Uro gynacology- uvf

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

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.  Urinary leakage following gynaecological or obstetric
surgery is a complication due to the formation of
urogenital fistula.
 Significant morbidity, with social and psychological
aspects aggravating the clinical situation.
 Ureterovaginal fistula -most serious of the urinary
fistulas because of its potential to cause incontinence,
sepsis, and renal loss.
Dept Of Urology, KMC and GRH, Chennai 3

4.  Ureteral fistulae to the genital tract in the female most
often connect with the vagina .
 fallopian tube , Uterus -Very rare
 Iatrogenic Ureteric injuries - 52-82% during Gynaec Sx.
 Iatrogenic ureteral injury leading to UVF - 0.5% to 2.5%
 Up to 10% patients- Concomittant VVF.
Dept Of Urology, KMC and GRH, Chennai 4

5. Etiology
Gynecologic Surgery
 Abdominal hysterectomy
1.3-2.2%
 Lap hysterectomy 1.3 %
 Vaginal hysterectomy
0.03%
 Radical hysterectomy
 Caesarian section
 Anterior colporrhaphy
(cystocele repair)
 transvaginal oocyte
retrieval.
Other Pelvic Surgical
Procedures
 Vascular surgery
 Urologic surgery including
retro pubic bladder neck
suspensions
 Colon surgery
Other
 Locally advanced
malignancy
 Radiation therapy
 Pelvic trauma
 Chronic inflammatory
diseases: actinomycosis,
etc.
Dept Of Urology, KMC and GRH, Chennai 5

6. Risk factors
Anatomical Pathological Technical
1. Ureter attached
peritoneum
1. Congenital anomalies
of ureter/ kidney
1. Massive intraoperative
hemorrhage 2
2. Close to female genital
Tract
2. Ureteric displacement:
(uterus size ≥12 weeks,
prolapse, Tumors
(ovarian),cervical or
broad ligament swelling.
2. Coexisting bladder
injury
3. Ureter has variable
course
3. Adhesions (previous
pelvic surgery,
Endometriosis, PID)
3. Technical difficulties
4. Not easily seen or
palpated
4. Distorted pelvic
anatomy
4. Inexperienced surgeon
Half of ureteric injuries has no identifiable risk factors
Dept Of Urology, KMC and GRH, Chennai 6

7. Gynaecology procedure –Injury risk
 During control of
active bleeding /
clamping large segments
of the tissues.
 Lower third of the
ureter
 - lateral edge of the
uterosacral ligament,
-ventral to the uterine
artery
- just lateral to the cervix
and fornix of the vagina.
Dept Of Urology, KMC and GRH, Chennai 7

8. Obstetric procedure –Injury risk
 Pelvic adhesions due to
repeated caesarean
section,
 Markedly enlarged
uterus
 Massive bleeding
obscuring the operative
field
Dept Of Urology, KMC and GRH, Chennai 8

9. Pathogenesis
• Urinary extravasation , urinoma formation,
• Subsequent extension along Non anatomic
planes created during surgery.
• Eventual drainage through the vaginal
incision / an ischemic area of vaginal cuff.
Dept Of Urology, KMC and GRH, Chennai 9

10. Dept Of Urology, KMC and GRH, Chennai 10

11. Intra op Ureteric injuries
 1. Ligation (suture)
 2. Crushing injury (clamp)
 3. Transection ( partial, complete)
 4. Angulation
 5. Ischemia (ureteral stripping, Electrocoagulation)
 6. Resection of ureteral segment.
 Electrical , thermal , or laser energy, or from linear stapler
during laparoscopy
Dept Of Urology, KMC and GRH, Chennai 11

12. Risk factors for Postoperative fistulae
Dept Of Urology, KMC and GRH, Chennai 12

13. Prevention
Pre operative Intra operative
1. To identify ureteral
abnormalities - IVP
1. Adequate exposure
2. Preoperative stenting 2. Stay outside the vascular
sheath zone of thermal injury
3. Lighted ureteric stents are
popular in laparoscopy
3. Ureteric dissection and direct
visualization
4. Incise the peritoneal
reflection between the uterus
and bladder
5. the bladder is reflected
inferiorly with sharp dissection
Vaginal Surgery / anterior colporrhaphy - sutures should not be inserted too
deeply while plicating the bladder
Vaginal hysterectomy – adequate vesico-uterine space before clamping
Dept Of Urology, KMC and GRH, Chennai 13

14. The venial sin is injury to the ureter
the moral sin is failure of recognition -
Higgins
Almost ½ of ureteric injuries can be prevented ,
out of these ½ can be detected Intraoperativly.
Dept Of Urology, KMC and GRH, Chennai 14

15. Identification –Intra Op
Dye test - intravenous pyridium or methylene blue
Urinary extravasation within 3-5 mts.
Cystoscopy- detects only obstructive injuries
non obstructive ,partially obstructive ,late
injuries secondary to ischaemia and avascular necrosis
Perioperative laparoscopic ultrasound probe
-ureteric diameter exceeds 3.0mm
- no peristaltic activity during 5 min of follow-up
Dept Of Urology, KMC and GRH, Chennai 15

16. Clinical Presentation
 Presentation of a patient with a UVF usually varies
- in relation to timing after surgery.
 Immediate postoperative period - abdominal or
flank pain, abdominal fullness, fever, or any
combination of the above.
Dept Of Urology, KMC and GRH, Chennai 16

17. Delayed presentation :
 days or weeks postoperatively,
 C/o Continuous urinary leakage, which the patient may
or may not be able to discern is from the vagina.
 Volume of leakage may vary .
Continuous urinary incontinence -large fistulas
Watery discharge - small fistulas.
 Patients typically void normally.
Dept Of Urology, KMC and GRH, Chennai 17

18. Clinical examination
 Abdominal examination :- nonspecific generalized
tenderness, and costo vertebral tenderness may be
present.
 Vaginal examination :- a mass or erythema of the
vaginal wall may be visible.
Dept Of Urology, KMC and GRH, Chennai 18

19. Diagnostic Evaluation
Imaging studies :
 USG
 CT urogram,
 MRU
 intravenous urography (IVU), and
 retrograde pyelography
Double dye test
Dept Of Urology, KMC and GRH, Chennai 19

20. DOUBLE DYE or TAMPOON TEST
 For diagnosing vesicovaginal or ureterovaginal fistulae.
 oral phenazopyridine (Pyridium)
 methylene blue is filled in to the empty bladder via a
urethral catheter.
A tampoon is placed into the vagina.
 blue- vesicovaginal fistula
 orange- ureterovaginal fistula is suspected.
Dept Of Urology, KMC and GRH, Chennai 20

21. USG
Hydroureteronephrosis ,
Urinomas
Dept Of Urology, KMC and GRH, Chennai 21

22. IVU-Findings
 Extravasation outside the ureter,
 Drainage of contrast media into vagina (Fistula track )
 Hydronephrosis and hydroureter
 Delayed function /Non excretion
High oblique or lateral film - to differentiate the
contrast in the bladder from that in the vagina.
Sensitivity of excretory urography in detecting
ureterovaginal fistula is about 33%
Dept Of Urology, KMC and GRH, Chennai 22

23. IVU
Left HUN with a distal tapering of
the ureter
Opacification of the vagina
Dept Of Urology, KMC and GRH, Chennai 23

24. IVU
Left Ureter entering the vagina Rt HUN with contrast in vagina
Dept Of Urology, KMC and GRH, Chennai 24

25. CECT
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26. CECT
Dept Of Urology, KMC and GRH, Chennai 26

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

28. RGP
 Outlines the ureter and fistula well,
 an abrupt termination of the ureter 2 to 4 cm from
the ureteral orifice.
 Ureteral continuity cofirmed - an attempt at
stenting is warranted.
Dept Of Urology, KMC and GRH, Chennai 28

29. RGP
abrupt termination of the distal
ureter.
extravasation of
contrast in the distal ureter.
Dept Of Urology, KMC and GRH, Chennai 29

30. Investigation Sequence
Dept Of Urology, KMC and GRH, Chennai 30

31. Goals of Therapy
 Expeditious resolution of urinary leakage
 Avoidance of Urosepsis
 Preservation of renal function
 Preservation of fertility
 Exclude associated VVF
Dept Of Urology, KMC and GRH, Chennai 31

32. Management
 Upper tract diversion
 Timing of the repair
 Surgical technique
Dept Of Urology, KMC and GRH, Chennai 32

33. Conservative Non operative
 Spontaneous fistula closure in patients with
ureteral continuity and a normal-appearing
ureter beyond the fistula , although this is
unusual.
 with varying success, in 5–15%
Labasky et al
Dept Of Urology, KMC and GRH, Chennai 33

34. Upper tract diversion
 Prompt drainage of upper urinary tract - partial
ureteral obstruction is often present
 An attempt at RGP & ureteral stenting or
percutaneous nephrostomy tube
as soon as possible if direct open surgical repair
is not immediately considered.
Dept Of Urology, KMC and GRH, Chennai 34

35. Percutaneous Nephrostomy
 HUN
 Palpable mass
 Infection
 Sepsis
 Raised RFT
Dept Of Urology, KMC and GRH, Chennai 35

36. Endoscopic Management
 Presentation within 3 weeks of injury,
 <2 cm length of injury,
 with remaining ureteral continuity.
 a retrograde ureteral stent,
 percutaneous nephrostomy, and
 antegrade ureteral stent .
Dept Of Urology, KMC and GRH, Chennai 36

37. Dept Of Urology, KMC and GRH, Chennai 37

38. Retrograde ureteral stent
 If a point of obstruction is unable to be traversed, rigid
ureteroscopy may be helpful.
 Low flow irrigation should be used, Guidewire is passed
under direct vision.
 Inflamed, edematous ureters may tear
 Guidewire does not pass easily - aborted.
Dept Of Urology, KMC and GRH, Chennai 38

39.  Following successful stent placement, CBD should be
maintained for a minimum of 2 Weeks to prevent
extravasation secondary to vesicoureteral reflux up the
stent.
 Followup IVP should also be performed prior to
discontinuation of the ureteral stent and 3–6 months later to
document patency of the ureter.
Dept Of Urology, KMC and GRH, Chennai 39

40. PCN +/- antegrade stent placement
 Nephrostomy alone may allow spontaneous
healing of a small fistula.
 If a wire cannot be passed through a point of
obstruction, the attempt should be discontinued, and
the nephrostomy is left in place.
 Persistent attempts - tearing of the ureter
,submucosal dissection and edema.
Dept Of Urology, KMC and GRH, Chennai 40

41. Memokath 051 stent
 Thermo expandable nickel-titanium alloy
content and the closed tight spiral structure.
 Wide calibre of the strictured segment,
provides adequate urinary drainage, and
prevents the escape of urine to a coexisting UVF
 Minimal risk of crystal deposition, urothelial
in-growth, ischaemic damage or corrosion of the
ureteric wall.
 Neither hinders ureteric peristalsis nor
causes VUR.
 Stent migration- remote chance only
Dept Of Urology, KMC and GRH, Chennai 41

42. If ureteral stenting is Unsuccessful due to
Complete ureteral occlusion or prolonged leakage
Persists , formal surgical repair is indicated …
Dept Of Urology, KMC and GRH, Chennai 42

43. Timing of the repair
 Timing of the repair of ureterovaginal fistulae is controversial.
 Some authors advocate early repair
 While others recommend a delay of 4 to 8 weeks
 More recent literature suggests that early repair is preferred and
is not associated with an increase in morbidity or higher failure
rates. (Payne, 1996).
Dept Of Urology, KMC and GRH, Chennai 43

44. Timing of surgical intervention :
 Extent of the causative operation
 Condition for which it was performed
 Type and time of ureteric injury
 Condition of the pelvic tissues
 General condition of the patient
Mandal AK,Sharma SK,Vaidyanathan S,Goswami AK.,Ureterovaginal fistula:
summary of 18 years' experience . Br J Urol. 1990 May;65(5):453-6.
Dept Of Urology, KMC and GRH, Chennai 44

45. Surgical technique
1. URETERIC REIMPLANTATION
 Open surgical repair most commonly involves
URETERONEOCYSTOSTOMY.
 Ureteroneocystostomy is performed with / without a
psoas hitch.
 Occasionally, a Boari flap may be necessary due to
extensive ureteral injury.
Dept Of Urology, KMC and GRH, Chennai 45

46. Principles
 Meticulus dissection, preserving ureteral sheath
 Tension free anastomosis ( ureteral mobilization)
 Water tight closure , absorbable suture.
 Peritonium or omentum to surround the anastomosis
 Drain ( closed, suction) to prevent urine collection
 Stenting the anastomotic site
 Consider proximal diversion with PCN
Dept Of Urology, KMC and GRH, Chennai 46

47. Ureteroneocystostomy
 Transperitoneal /Extraperitoneal approach
 Ureteral mobilisation – Prox healthy ureter
- Pathological site
 Bladder mobilisation – Sup vesicle pedicle
 Fistula localisation
 Division of ureter & closure of stump
 Vaginal defect closure- Not always
Dept Of Urology, KMC and GRH, Chennai 47

48. Ureteral Lenghtening
Technique Lengthening ( in Cms )
Ureteroneocystostomy 4-5
Psoas Hitch 6-10
Boari Flap 12-15
Renal Descensus 5-8
Dept Of Urology, KMC and GRH, Chennai 48

49. PSOAS HITCH
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50. Dept Of Urology, KMC and GRH, Chennai 50

51. BOARI FLAP
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52. Dept Of Urology, KMC and GRH, Chennai 52

53. Psoas Hitch Boari Flap
Dept Of Urology, KMC and GRH, Chennai 53

54. 2.OTHER PROCEDURES : rarely indicated are
 Transureteroureterostomy,
 Ileal substitution of the ureter,
 Renal autotransplantation
3.IPSILATERAL NEPHRECTOMY – Very rare
Extensive renal damage due to obstruction or infection.
Dept Of Urology, KMC and GRH, Chennai 54

55. Ileal ureteral substitution
Dept Of Urology, KMC and GRH, Chennai 55

56. Transureterouretorostomy
Dept Of Urology, KMC and GRH, Chennai 56

57. Lap Bladder Advancement Flap
Dept Of Urology, KMC and GRH, Chennai 57

58. Complications
 Urine leak
 Injury to opposite ureter
 Bladder spasm
 Stenosis at anastomosis site
 VUR – due to inadequate tunneling
Dept Of Urology, KMC and GRH, Chennai 58

59. VVF associated with UVF
 If the Associated VVF overlooked , urinary leakage
will persist post operatovely.
 Combination closure of VVF with reimplantation of
the ureter into the bladder and interposition of
omentum or a peritoneal patch between the bladder and
vagina.
Dept Of Urology, KMC and GRH, Chennai 59

60. Management of Ureterovaginal Fistula
Confirm diagnosis (IVP +/- RPG/CT)
Successful placement
Exclude VVF (Cystoscopy +/- VCUG, double dye test)
Unsuccessful
Attempt stent placement
Suspect Ureterovaginal Fistula
Surgical repair
(ureteroneocystostomy)
Remove stent in 4-6 wks
Repeat imaging
Persistent fistula Resolution of fistula
Wein, Alan J. et al., Campbell-Walsh Urology, 10th Ed., Vol 3, 2012
60

61. SUMMARY
 All patients with suspected uretrovaginal fistula should
undergo upper tract evaluation ( IVP and/or CT urogram )
 Cystoscopy - essential to rule out the associated
vesicovaginal fistula.
 Minimal invasive approach should be the first choice of
treatment. At least 6 weeks of stenting is allowed for healing.
 In the case of failure, an open surgical repair is
necessary.
Dept Of Urology, KMC and GRH, Chennai 61

62. Dept Of Urology, KMC and GRH, Chennai 62

63. Dept Of Urology, KMC and GRH, Chennai 63