Uro gynacology- urethrovaginal f.

1. Urethrovaginal Fistula
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical
College
Chennai

2. Moderators:
Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D. Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH,
Chennai
2

3.  urethrovaginal
fistulae are not
identical to
vesicovaginal
fistulae
 major causes
Obstetric trauma &
vaginal surgery
 Increasing
incidence with slingDept Of Urology, KMC and GRH,
Chennai
3

4. Contents Etiology,Clinical features
Preoperative evaluation
Goals of treatment
Timing of repair
Foreign body
Fistula tract excision or no excision
Steps of surgical repair
Martius flap/ Adjuvent flaps
Management of concommitent SUI
Prevention of fistulae formation
Dept Of Urology, KMC and GRH,
Chennai
4

5. ETIOLOGY & CLINICAL
PRESENTATION
Dept Of Urology, KMC and GRH,
Chennai
5

6. Etiology
 obstructed
deliveries
 Post surgical
- urethral diverticulectomy
- anterior colporrhaphy,
- transurethral resection
of the bladder neck,
-Transsexual surgery
- drainage of a
periurethral abscess
-paraurethral cyst
removal
 anti-incontinence
 Trauma
- Pelvic fractures
and urethrovaginal
lacerations
.
 Radiotherapy
induced necrosis
- vaginal and
urethral neoplasms
 Infective- LGV , TB,
Schistosomiasis
 congenital
Dept Of Urology, KMC and GRH,
Chennai
6

7. Poor surgical
techniques
- closure of the urethral
lumen without verifying
water-tightness,
- overlapping suture
lines,
- lack of consideration
for tissue interposition,
- insufficient bladder
drainage
Dept Of Urology, KMC and GRH,
Chennai
7

8. Obstetric injuries – Field injury
 prolonged pressure on the
soft tissues of the vagina,
bladder base, and urethra
 causing widespread tissue
edema, hypoxia,necrosis,
and sloughing
 even if the fistula can be
repaired successfully
Complex neuropathic
bladder dysfunction and
urethral sphincteric
incompetency often result,
Dept Of Urology, KMC and GRH,
Chennai
8

9. Obstetric fistula (Waaldijk)
Dept Of Urology, KMC and GRH,
Chennai
9

10. Clinical Features
 proximal Fistulae
- continuous
incontinence,
perineal skin
irritation,recurrent
UTI
 Distal fistula
- asymptomatic.
- spraying-type split
stream.
Vaginal voiding
Pseudo incontinence
Dept Of Urology, KMC and GRH,
Chennai
10

11. Obstetric Injury complex
 Urethral loss
 Stressincontinence
Hydrouretronephrosis
 Renal failure
 Rectovaginalfistula
 Rectal atresia
 Anal sphincter
incompetence
 Cervical destruction
 Amenorrhea
 Pelvic inflammatory
disease
 Sec. infertility
 Vaginal stenosis
 Osteitis pubis
 Foot drop
Dept Of Urology, KMC and GRH,
Chennai
11

12. Clinical presentation
 90% of genitourinary fistulas associated with
pelvic surgery are symptomatic within 7–30d
postoperatively.
 anterior vaginal wall laceration associated
with obstetric fistulas (75%) presents within
the first 24 h after delivery.
 radiation induced UVFs are associated with
slowly progressive devascularisation necrosis
and may present 30d to many years later
Dept Of Urology, KMC and GRH,
Chennai
12

13. History and Physical
Examination
 Review the prior operative notes
evaluate tissue quality
multi-operated,
densely scarred, or atrophic tissues
 Risk factors for deficient healing
immunosuppression,
malnutrition,
irradiation
Dept Of Urology, KMC and GRH,
Chennai
13

14. Differential diagnosis
 vesicovaginal fistula,
 ureterovaginal
fistula,
 severe stress or
urgency
incontinence,
 copious vaginal
discharge
Dept Of Urology, KMC and GRH,
Chennai
14

15. Preoperative
evaluation
Dept Of Urology, KMC and GRH,
Chennai
15

16. key factors in approaching
the patient with a UVF
 The underlying
cause,
 number of prior
repairs,
 damage to the
continence
mechanism
Dept Of Urology, KMC and GRH,
Chennai
16

17. voiding cystourethrography
(VCUG)
Dept Of Urology, KMC and GRH,
Chennai
17

18. A) Axial CT image:
opacification of the vagina.
B) Sagittal CT image:
continuity between the urethra and vagina.
Dept Of Urology, KMC and GRH,
Chennai
18

19. Renal ultrasonography and
intravenous pyelography
- to exclude congenital abnormality.
- for large or multiple fistulas to exclude
ureteral obstruction or an associated
UVF
Dept Of Urology, KMC and GRH,
Chennai
19

20. Urethral magnetic resonance
imaging
- to identify a fistula tract
- in case of suspected residual
diverticulum pocket
- after urethral diverticulectomy
Dept Of Urology, KMC and GRH,
Chennai
20

21. Dept Of Urology, KMC and GRH,
Chennai
21

22. Sagittal fat-suppressed T2-
weighted MR image
 Urethrovaginal
fistula in a 23-year-
old woman with a
history of prior
vaginal septum
resection.
 The bladder is
empty
Dept Of Urology, KMC and GRH,
Chennai
22

23. Retrograde positive-pressure
urethrography- Trattner catheter
 Under anesthesia
 Triple lumen catheter
 Proximal balloon is
placed in the bladder
 the distal (wedge-
shaped) balloon slides
to occlude the external
meatus
 Contrast egresses
through an opening
between the two ballons
 Outlining diverticula
with ostial diameter of
1.7 mm
Dept Of Urology, KMC and GRH,
Chennai
23

24. Urodynamic studies
 higher incidence of
SUI & detrusor
instability in fistulae
involving the
urethra or bladder
neck
 Obtain informed
consent from the
patients about fistula
recurrence, SUI, or
obstructive voiding
complications
Dept Of Urology, KMC and GRH,
Chennai
24

25.  type & size of the defect
 its location in the urethra
 status of the bladder neck,
trigone & ureteric orifice
Cystourethroscopy - under Anesthesia
Dept Of Urology, KMC and GRH,
Chennai
25

26.  Condition of the surrounding
tissues for changes
 Biopsy for friable and
irregular fistula edges
 Quality & length of the
anterior vaginal wall
 Condition of the labia minora
& the labia majora.
Dept Of Urology, KMC and GRH,
Chennai
26

27. MANAGEMENT
Dept Of Urology, KMC and GRH,
Chennai
27

28. Goals of treatment
 To restore urethral continuity
 To secure continence
 To cover the defect with fresh
vascularised tissue to prevent
recurrence
Dept Of Urology, KMC and GRH,
Chennai
28

29. Principles of Fistula Repair
Technique
 Intraoperative use of
urethral sounds
helps to identify
small defects
 Watertight closure
with fine
monofilament
synthetic absorbable
material
Dept Of Urology, KMC and GRH,
Chennai
29

30. Principles of Fistula Repair
Technique
 To minimise urethral stenosis
postoperatively
 Avoidance of deep suturing of the
urethral wall
 suturelines, which are oriented
longitudinally to the axis of the urethra,
 Bring additional tissues with great
care after sufficient vaginal wall
mobilisation.
Dept Of Urology, KMC and GRH,
Chennai
30

31. Management - Observation
 Small fistulas in the
distal urethra may
observed if
asymptomatic.
 catheter drainage
in the case of a
small fistula -
Dept Of Urology, KMC and GRH,
Chennai
31

32.  small , non-irradiated UVF
- multilayered closure with an
interpositional graft such as a Martius
flap
 larger UVF
- urethral reconstruction &
flap interposition for continence and
closure
Dept Of Urology, KMC and GRH,
Chennai
32

33. An inverted U-incision
is made in the vaginal
wall with the apex just
proximal to the fistula
Fistula is circumscribed
but not excised.
Avascular plane beneath
the lateral vaginal wall is
developed.
Dept Of Urology, KMC and GRH,
Chennai
33

34. fistula is closed with
absorbable suture
Two longitudinal incisions
are made to create
medially based flaps.
Dept Of Urology, KMC and GRH,
Chennai
34

35. The flaps are rolled
over a 14Fr urethral
catheter.
vaginal flap is closed with a
running, locking absorbable
suture
Dept Of Urology, KMC and GRH,
Chennai
35

36. Martius fat-pad graft
 The labium majus is
incised,
 Martius fat-pad graft
is mobilized with
care to preserve the
posteriorly located
pudendal vessels
Dept Of Urology, KMC and GRH,
Chennai
36

37.  The labial fat pad is
passed through a
medial tunnel and
secured over the
fistula repair site.
Dept Of Urology, KMC and GRH,
Chennai
37

38.  The vaginal wall flap
is advanced over
the fat-pad graft,
resulting in closure
with no overlapping
suturelines.
 it becomes difficult
to close the vaginal
incision if the fat pad
is bulky
Dept Of Urology, KMC and GRH,
Chennai
38

39. A meatus-based
vaginal flap is rotated distally.
Dept Of Urology, KMC and GRH,
Chennai
39

40. Tissue interposition
 interposition of well-vascularized tissue is
often required to ensure adequate healing
 The fascial sling has the added benefit of
providing an extra layer of tissue between
the urethral repair and vaginal closure
 synthetic sling should never be used in an
incontinence procedure at the time of a
urethrovaginal repair
Dept Of Urology, KMC and GRH,
Chennai
40

41. Timing of repair
 Repair is usually delayed for >2 months
after the initial injury to allow the
inflammation to resolve.
 When the fistula is a result of radiation
therapy, repair is usually delayed for
≥1 year until the fistula tract has time to
mature and the ischemic injury has
stabilized
Dept Of Urology, KMC and GRH,
Chennai
41

42. foreign body
 synthetic sling
should be excised
as widely as
possible from the
margins of the
fistula
 Debridement
performed on the
associated inflamed
tissue
 fistula closed with
healthy tissues and
flaps
Dept Of Urology, KMC and GRH,
Chennai
42

43. Additional tissue flaps
 gracilis flap, rectus flap – Post radiation fistula
peritoneal flaps,
 gluteal skin flaps,
omental flaps,
 lyophilized dura mater patches.
 pedunculated rectus flap - useful in treating both the fistula
and the SUI related to intrinsic sphincter deficiency
 If the surgeon has already decided to use an autologous
pubovaginal sling, it will be harvested and the sutures passed
before fistula closure.
Dept Of Urology, KMC and GRH,
Chennai
43

44. Reverse Boari-flap
 patients with significant loss of urethral
tissue necessitating urethral reconstruction
or a neourethra
 fistula involving the bladder neck or trigone
 three categories:
 1. Anterior bladder flaps
 2. Posterior bladder flaps
 3. Vaginal flaps
Dept Of Urology, KMC and GRH,
Chennai
44

45. Repair of SUI concomitantly with the fistula surgery, or
not
 Blaivas -
Martius flap interposed between the
fistula repair and a pubovaginal fascial
sling.
 Webster –
SUI associated with a proximal or
midurethral UVF should not be
corrected until the fistula is closed
Dept Of Urology, KMC and GRH,
Chennai
45

46. complete erosion of the urethra
 secondary to
chronic indwelling
urinary catheter in
multiple sclerosis
 bladder neck
closure and
ileovesicostomy
Dept Of Urology, KMC and GRH,
Chennai
46

47. continent urinary diversion
 Mitrofanoff
appendicovesicostomy
distal appendix is
tunneled into the
bladder to provide
continence
proximal
appendix,with the
cecal cuff, is brought
to the umbilicus as a
catheterizable stoma.
Dept Of Urology, KMC and GRH,
Chennai
47

48. PREVENTION
“An ounce of prevention is worth a pound of cure”
Dept Of Urology, KMC and GRH,
Chennai
48

49. PREVENTION
 Preserve the periurethral fascia
to avoid the risk of injuring the urethral
spongiosum
Dept Of Urology, KMC and GRH,
Chennai
49

50. Anterior Colporrhaphy
 Avoid overplication of
tissues around a
urethral catheter
using silk sutures.
 Palpation through the
vaginal wall to identify
the location of the Foley
catheter balloon at the
bladder neck is an
important step to avoid
extending the
dissection underneath
the urethra.
Dept Of Urology, KMC and GRH,
Chennai
50

51. Pubovaginal Sling and
Urethrolysis Procedures
 In the midurethra ,
the plane between
urethra and vagina
is thinner
compared with that
in the proximal
urethra
 venous bleeding
from the urethral
side may suggest
subtle urethral injury
Dept Of Urology, KMC and GRH,
Chennai
51

52. Urethral Diverticulectomy
 To limit the size of the
urethral defect after
excision of the diverticulum
pocket, (along the inside wall
of the diverticulum adjacent
to the urethral lumen.)
 the integrity of the closure
is tested with a 5-Fr feeding
tube or ureteral catheter in
the lumen, occluding the
distal outlet and bladder
neck.
Dept Of Urology, KMC and GRH,
Chennai
52

53. Key Points: Urethrovaginal
Fistulae
 Distal urethrovaginal fistulae are often
asymptomatic,
 Proximal fistulae may present with intermittent or
constant urinary leakage.
 Urethro vaginal fistula due to surgical trauma may
be difficult to visualize on physical examination or
cystoscopy.
 Diagnosis of a urethrovaginal fistula is best made
with VCUG.
 Repair of urethrovaginal fistulae often involve an
interpositional tissue flap due to the relative lack of
surrounding connective tissue in the mid and distal
urethra. Dept Of Urology, KMC and GRH,
Chennai
53

54. Thank You
 REFERENCES
 Campbell Walsh
Urology
 Gillenwater - Adult
and Pediatric
Urology
 Reconstructive
urological surgery
 Complications in
urological surgery
 Female Urology
 Urogynecology
Dept Of Urology, KMC and GRH,
Chennai
54

55. urethro-vaginal fistule
View from the urethra View from the vagina
Dept Of Urology, KMC and GRH,
Chennai
55

56. Transvaginal endoscopy
accessing the fistula tract and possibly the bladder by
advancing a small flexible scope through the tract.
Dept Of Urology, KMC and GRH,
Chennai
56

57. Dept Of Urology, KMC and GRH,
Chennai
57

58. Postoperative Care
 Broad-spectrum antibiotic coverage
 vaginal pack is removed after 24 to 48 hours.
 bladder drainage with urethral and suprapubic
catheters
 Anticholinergic medications to limit bladder
spasm
 After 3 to 4 weeks, VCUG to document
urethral integrity and exclude a fistula
recurrence.
 Return to sexual activity is delayed until
complete healing of the vagina has occurred
Dept Of Urology, KMC and GRH,
Chennai
58

59. Dept Of Urology, KMC and GRH,
Chennai
59

60. Dept Of Urology, KMC and GRH,
Chennai
60

61. Dept Of Urology, KMC and GRH,
Chennai
61

62. Principles of Fistula Repair
Technique
 Optimal exposure of the fistula
 Wide mobilization of tissues
 Tension-free approximation of the
tissues
 Watertight closure
 Multilayer repair with no overlapping
suture lines
 Use of vascularized interposition grafts
Dept Of Urology, KMC and GRH,
Chennai
62

63.  Management issues
– Goals of treatment
– Preoperative evaluation
– Timing of repair
– Foreign body
– Fistula tract excision or no excision
– Adjuvent flaps
» Martius flap
– Management of concommitent SUI
– Temporary urinary diversion
– Steps of surgical repair
Dept Of Urology, KMC and GRH,
Chennai
63

64. Blaivas and Heritz approach
 An inverted-U–shaped incision is made in the anterior
vaginal wall, through the fistula site, thus circumscribing
the fistula and closing the site with absorbable suture.
 The neourethra is created by making two parallel incisions
in the anterior vaginal wall on both sides of the Foley
catheter; this maneuver creates flaps that are then
tubularized around the catheter.
 These well-vascularized grafts provide a new blood supply
to the neourethra and allow the defect to be closed in a
tension-free manner.
 Sexual function may be preserved because vaginal
stenosis is unlikely to occur.
Dept Of Urology, KMC and GRH,
Chennai
64

65. Dept Of Urology, KMC and GRH,
Chennai
65

66. Dept Of Urology, KMC and GRH,
Chennai
66

67. Perioperative Checklist
Dept Of Urology, KMC and GRH,
Chennai
67

68. Dept Of Urology, KMC and GRH,
Chennai
68

69.  sitz-baths twice a
day.
 drink a large
volume of fluids
 • The vagina should
be examined as
soon as possible, by
speculum, and any
 necrotic tissue
gently excised. This
should be performed
under aseptic
 conditions and may
need to be repeated
until the vagina is
Dept Of Urology, KMC and GRH,
Chennai
69

70. Dept Of Urology, KMC and GRH,
Chennai
70

71.  obstructive labor delivery
complex
 urethrovesical fistulas,
 rectal injuries (17%),
 foot drop(20%),
 amenorrhea with infertility
(63%).
 Of UVF patients, 20% to 40%
will have associated stress
incontinence.
 19% of patients with UVF, may
have a secondary
communication between the
bladder and vagina
Dept Of Urology, KMC and GRH,
Chennai
71