Neobladder-to-vagina fistula management: Case report and short literature review

Abstract

Neobladder-vaginal fistula (NVF) is a rare complication after radical cystectomy with orthotopic neobladder, impacting patient quality of life. This case report describes successful transvaginal, multilayered closure of NVF in a 59-year-old woman with urinary incontinence post-surgery. Despite prior intraoperative repair, an 8mm fistula was detected and repaired transvaginally. A watertight test confirmed closure, and the patient remained continent at 22 months follow-up. NVF rates range from 3 to 6%, with risk factors including poor vaginal vascularity and intraoperative injury. This case supports transvaginal repair as an initial approach, with further research needed to refine NVF management strategies.

1 Introduction

Neobladder-vaginal fistula (NVF) is a rare but significant complication following radical cystectomy with orthotopic neobladder (ONB) reconstruction. This complication can severely impact a patient’s quality of life, leading to urinary incontinence, infections, and the potential need for further invasive procedures.

In this case report and short literature review, we discuss a case of a Neobladder-Vaginal Fistula (NVF) successfully treated by surgery and explore the epidemiology these fistulas, risk factors, timing and presentation and its subsequent management.

2 Case presentation

We present the case of a 59-year-old caucasian woman who developed continuous urinary incontinence 4 months after undergoing a pelvic organ-preserving RC with complete anterior vaginal wall preservation for a localized muscle invasive bladder cancer. Intra-operatively a direct inadvertent injury to the anterior vaginal wall was reported and immediately corrected with a continuous suture of polyglycolic acid. In the post-operative period, she developed an abscess in the pelvic cavity successfully treated with antibiotics. During a cystoscopic evaluation a fistula to the vagina of about 8 mm at 6’oclock was diagnosed and confirmed after speculum examination.

The patient was taken to the operating room for a layered closure of the fistula through a vaginal approach.

In an exaggerated lithotomy position ( Fig. 1 ), a LONE STAR® retractor was put in place, opening the vaginal introit and exposing a larger fistula than previously anticipated with around 2 × 2cm ( Fig. 2 ). A circular incision around the fistula was made with a 15 blade scapel and the underlying vaginal epithelium was dissected off the muscularis circumferentially around it. Once there was adequate mobilization around the fistula circumferentially, a single interrupted layer of 3-O Vicryl® was placed transmurally into the neobladder to close the defect. A second imbricating layer of the same suture was then placed perpendicular to the first suture line ( Fig. 3 ). A watertight test was done, after distending the bladder with the injection of 300mL of saline solution. No flap was performed. The vaginal epithelium was closed in a running-locked fashion with 2-0 Vicryl® suture ( Fig. 4 ). A Foley catheter was placed intraoperatively. A vaginal packing was left for 24h and removed the following day.