Presentation

The most common complaint in patients with VVF is constant urinary drainage per vagina. The amount of urinary leakage can vary considerably from patient to patient and may be proportional to the size of the fistula tract. Patients may void a variable amount, depending on the size of the fistula and the volume of urinary leakage. For example, when a large VVF is present, patients may not void at all and simply have continuous leakage of urine into the vagina. Small, pinpoint fistulae may present with intermittent wetness, which is positional in nature. In the supine position, when sleeping, the amount of leakage reported by the patient may be minimal, but upon rising to a seated or standing position, the amount of leakage may increase precipitously. Patients may also complain of recurrent cystitis, perineal skin irritation due to constant wetness, vaginal fungal infections, or rarely pelvic pain. In fact, pain is an uncommon finding in patients with VVF, unless there is considerable skin irritation or the VVF occurred as a result of radiation therapy.

VVF following hysterectomy or other surgical procedures may present upon removal of the urethral catheter, or VVF may present 1 to 3 weeks later with urinary drainage per vagina. It may be possible to identify some patients at high risk for VVF in the immediate postoperative period. Kursh and colleagues (1988) noted that patients who developed VVF following hysterectomy more commonly had postoperative ileus, hematuria, bladder irritability, and elevated white blood cell count compared with a cohort of patients who did not develop VVF. Occasionally, posthysterectomy VVF may go undiagnosed for an extended period of time, because postoperative clear or serosanguinous vaginal discharge is often attributed to the surgery itself.

As noted previously, VVF resulting from radiation therapy may not present for months to years following completion of radiation. These tend to be very challenging reconstructive cases due to the size and complexity of the fistula, the poor quality of the surrounding tissues, and the associated voiding dysfunction due to the radiation effects on the urinary bladder.

Physical Examination

A pelvic exam with a speculum should always be performed in the evaluation of VVF. The bivalved speculum examination usually provides a precise assessment of VVF including the location, size, and number of fistulae. Vaginoscopy has been suggested as an adjunct measure, in some cases, using a modified endoscope to precisely visualize the fistula tract (Redman, 1990). Most commonly, VVF following hysterectomy are located along the anterior vaginal wall at the level of the vaginal cuff (Fig. 77–4). A visual and manual assessment of inflammation surrounding the fistula is necessary, because it may affect timing of the repair. Significant inflammation, infection, or induration around the fistula may mitigate against immediate repair. Relevant vaginal anatomy, including depth, associated prolapse, atrophy, and introital size are carefully recorded, because these may affect the surgical approach to repair. Anatomically, fistulae located high in the vagina, at the level of the hysterectomy cuff in a deep narrow vagina, may be best approached by some surgeons abdominally because a vaginal approach in these patients can be challenging. This may be especially relevant in nulliparous females in whom there is usually very limited pelvic floor laxity or vaginal prolapse. Postmenopausal vaginal atrophy may be treated with preoperative topical estrogen replacement, thereby optimizing the health and vascularity of potential reconstructive flaps. Palpation for masses or other pelvic pathology, which may require attention at the time of fistula repair, is also performed. Notation of prior incisions in the perineum, lower abdomen, and thigh is necessary because these tissues may be required for flap reconstruction when definitive repair is undertaken.

Figure 77–4 Vesicovaginal fistula (VVF) on physical examination. A large VVF is seen at the apex of the vagina after hysterectomy. The VVF in this image is seen as reddish pink bladder mucosa prolapsing into the vagina. Hand-held Heaney right-angled retractors provide lateral retraction in this image.

The presence of a VVF may be confirmed by instilling a vital blue dye into the bladder per urethra and observing whether vaginal drainage is discolored. Small or occult fistulae may be identified in this fashion (Drutz and Mainprize, 1988). A colored solution, such as methylene blue or indigo carmine, is mixed into solution and infused into the bladder. The vagina may be packed with gauze or directly inspected for blue-tinged leakage. If blue-tinged leakage is not apparent and the diagnosis of VVF is in doubt, the sensitivity of this test may be improved by placing a vaginal packing and ambulating the patient for a short period of time. Staining at the introital (distal) end of the packing suggests urinary incontinence or a urethrovaginal fistula, whereas proximal staining suggests a VVF. If the vaginal packing remains dye-free with this maneuver, then the possibility of a ureterovaginal fistula can be investigated with the use of a clean vaginal packing, intravenous indigo carmine (or other vital dye), and a repeat pad test. Blue staining at the proximal end of the pad, following this maneuver, suggests the presence of a ureterovaginal fistula.

A double dye or tampon test may confirm the diagnosis of urinary fistula, as well as suggest the possibility of an associated ureterovaginal or urethrovaginal fistula (Moir, 1973; Raghavaiah, 1974). In one variation of the double dye test, a tampon is placed per vagina. Oral phenazopyridine is administered, and vital blue dye is instilled into the bladder. If the tampon is discolored yellow-orange at the top, it is suggestive of a ureterovaginal fistula. Blue discoloration in the midportion of the tampon suggests VVF, whereas blue staining at the bottom suggests a urethrovaginal fistula.

Clear vaginal discharge following hysterectomy does not invariably represent a urinary fistula or incontinence. Other than normal vaginal secretions, less common causes include a peritoneovaginal fistula (Ginsberg, 1998), lymphatic fistula (Lau and Wong, 1994), vaginitis, and fallopian tube fluid (Leach, 1987). Incontinence following caesarian section, in which a VVF has been excluded, may suggest the possibility of a ureterovaginal or vesicouterine fistula.

Cystoscopy

An endoscopic examination should be performed in patients with a suspicion of VVF (Fig. 77–5). Immature fistulae may appear as an area of localized bullous edema without distinct ostia. Mature fistulae may have smooth margins with variably sized ostia. In some cases, multiple pits and cavities along an area of the traumatized posterior bladder wall, in the setting of a small VVF, may make it difficult to identify the exact fistula tract. In these cases, a guidewire or ureteral catheter may be placed through the working channel of the cystoscope and into the fistula tract (Fig. 77–6). Visualization of the wire in the vagina confirms the exact location of the VVF on both the bladder and genital sides. Cystourethroscopy can confirm the presence of the fistula, but also may assess the size of the tract, the presence of collateral fistulae, and the location of the ureteral orifices in relation to the fistula. Small fistulae, usually less than 3 to 4 mm in diameter may be amenable to simple fulguration, which can be performed at the time of cystoscopy (see later discussion) (Stovsky et al, 1994). Importantly, in the setting of a prior history of pelvic malignancy, a biopsy of the fistula is often done to evaluate for the possibility of a recurrent malignancy. Fistulae located near or at the ureteral orifice may require ureteral reimplantation at the time of VVF repair. This type of requirement would usually mitigate against a completely transvaginal attempt at repair.

Figure 77–5 Endoscopic view of vesicovaginal fistula (VVF). This is the same patient as in Figure 77–4. The fistula is now seen from the bladder side. This VVF is large enough to see directly into the vagina (V) through the bladder (B).

Figure 77–6 Confirmation of a vesicovaginal fistula (VVF). A 4-Fr ureteral catheter traverses the fistula tract in this endoscopic photograph. The VVF is high on the posterior bladder wall, the typical location for a post-hysterectomy VVF. The right ureter is seen (arrow).

Imaging

A cystogram and/or voiding cystourethrogram (VCUG) and an upper tract study should be performed in patients being evaluated for a VVF. The cystogram may objectively determine the presence and location of the fistula. Upon filling of the bladder, contrast often begins to opacify the vagina, almost immediately confirming the presence of a VVF. VVF are often best seen in the lateral projection (Fig. 77–7) in which the bladder and vagina are not superimposed. Often, the actual VVF tract may be visible in the lateral projection (Fig. 77–8). However, voiding images may be necessary in some patients with small fistulae, to demonstrate the VVF. The slight increase in intravesical pressure that accompanies micturition is usually adequate to demonstrate even very small fistulae. Importantly, a cystogram that fails to demonstrate a suspected VVF, but lacks voiding images or postvoid images, should be considered nondiagnostic. During voiding, care should be taken to exclude vaginal voiding or reflux of contrast from the introital region cephalad into the vagina, which would produce a falsely positive image. An involuntary bladder contraction can be provoked with rapid filling during cystography, and if the intravesical pressure rises sufficiently, this may also be sufficient to demonstrate a VVF when the filling images of the cystogram failed to demonstrate it. In some instances, a cystogram can also make an assessment of bladder capacity (important in the setting of prior radiotherapy), cystocele, bladder neck competence, and vesicoureteral reflux, any of which may have an impact on operative repair.

Figure 77–7 Cystogram demonstrating a vesicovaginal fistula (VVF). A, Lateral image demonstrates a posthysterectomy VVF. B, Anteroposterior view. The contrast agent is seen opacifying and outlining the vagina superimposed on the bladder.

Figure 77–8 Lateral image during cystography demonstrates the vesicovaginal fistula tract.

Up to 12% of postsurgical VVF have an associated ureteral injury or ureterovaginal fistula (Goodwin and Scardino, 1980); thus, upper urinary tract evaluation is important. Intravenous urography (IVU) (Gerber and Schoenberg, 1993), or, more recently, computed tomography (CT) urography is usually sufficient for this purpose. In one series of 216 consecutive patients with VVF due to obstructed labor, almost 50% of patients were diagnosed with an upper tract abnormality on IVU; caliectasis was found in 71% of those affected; however, almost 10% were found to have a nonfunctioning renal unit (Lagundoye et al, 1976). If there is a suspicion for a ureterovaginal fistula, or if the distal ureter is not well seen IVU, retrograde pyelography may be performed (Blandy et al, 1991) (Fig. 77–9).

Figure 77–9 Algorithm for the diagnosis of vesicovaginal fistula (VVF). CT, computed tomography; IVU, intravenous urography; RPG, retrograde pyelography; VCUG, voiding cystourethrography.

In addition to contrast cystography and VCUG, CT, ultrasonography, and magnetic resonance imaging (MRI) have been used in the evaluation of VVF (Kuhlman and Fishman, 1990; Outwater and Schiebler, 1993; Yang et al, 1994). Delayed CT visualization of contrast within the vagina is considered highly suspicious for VVF in the majority of cases (Kuhlman and Fishman, 1990) (Fig. 77–10). In cases of suspected VVF, CT should be performed with only intravenous contrast, or, alternatively, a CT cystogram can be performed to isolate the bladder. A vaginal tampon placed per vagina during IVU or CT scan may improve the sensitivity for finding small or occult VVF in patients with an otherwise negative evaluation (Wesolowski and Meaney, 1977). Cross-sectional imaging may also be helpful in assessing for recurrent malignant disease in those with such a history.

Figure 77–10 CT scan of vesicovaginal fistula (VVF). A, After intravenous administration of the contrast agent, there is high-density material in both the bladder and vagina consistent with a VVF. The fistulous connection between the bladder anteriorly and the vagina posteriorly. B, Sagittal CT reconstruction demonstrating VVF.

Other Studies

Appropriate urine studies including culture, and cytology when indicated, are performed. When infection is detected, appropriate antibiotic coverage is initiated. Urodynamics, including videourodynamics, are generally not necessary in the evaluation of routine posthysterectomy VVF. However, in the setting of a prior history of radiation, radical pelvic surgery (e.g, radical hysterectomy), or in those with preexisting neurogenic vesicourethral dysfunction, a urodynamic evaluation can be used to evaluate for significant detrusor dysfunction, including impaired bladder compliance. In patients with a history of significant symptoms of voiding dysfunction and incontinence preceding the VVF, urodynamic evaluation may help to define these symptoms prior to repair of the VVF (Hilton, 1998), an important element in preoperative counseling regarding potential outcomes and preparation for the optimal operative plan.

Timing: Immediate versus Delayed Repair

The timing of VVF repair is somewhat controversial. Repair of VVF should be as expeditious as possible to minimize patient suffering; however, optimal timing for repair should allow consideration of certain medical and surgical factors as well. It is generally accepted that VVF resulting from obstructed labor should be associated with a 3- to 6-month delay prior to definitive repair (Wein et al, 1980a, Arrowsmith, 1994; Waaldijk, 1994) to allow maximum demarcation of ischemic tissue and resolution of the associated edema and inflammatory reaction. Longer periods of time, up to 6 to 12 months, have been advocated for radiation-induced fistulae (Wein et al, 1980a), which are often associated with severe obliterative endarteritis and reduced tissue vascularity.

In the classical teaching of VVF, a minimal waiting period of several months is suggested—from the inciting event prior to the definitive repair attempt—to allow reduced tissue edema and inflammation, and optimal pliability of the tissues (Persky and Rabin 1973; Lawson, 1978; O’Conor, 1980; Wein et al, 1980a). O’Conor recommended a waiting period of 3 to 6 months for suprapubic VVF repairs (O’Conor et al, 1973). In this setting, reduced inflammation and edema permit easier identification of tissue planes (and therefore flap development), less bleeding, and less tension on the reapproximated suture lines. However, over the ensuing decades, the enthusiasm for delayed management has waned and, in general, uncomplicated postgynecological urinary fistulae may be repaired as soon as they are identified and confirmed, thereby minimizing patient discomfort and anguish (Collins et al, 1971; Persky et al, 1979; Fourie, 1983; Badenoch et al, 1987a; Cruikshank, 1988; Wang and Hadley 1990; Blandy et al, 1991; Blaivas et al, 1995; Kostakopoulos et al, 1998b). This is especially true when they occur as a result of clean surgical trauma (Wang and Hadley, 1990). Nondelayed closure has also been applied to obstetric fistulae with good results (Waaldijk, 1994; Waaldijk, 2004). Nevertheless, in some cases, the timing of a VVF repair is best tailored to the individual patient (Blaivas et al, 1995). Raz and colleagues (1993) suggested that uncomplicated VVF following abdominal hysterectomy could and should be repaired as expediently as possible transvaginally; however, a 2- to 3-month waiting period may be warranted for some VVF following vaginal hysterectomy. Conversely, if an abdominal approach is being considered following a particularly difficult or complicated abdominal surgery that resulted in the VVF (i.e, complicated by abscess, urinoma), then a delay may be warranted to allow resolution of active inflammation. Another potential reason to delay repair is to treat ongoing infection or inflammation at the level of the vaginal cuff. Periodic reexamination of the vaginal tissues can be performed every 1 to 2 weeks and definitive repair scheduled when suitable pliability is noted (Carr and Webster, 1996).

A vaginal approach can be attempted as soon as 2 to 3 weeks after the initial injury, if conservative therapy fails (i.e., the patient remains wet when a Foley catheter is in place to provide adequate drainage of the bladder) and the patient is in good general health. The vaginal tissues are usually relatively undisturbed from the prior causative surgery, especially if the surgery was transabdominal. Wide healthy vaginal flaps can usually be obtained. In the rare circumstance when a VVF presents within the first 24 to 48 hours postoperatively, an immediate repair can be attempted (Margolis and Mercer, 1994); however, it is possible that these VVF, especially if small in diameter, may heal spontaneously with catheterization over the course of several weeks. It is well documented that similar outcomes can be achieved with early versus delayed abdominal and vaginal repair (Collins et al, 1960; Persky et al, 1979; Zimmern et al, 1985; Badenoch et al, 1987a; Wang and Hadley, 1990; Blandy et al, 1991) with success rates in excess of 90% for uncomplicated VVF.

Approach: Abdominal versus Vaginal

Vesicovaginal fistulae may be repaired through a transvaginal or transabdominal (transvesical) approach. Each approach has merits depending on the particular circumstances of the fistula, and excellent outcomes can be expected with both approaches (Table 77–4). Although factors such as size, location, and the need for adjunctive procedures often influence the choice of approach, the most important factor is the experience of the operating surgeon. Thus there is no preferred approach for all fistulae, and the “optimal” approach to the uncomplicated postgynecological VVF is usually the one that is most successful in the individual surgeon’s hands (Gerber and Schoenberg, 1993; Akman et al, 1999). Although it has been a long-held belief that gynecologists prefer to fix VVF transvaginally, and urologists prefer a transabdominal approach due to their respective training and experience, (Edwards, 1982; Gerber and Schoenberg, 1993), this difference is becoming increasingly blurred as urologists gain more experience and comfort operating transvaginally for a variety of disparate indications.

Table 77–4 Abdominal versus Transvaginal Repair of Vesicovaginal Fistula

The vast majority of VVF in the industrialized world are amenable to a transvaginal repair (Turner-Warwick, 1972; Margolis and Mercer, 1994). The relative advantages of a transvaginal approach compared with an abdominal approach are outlined in Table 77–5 and include shorter operative times, briefer hospital stay, and less blood loss (Goodwin and Scardino, 1979). The principal disadvantages of the transvaginal approach include the relative lack of familiarity of the vaginal cuff anatomy to many urologists; the potential for vaginal shortening, especially with the Latzko approach; and, finally, the difficulty in exposing high or retracted fistulae located near the vaginal cuff, especially in deep, narrow vaginas, or in those without any apical prolapse, such as that found in nulliparous females (see Fig. 77–2). Patients who are unable to get into the high-lithotomy position due to musculoskeletal conditions are not candidates for a transvaginal approach.

Table 77–5 Potential Advantages of a Transvaginal Approach for Posthysterectomy Vesicovaginal Fistula

The abdominal approach to VVF repair is advantageous in several circumstances. If the VVF is associated with other intra-abdominal pathology requiring repair—including an associated ureteral injury (i.e., ureterovaginal fistula), or a complex fistula, including those involving another intra-abdominal organ—then a transabdominal approach is indicated to address the problems simultaneously. If the VVF is located adjacent to the ureteral orifice, some authors have suggested that this is an indication for an abdominal approach (Carr and Webster, 1996), whereas others have not so advocated (Dupont and Raz, 1996). In patients with a small capacity or poorly compliant bladder (often secondary to radiation) requiring augmentation cystoplasty, an abdominal approach is indicated, because both procedures can be performed using the same incision. Complicated fistulae, including those associated with multiple prior failed attempts at repair (Kristensen and Lose, 1994) or those which are quite large (>5 cm), might be best approached abdominally as well. Nevertheless, a prior failed attempt at repair is not necessarily a contraindication to a transvaginal approach because excellent results can be achieved in this setting (Eilber et al, 2003).

Combined transabdominal-transvaginal approaches to VVF have been described (Clark and Holland, 1975; Taylor et al, 1980; Henriksson et al, 1982a). This approach may be applicable selectively in the setting of large, complex, or recurrent VVF after prior attempts at repair.

Handling of Fistula Tract: Excision versus No Excision

A long-held tenet for successful fistula closure, dating back to Sims’ original description in 1852, involves complete excision of the fistulous scar tissue and tract (Fearl and Keizur, 1969; Persky et al, 1979; Wein et al, 1980a; Fourie, 1983). This approach ensures clean, well-vascularized viable edges to be approximated for the initial layer of repair. Simple excision of the scar in an inverted “funnel” shape with careful reapproximation of the defective edges has been shown to be an effective repair of VVF (Iselin et al, 1998; Flynn et al, 2004). However, excision of the fistula tract itself is not always necessary and may even compromise the repair in some patients (Zimmern et al, 1985; Cruikshank, 1988; Tancer, 1992; Raz et al, 1993; Margolis and Mercer, 1994). There are several potential disadvantages of excision of the fistula tract. Firstly, this creates a larger soft tissue defect to be repaired. Excision of the fibrous tract may lead to bleeding, which, if cautery is used, may result in tissue necrosis and impede healing (Eilber et al, 2003). If the VVF is adjacent to the ureter, then excision of the tract may mandate reimplantation of the ureter. Alternatively, if the tract is left in situ, the ureter may be catheterized for the repair and then left undisturbed during a transvaginal operation, obviating the need for reimplantation. In addition, in chronic fistulae, a strong fibrous ring forms outside the epithelialized tract, which maintains some strength through the repair if this layer is incorporated into the closure. This can be an important consideration in those patients with significant detrusor overactivity postoperatively from either the repair itself or the indwelling drainage catheters.

Use of Adjuvant Flaps or Grafts: Type and Application

Prior to embarking on surgical repair, the surgeon should be familiar with a variety of adjuvant flaps and grafts that allow for the interposition of healthy tissue during VVF repair. It is often not possible to predict which patients will require these procedures ahead of time. The indications for tissue interposition are not well defined, but these measures are most commonly used in the setting of radiated tissues, obstetrical fistulae, failed prior repairs, large fistulae, and those with tenuous repairs. The various types of flaps will be discussed in more detail later in the chapter.

Other Considerations

Preoperative estrogen supplementation may be beneficial in the postmenopausal patient with vaginal atrophy and VVF (Massee et al, 1964). There exists little data in the literature, beyond expert opinion, to support their use. However, topical estrogen preparations may improve vascularity (Margolis and Mercer, 1994) and local tissue quality (Carr and Webster, 1996). Therefore a trial of topical estrogens in individuals with postmenopausal vaginal atrophy and a posthysterectomy VVF may be warranted provided that there are no contraindications to their use.

Perioperative intravenous antibiotics are often administered, although their utility in the posthysterectomy VVF repair is questionable in the absence of infection. Whether antibiotics should be administered prophylactically prior to surgical repair is controversial, but at least one study suggests that preoperative antibiotics do not improve outcomes when administered prior to the repair of obstetric fistula (Tomlinson and Thornton, 1998). Treatment of existing infection based on preoperative urine culture is potentially beneficial in preventing bacteremia during surgery. However, prolonged use of broad-spectrum antibiotics postoperatively following repair may result in bacterial resistance and possibly fungal vaginal infections that may compromise suture lines.

Sexual activity should be documented preoperatively. Patients should be specifically queried regarding sexual function and dyspareunia occurring prior to the onset of the event that resulted in the fistula. Although this data is subject to recall bias, it may play an important role in the choice of surgical approach, as well as having medicolegal implications postoperatively.

Related posts:

Definitive Therapy for Localized Prostate Cancer: An Overview Tuberculosis and Other Opportunistic Infections of the Genitourinary System Surgical Procedures for Sphincteric Incontinence in the Male: The Artificial Genitourinary Sphincter and Perineal Sling Procedures Prosthetic Surgery for Erectile Dysfunction Minimally Invasive and Endoscopic Management of Benign Prostatic Hyperplasia Ectopic Ureter, Ureterocele, and Ureteral Anomalies

Stay updated, free articles. Join our Telegram channel

Join