic fistula formation is thought to arise secondary to traumatic instrumentation or radiation along the genitourinary tract. The initial injury causes tissue ischemia. Eventually the affected area will undergo necrosis, and a fistulous communication will be formed with the genitourinary tract allowing for the aberrant passage of urine. The temporal relationship between the inciting event and actual leakage of urine is variable and can range from days, weeks, to even years after the traumatic incident. Delayed presentation of genitourinary manifestations is particularly notorious in patients undergoing pelvic radiation. Ischemic microvascular damage arising secondary to obliterative endarteritis may take years to become apparent. A fistula that arises in the setting of prior radiation must raise suspicion for a possible malignancy and should be biopsied prior to surgical repair. The ischemic changes that caused the fistula may also compromise the surrounding tissue available for reconstruction. These repairs are challenging and are often with inferior outcomes. In a fistula arising after surgery for malignancy, one must also exclude the possibility of a recurrence within the fistulous tract with a biopsy prior to surgery.

Any surgery in the vicinity of the genitourinary organs can lead to the formation of a fistula. Lacerations to the bladder if unrepaired will cause leakage of urine. A concomitant injury or opening in another pelvic structure raises the possibility of establishing a fistulous tract. The persistent output of urine production allows for the tract to persist by not allowing the injured tissue to heal. Once the fistulous tract is epithelialized it truly declares itself. Hysterectomy is a notorious culprit behind fistula formation particularly at the site of the vaginal cuff and along the anterior wall of the vagina. Fistulas can also form after retroperitoneal lymph node dissections, low anterior or abdominoperineal resections, or surgery to the uterus or cervix.

Presentation

The clinical presentation of VVF is variable and highly dependent on the mechanism of injury to the bladder and vagina. Leakage of urine usually occurs within 1 week of catheter removal, although the presentation may be delayed. Patients that incur surgical injuries may develop signs and symptoms of peritonitis including fever, chills, vomiting, rebound, and guarding in the postoperative period suggesting the presence of a urinoma or possibly urinary ascites. A study in the prevention of fistula formation in women undergoing hysterectomies concludes that patients with abdominal pain and distention or paralytic ileus in the postoperative period should be assessed for trauma to the lower urinary tract. Hematuria or voiding symptoms such as frequency and urgency are also highly suggestive of injury to the bladder. Often it is difficult to distinguish discharge after vaginal surgery from urinary leakage, and one must maintain a high index of suspicion for a fistula. The majority of patients with a VVF will declare themselves within a month of catheter removal with complaints of continuous leakage of urine per the vagina; however, the presentation may also be delayed. Very large fistulas may cause continuous or gravitational incontinence.

Diagnosis

A targeted history and physical examination including a thorough pelvic examination are in order when evaluating for a VVF. A half speculum should be employed to assess all three vaginal compartments. In the acute setting there can be severe erythema and inflammation concealing the opening of the tract. Intraabdominal and vaginal collections of fluid may be sent for creatinine and urea measurements. A rectal examination should be considered to assess the posterior vaginal wall and rule out rectal involvement. If digital rectal examination is suggestive of rectal involvement, proctoscopy should be performed.

Once a fistula is suspected, attention must be turned to promptly identifying the size and location, as this will dictate management. Imaging of the upper tract is mandated as 10% of VVFs may have concomitant injury to the ureters. Historically this had been achieved with intravenous pyelograms. This has in great part been replaced by retrograde pyelograms and contrast-enhanced, cross-sectional imaging with a urographic phase, given its superior anatomic detail. Direct inspection of the fistulous tract with cystoscopy is important in its characterization. One can identify necrotic tissue of possible recurrence of malignancy that may alter management. Cystograms can also aid in visualization of the tract. Some fistulas are clearly evident and may be stented with a ureteral catheter or feeding tube for ease of resection. If the fistula is not clearly evident, any patch of erythema or bullous edema must raise suspicion as the offending site. A vaginoscopy may also be performed at the time of cystoscopy, adding minimal time to the procedure and enhancing diagnostic value. If the upper tract has not been assessed or if the patient has a contraindication to intravenous contrast or cross-sectional imaging, retrograde pyelograms should be employed at the time of intraoperative cystoscopy ( Figs. 12.3 , 12.4 ).

Cystogram demonstrating contrast in the vagina.

(From Roslan M, et al. Suprapubic transvesical laparoendoscopic single-site surgery for vesicovaginal fistula repair: a case report. Wideochir Inne Tech Maloinwazyjne. 2012;7(4):307-10.)

Catheterized ureters (green) and fistulous tract (yellow).

(From Roslan M, et al. Suprapubic transvesical laparoendoscopic single-site surgery for vesicovaginal fistula repair: a case report. Wideochir Inne Tech Maloinwazyjne. 2012;7(4):307-10.)

When there is doubt as to whether the discharge is urine or vaginal secretions, a “dye test” may be performed. A simple way to diagnose lower tract fistula is to fill the bladder with methylene blue and observe for leakage across the vaginal epithelium. If not clearly evident, the patient can insert a tampon and walk around the clinic to elicit leakage in the way it occurs naturally. If there is suspicion of an injury to the upper tract, phenazopyridine may be administered orally and a “double dye test” employed. The presence of the orange dye in the proximal tampon suggests a ureterovaginal fistula versus blue dye, a VVF. The presence of dye on the distal tampon may be indicative of leakage from the urethra, perhaps secondary to SUI. Urodynamic studies may be of diagnostic value in the evaluation of a fistula, particularly if there is suspected concomitant storage or voiding dysfunction. Urodynamics allow for determination of capacity and compliance, which may be useful for patients that have been radiated. Videourodynamic testing has the added benefit of providing anatomic as well and functional information. Patients with injuries in the trigone or bladder neck are at risk for developing detrusor overactivity and SUI. Patients that have received radiation may have decreased compliance and capacity as a consequence. Urodynamic studies may help plan for concomitant augmentation cystoplasty at the time of fistula repair or consideration of urinary diversion in severe cases ( Box 12.1 ; Fig. 12.5 ).

Instillation of indigo carmine in the bladder can help to locate the fistula.

(From Nitti VW, Rosenblum N, Brucker BM. Vaginal Surgery for the Urologist. 1st ed. Female pelvic surgery video atlas series. Philadelphia: Elsevier/Saunders; 2012:xvi.)

Prevention

Vesicovaginal fistulas are largely a consequence of synchronous injury to the bladder and injury or incision of the vagina. This usually occurs after hysterectomy. The rate is highest after radical hysterectomy for malignancy and lowest following hysterectomy for pelvic organ prolapse. ⁶ Tissue is more prone to damage in patients with active malignancy or prior radiation. Injury to the bladder occurs during dissection from the cervix, especially when the procedure is complicated by prior radiation therapy, obesity, or prior surgery. Excessive fulguration and/or suture placement through the vaginal epithelium and into the bladder are notorious offenders. Prevention of VVF formation is contingent on proper surgical technique and postoperative urinary drainage. Using a Foley catheter during pelvic or vaginal surgery can help in identifying the bladder and maintains the bladder decompressed by allowing for adequate bladder drainage. The surgeon must maintain a high index of suspicion for injury, and in cases of suspected bladder or ureteral injury the urologist should be consulted at once.

Intraoperative use of cystoscopy should be employed whenever there is suspicion of bladder injury that is not readily identified. Studies suggest the combined used of cystoscopy and vaginoscopy can be of added benefit to identify bladder injury. The use of dyes and retrograde filling of the bladder, such as with dilute methylene blue, can also reveal an injury. The intravenous injection of indigo carmine can assist in the diagnosis of a ureteral injury. In the absence of indigo carmine, sodium fluorescein may be used to visualize the ureteral jets. In some cases an intentional cystotomy is needed to ensure that the bladder is fully inspected and the ureteral orifices are identified. Whether from an endoscopic or open approach, ureteral support stents (i.e., open ended catheters, feeding tubes) can also be used to ensure patency of the distal ureter and serve as a referent point during bladder closure. Technical points in closing a bladder injury include watertight bladder anastomosis, tension-free repair, and in many cases, if possible, interposition of healthy tissue between the bladder repair and vaginal cuff closure.

Postoperatively, adequate urinary drainage should be accompanied by maximal detrusor relaxation induced by anticholinergic/antimuscarinic medication. In many cases a cystogram can be utilized prior to catheter removal to confirm integrity of the bladder. Any complaint of vaginal discharge before or after catheter removal should prompt evaluation. This would involve a complete history, and, if suspicious for recurrence or persistence of a VVF, a full vaginal examination (i.e., with a half speculum) is warranted. If the exam in the immediate postoperative period confirms persistence of a fistula, a longer period of bladder drainage is needed. Hypothetically, if a foreign body was identified (i.e., suture) one could consider removal in the early recovery period.

Management

Vesicovaginal fistulas can be categorized with a basic system of “simple,” “intermediate,” or “complex.” Angioli et al. consider a singular fistula measuring less than 0.5 cm as “simple.” “Complex” fistulas include radiation-induced fistula, previously failed fistula repairs, multiple fistulas, or those measuring greater than 2.5 cm. These are often the result of chronic disease or radiation. Fistulas falling in the range of 0.5 to 2.5 cm in size are termed intermediate. For management purposes, intermediate fistulas are treated as complex fistulas ( Table 12.1 ).

Simple fistulas may be amenable to conservative management, which includes bladder drainage, fulguration of the fistulous tract, and plugs with surgical glue. Conservative treatment has been attempted in simple fistula 2 weeks to 2 months after injury, with success rates ranging from 0% to 100%. Retrospective studies have shown the best rate for spontaneous closure occurs with bladder drainage. No prospective study has correlated the duration of drainage with the chance for spontaneous healing, and often this is based on personal experience. At best, one-fourth of small fistulas will close with prolonged catheter drainage. Other conservative options for closure of VVFs include electrofulguration with or without injection of bovine collagen, fibrin glue, and/or autologous platelet rich plasma injection and platelet rich fibrin glue interposition. The bladder is subsequently drained for 4 weeks. We find that these approaches have limited utility, are seldom effective, and are rarely employed. They are best reserved for nonsurgical candidates. Surgical repair remains the mainstay of therapy.

There are several caveats to ensure successful surgical correction of any fistula. One must confirm removal of any foreign bodies or necrotic tissue in the offending site. The surgeon must consider the need to extract the fistulous tract or whether to include it in the surgical reconstruction. In cases of fistula from a recent surgery, with low suspicion of malignancy a well-healed fistula track may provide strong tissue to anchor sutures. Meticulous dissection and visualization are important for the reconstruction of the genitourinary tract. Lesions near the ureteral orifice merit stenting of the ureter. The closure of the bladder and fistula site must aim to be watertight and tension free in multiple nonoverlapping layers. Interposition grafts are useful in complex, radiated, or recurrent cases. The patient must be optimized for surgery. Infections must be cleared using targeted antimicrobial therapy. Atrophic vaginal epithelium in the postmenopausal woman should be fortified with topical estrogen replacement therapy preoperatively ( Box 12.2 ).

Correct timing of the repair is imperative. Surgical repair should not be performed in the presence of active infection or significant inflammation. Conventional wisdom dictated a delayed repair with a 3- to 6-month “cooling-off” period to allow the fistula tract to mature and inflammatory process to subside. However, studies have shown that if a fistula is identified in the acute setting it may be treated successfully. Zimmern et al. observed that surgical repair performed within 2 to 3 weeks of the injury had no increased morbidity or failure rates when compared with delayed repair. Contraindications to early closure include multiple unsuccessful closures, associated enteric fistula with pelvic phlegmon, and previous radiation. These types of fistulas are usually repaired after a 4- to 8-month waiting period. Ultimately, the timing of surgery should be based on the preference of the surgeon and the patient, and other factors involving the specific clinical scenario.

Convention had dictated an abdominal approach for supratrigonal fistulas, whereas a vaginal approach was used for infratrigonal, bladder neck, and proximal urethral fistulas. Current practice among experienced transvaginal surgeons is a vaginal approach in cases of VVF with a few exceptions. The advantages of a vaginal approach include patient comfort and recovery time. It provides excellent exposure, access to multiple types of tissue interpositions, and the ability to perform multilayered closures without the morbidity associated with procedures that enter the abdominal cavity. Contraindications to a vaginal approach include severely indurated vaginal epithelium around the fistula, small capacity or poorly compliant bladder requiring augmentation, repair requiring ureteral reimplantation, involvement of other pelvic structures, vaginal stenosis, or the inability to obtain proper exposure .

An attempt should be made to repair the uncomplicated, or simple, fistula through the transvaginal approach ( Fig. 12.6 ). This technique was refined by Dr. Raz. The patient should be placed in dorsal lithotomy with care being taken to ensure protection of pressure points and adequate positioning. A cystoscopy is performed along with bilateral retrograde pyelograms if the upper tracts have not yet been assessed. An attempt should be made to catheterize the tract with a wire or conversely with a small Foley catheter or Fogarty catheter allowing for ease of dissection. A Foley catheter is inserted at the beginning of the case, the bladder is drained, and the catheter is clamped. Allis clamps and a ring retractor with sharp hooks are useful in retracting the vaginal epithelium ensuring adequate visualization for the dissection. A vaginal flap is raised using the inverted “J” or “U” configuration to include the fistulous tract. It is useful to mobilize the vaginal epithelium away from the fistula. The margins of the fistula are trimmed and closed using absorbable sutures. The fistulous tract may be left or excised. Excision provides the advantage of eliminating the fibrous tract and closure of mucosa-to-mucosa. The disadvantage is increasing the size of the repair. If the bladder is friable it may not hold stitches well. The fistulous tract provides tensile strength to the closure. The perivesical fascia is then closed with absorbable sutures in a perpendicular fashion (over the fistula tract), with the edges inverted. The bladder is filled with fluid or diluted methylene blue dye at this point to check for a watertight closure. At this point if a flap is needed it would be used to cover the repair. Finally, the vaginal wall is closed in a third layer, in a nonoverlapping absorbable suture line. A suprapubic tube and/or a Foley catheter are left for straight drainage, and anticholinergic/antimuscarinic medications are given liberally. Not all surgeons elect to leave two catheters in place postoperatively. A cystogram is performed 10–14 days postoperatively; if no extravasation is evident, the Foley and suprapubic catheters are sequentially removed. Refractory cases or those with fistulas near or at the vaginal cuff in patients that do not wish to preserve sexual function may be treated with obliterative procedures ( Fig. 12.7 ). In cases where the uterus is present a partial colpocleisis, such as the Latzko repair, will achieve closure of the fistula and vaginal canal while preserving the uterus. A 3- to 4-cm elliptical segment of the vaginal epithelium is excised on the anterior and posterior portion of the prolapsed vaginal wall. Linear sutures are then placed to invert the bladder wall while avoiding the bladder lumen. Further layers continue to invert the bladder wall. The vaginal wall is then closed with a running suture. A benefit of this procedure is that it requires minimal resection, as the vaginal space is obliterated.

Incisions for vaginal flap repair of a vesicovaginal fistula. The configuration of the J incision will depend on the location of the fistula.

A, For a more proximally located fistula, an anterior J is made. This allows for an anteriorly based flap.

B, For a more distally located fistula, a posterior J is made to allow a posteriorly based flap to be mobilized.

C, After mobilization of the vaginal wall, the fistula is fully exposed and ready for a two-layer closure. Ideally, there should be a distance of at least 1.0 to 1.5 cm from the fistula to the vaginal wall in all directions.

D, Two-layer closure of the fistula. The deep layer is full thickness, including the bladder mucosa. The more superficial layer is an imbrication of the seromuscular wall of the bladder.

(From Nitti VW, Rosenblum N, Brucker BM. Vaginal Surgery for the Urologist. 1st ed. Female pelvic surgery video atlas series. Philadelphia: Elsevier/Saunders; 2012:xvi.)

A vesicovaginal fistula located near the vaginal cuff has been catheterized with a small Foley catheter. Traction on the Foley catheter allows easy exposure and dissection.

(From Nitti, V.W., N. Rosenblum, and B.M. Brucker, Vaginal surgery for the urologist . 1st ed. Female pelvic surgery video atlas series. 2012, Philadelphia: Elsevier/Saunders. xvi, 200 p.)

Fistulas associated with mesh complications or radiation, or complex fistulas will require the use of tissue interposition grafts. Nonoverlapping suture lines in the vaginal and vesical repair ensure a successful reconstruction. The well-vascularized adipose tissue in the labia majora provides a supple graft for distal fistulas. A peritoneal flap may be harvested for a fistula high in the vaginal vault, particularly if there is a fresh closure of the vaginal cuff. The selection of autologous tissue depends on the size of the fistula, its location, the quality of patient tissues, and the surgeon’s preference. The bulbocavernosal fat, or Martius flap, is reliable, but it requires a separate incision. The pedicle originates from the posterior labial artery, a branch of the internal pudendal artery. The Martius flap may not reach fistulas high in the vaginal vault. The vagina may be shortened during attempts to extend the flap from the labia to the vagina. Peritoneum is an excellent substitute in these high fistulas; however, it can be challenging to mobilize to the lower vagina. The peritoneal flap is well vascularized and readily available, can be done with an open or closed peritoneum, and can be harvested with no additional incision. Patients that have devastating fistulas that require complex vaginal repairs can be treated with a Singapore flap. This is a fasciocutnaeous flap with a pedicle that is supplied by the pudendal artery. One can rotate the graft superior and medially to reconstruct the vaginal canal ( Fig. 12.8 ).

A, A Martius flap can be mobilized by making a longitudinal incision over the labia majora or in the crease between the labia minora and majora. Just underneath the skin is an avascular plane that sits between the skin and the underlying fat pad. B, In this case the flap is based on the blood supply from the inferior pudendal artery. The flap has been mobilized off the pubic bone and can now be tunneled under the labia minora and vaginal epithelium.

(From Nitti, V.W., N. Rosenblum, and B.M. Brucker, Vaginal surgery for the urologist . 1st ed. Female pelvic surgery video atlas series. 2012, Philadelphia: Elsevier/Saunders. xvi, 200p.)

When the Martius flap fails or in the case of a larger fistula as associated with obstructive labor, there are adjuvant flaps and techniques in the armamentarium of the reconstructive urologist. Techniques include the use of vaginal wall flaps, omental flaps, biologic patches, and muscle flaps. In a series of patients with complex urethrovaginal fistulas (UVFs) that were refractory to anatomic repair with Martius interposition flap, Bruce and colleagues used rectus abdominus flaps based on the inferior epigastric artery to successfully treat 83% of their patients. These flaps are not only useful as interposition flaps but also have been proposed to fortify the bladder neck in cases of intrinsic sphincter deficiency. The rectus flap has the advantage of being the least deforming to the exterior appearance of the patient. Similar techniques have been described using the gracilis muscle. In cases where the urethra is completely obliterated, tubularized bladder wall flaps and/or vaginal wall flaps are used to create a neourethra. An autologous fascial sling is then placed to reestablish the continence mechanism.

An open abdominal approach may be considered for complicated fistulas, previous failed repairs, a narrowed or stenotic vagina, those in close proximity to the ureters, or when concomitant procedures are being considered, such as ureteral reimplant or bladder augmentation. Further, if the surgeon is not well versed in vaginal surgery or is more comfortable with the abdominal approach, it is reasonable to perform the surgery with the probability of the best outcome. Abdominal surgery allows for harvesting of omentum, which serves as a supple interposition graft for the repair. A laparotomy does have the advantage of excellent exposure and visualization of the fistulous tract; however, it is at the expense of higher complications and the prolonged convalescence associated with abdominal surgery. Patients with abdominal repair also require longer hospitalizations when compared to transvaginal repairs. An abdominal surgery approach may be extraperitoneal or transperitoneal, as well as extravesical or transvesical. The classic approach as described by O’Connor and Sokol entails a transabdominal transvescial repair where the bladder is bivalved to the fistulous tract. The vaginal wall is dissected off the bladder, and the fistulous tract is closed on both ends. An omental or peritoneal flap is placed in between the bladder and vaginal wall to prevent recurrence. The incidence of bladder spasms is usually more pronounced following abdominal repairs and the standard use of a suprapubic tube. Urethral catheters and anticholinergics/antimuscarinics are maintained until a voiding cystourethrogram is performed 2–3 weeks postoperatively. In severely refractory cases one may consider the use of urinary diversion. This has been found useful in patients with multiple failed attempts, patients with extensive radiation, or very large soft tissue defects. One may consider a continent pouch (i.e., Indiana pouch) versus an incontinent diversion (i.e., ileal conduit); however, orthotopic neobladders (i.e., Studer) are usually not employed.

Advances in minimally invasive techniques have seen a rise in the surgical repairs approached via pure laparoscopy or with robotic assistance. While this technology is still being developed and refined, successful outcomes have been reported. There were some initial difficulties maintaining pneumoperitoneum, but this has been overcome with the use of a vaginal packing and placing the Foley to mild traction. In a comparative analysis of outcome between open and robotic surgical repair of recurrent supratrigonal VVF, Gupta et al. noted similar outcomes in terms of fistula resolution, exceeding 90% in both groups. Surgical complications such as blood loss and hospital stay were less in the robotic versus open group. They concluded that due to the decreased morbidity of the robotic over open approach, a transabdominal robotic repair should be considered in refractory cases. The vaginal approach, however, may still remain the truly most minimally invasive approach, but does require a unique skill set.

The success rate of VVF repairs appears to be independent of the surgical approach, as long as the surgeon ensures a watertight repair with nonoverlapping suture lines and the use of interposition flaps as needed. In the absence of infection, inflammation, or previous radiation there is no additional benefit to delay of the surgical repair if the injury is recognized early in the postoperative period. This also minimizes the patient’s distress and discomfort. The ideal timing of repair is at the time of injury. The success rates of repairs are equivalent for the abdominal and vaginal approach and in most series exceed 80–90%. Fistulas in radiated patients and those with prior failed repairs have inferior results; patients must therefore be counseled adequately. These patients can be treated temporarily with urinary diversion. This allows for tissue healing and resolution of inflammatory processes. Healing can occur and large defects may decrease in size and granulate. Primary closure at times can be achieved using interposition grafts or muscle flaps. Some patients that persist with urinary leakage, even after successful fistula repair, may call for a permanent urinary diversion.