Uro gynacology- vvf

1. GENITO URINARY FISTULAE
VESICO VAGINAL FISTULA
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
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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
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3. GENITO-URINARY FISTULAE
An extra-anatomic communication between two or more
epithelial or mesothelial-lined body cavities or the skin surface.
Wein, Alan J. et al., Campbell-Walsh Urology, 10th Ed., Vol 3, 2012
Dept Of Urology, KMC and GRH, Chennai 3

4. VVF- Etiology
 Two main causes:
 Obstetric – Developing countries
 Iatrogenic – Developed countries
 Surgical, mainly.
 Other etiologies:
 Malignancy
 Radiation
 Infection (including TB)
 Foreign body (i.e. retained pessary, eroded mesh, calculi)
 Sexual assualt (traumatic- rape or under-aged marriages most common
setting)
 Smith GL, Williams G. BJU Int. 1999 Mar;83(5):564-9
Dept Of Urology, KMC and GRH, Chennai
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5. Etiology
 Developed countries - Gynecological surgery
 Incidence rate of VVF after total abdominal
hysterectomy (TAH) of 0.5-2%
 TAH - Incidental unrecognized iatrogenic
bladder injury near the vaginal cuff(benign cause)
 Other causes –
 malignant disease,
 pelvic irradiation, and
 obstetric trauma
Dept Of Urology, KMC and GRH, Chennai
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6. Obstructed labour
 7 million cases worldwide annually
 6.5 million occur in developing nations
 2-7 million affected cases of VVF- world wide
 Obstetric fistula – 50,000 to 1,00,000 cases/year
 100 fold disparity in maternal mortality exists between industrialized nations and
developing countries.
 Early age of marriage, CPD, illiteracy and malnutrition
 Wall LL. Lancet. 2006 Sep 30;368(9542):1201-9
Dept Of Urology, KMC and GRH, Chennai
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7. BLADDER INJURY
Incidence
10/10,000 deliveries
14/10,000 caesarean
100/10000 Gynaec surgeries
250/10000 Cystocele Repair
Dept Of Urology, KMC and GRH, Chennai
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8. Prolonged obstructed labour
 widespread tissue
edema, hypoxia,
necrosis, and sloughing
resulting from prolonged
pressure on the soft
tissues of the vagina,
bladder base, and
urethra.
Dept Of Urology, KMC and GRH, Chennai
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9. RISK FACTORS
 Intraoperative bladder injury
 Prior uterine surgery
 Endometriosis
 Infection
 Diabetes
 Arteriosclerosis
 Pelvic inflammatory disease
 Prior radiotherapy
Dept Of Urology, KMC and GRH, Chennai
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10. PROBLEMS
 Delayed diagnosis
 Abandoned from their families(60 – 70% in india)
 Co –Morbidity
 Infection
 Bladder stones
 Infertility
 malignancy
Dept Of Urology, KMC and GRH, Chennai
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11. Factors in prevention (Hutch)
 Immediate detection of bladder injury
 Water tight closure of bladder injury
 Extravesical drain placement
 Avoidance of vaginal incision if possible
 Prolonged uninterrupted post op bladder drainage
Dept Of Urology, KMC and GRH, Chennai
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12. Clinical features
 The uncontrolled leakage of urine into the vagina is
the hallmark symptom
 The drainage may be continuous; however, in the
presence of a very small VVF, it may be intermittent
 Recurrent cystitis or pyelonephritis, abnormal urinary
stream, and hematuria
Dept Of Urology, KMC and GRH, Chennai
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13. Clinical features
 Pain is an uncommon unless associated with skin irritation or
prior radiation therapy
 VVF following surgical procedures may present on catheter
removal or 1 to 3 weeks later
 VVF from radiation therapy can present months to years after
completion of therapy
Dept Of Urology, KMC and GRH, Chennai
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14. DD post hysterectomy clear vaginal
discharge
 VVF
 Fallopian tube fluid drainage
 Lymphatic fistula
 Urinary loss detrusor instability or poor compliance
 Ectopic ureteral discharge
 Ureterovaginal fistula
 Spontaneous vaginal secretions
Dept Of Urology, KMC and GRH, Chennai
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15. Evaluation
 Any fluid collection tested for urea, creatinine to
diagnose VVF
 Urine culture and sensitivity
 In patients with a h/o local malignancy, a biopsy of
the fistula tract
Dept Of Urology, KMC and GRH, Chennai
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16. 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.

Dept Of Urology, KMC and GRH, Chennai
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17. Imaging Studies
 USG ( in ureterovaginal fistula - HUN +,collection)
 IVU (R/o ureteral injury or fistula 10%)
 MCU (CYSTOGRAM)
 RGP ROLE
 CT UROGRAM / MRU - ? Invest. Of choice
Dept Of Urology, KMC and GRH, Chennai
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18. Cystogram in VVF
Dept Of Urology, KMC and GRH, Chennai
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19. IVU
Dept Of Urology, KMC and GRH, Chennai
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20. Fistula
Bladder
Vagina
Dept Of Urology, KMC and GRH, Chennai
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21. MR UROGRAM
Dept Of Urology, KMC and GRH, Chennai
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22. Cystoscopy
 To assure bilateral ureteral patency
 To determine the location, number and proximity to
ureteric orifices,
 To look for suture placement in the bladder or
urethra
Dept Of Urology, KMC and GRH, Chennai
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23. Cystoscopy
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24. Cystoscopy
Dept Of Urology, KMC and GRH, Chennai
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25. Complex Fistulae
 Primary fistula greater than 4 cm in size
 Recurrent fistula greater than 2cm in size
 Fistula involving urethra and/or bladder neck
 Fistula requiring ureteric reimplantation/ augmentation
cystoplasty,
 Fistula with large bladder stone
 Fistula with scarred and non capacious vagina
 Post radiotherapy fistula
 Multiple fistulae
 Malignant fistulae
Dept Of Urology, KMC and GRH, Chennai
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26. FISTULA
Dept Of Urology, KMC and GRH, Chennai
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27. Dept Of Urology, KMC and GRH, Chennai
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28. Conservative Management
 VVF diagnosed within the first few days of surgery,
a transurethral or suprapubic catheter should be
placed and maintained for up to 30 days.
 Small fistulae (<0.3 cm) may resolve or decrease
 if no improvement is observed after 30 days, a VVF
is not likely to resolve spontaneously
Dept Of Urology, KMC and GRH, Chennai
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29. MANAGEMENT
Dept Of Urology, KMC and GRH, Chennai 29

30. Medications
 Estrogen replacement therapy
 Corticosteroid and NSAIDS
 Acidification of urine
 parasympatholytics
 Sitz baths and barrier ointments, such as zinc oxide
preparations, can provide needed relief from local
ammoniacal dermatitis.
Dept Of Urology, KMC and GRH, Chennai
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31. Principles Of Fistula Management
 Adequate nutrition
 Elimination of infection
 Unobstructed urinary tract drainage or stenting
 Removal or bypass of distal urinary tract obstruction
 Beware of malignant etiology
Dept Of Urology, KMC and GRH, Chennai
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32. Timing Of Repair
 Longer intervals are universally accepted as the
standard care in infected or irradiated tissue
 Primary fistulae were repaired once local vaginal
tissue was healthy and infection-free
 recurrent or obstetric fistulae repair was delayed for
at least three months or unless infection-free.
Dept Of Urology, KMC and GRH, Chennai
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33. Surgical Principles
 Adequate exposure,
 Removal of foreign bodies
 Careful dissection
 haemostasis
 watertight closure
 Use vascularised healthy
tissue flaps
 Multiple layer closure
 Tension free non overlapping
suture
 Adequate urinary tract
drainage or stenting
 Treat infections
Dept Of Urology, KMC and GRH, Chennai
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34. Techniques Of Repair
1. Vaginal approach,
2. Abdominal approach,
3. Electrocautery
4. Fibrin glue(petersson etal..)
5. Endoscopic closure using fibrin glue with or without adding
bovine collagen,
6. Laparoscopic approach(nazler-1994)
7. Interposition flaps or grafts.
Dept Of Urology, KMC and GRH, Chennai
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35. Vaginal approach
MERITS
 Minimal blood loss,
 Low postoperative morbidity,
 Shorter operative time,
 Shorter postoperative recovery time
 Obviates bowel manipulation, reducing operative morbidity,
particularly in radiation-associated fistulas.
 Easier & safer, success rate 98 to 100%
Dept Of Urology, KMC and GRH, Chennai
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36. Ring retractor & traction on catheter placed through fistula to enhance exposure
fistula
VAGINAL FLAP TECHNIQUE
Dept Of Urology, KMC and GRH, Chennai
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37. LATZKO REPAIR
Dept Of Urology, KMC and GRH, Chennai
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38. Tissue interposition
Helpul in complex fistulas
 Recurrent fistulas
 Post radiotherapy
 Ischemic or obstetric fistulas
 Large fistulas
 Difficult or tenuous closure due to poor tissue quality
Dept Of Urology, KMC and GRH, Chennai
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39. Interposition flaps or grafts
 Granulation Tissue Formation,
 Neovascularity
 Obliterating Dead Space.
 A Barrier Layer
Dept Of Urology, KMC and GRH, Chennai
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40. Vaginal approach interposition grafts or
flaps
 Martius flap
 Gracilis muscle flap
 Peritoneal flap
Dept Of Urology, KMC and GRH, Chennai
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41. Martius flap
 The fibroadipose tissue in
the labium majus isolated.
 Blood supply -(cranial via
internal pudendal artery
,caudal via external
pudendal artery laterally
via obturator artery)
Dept Of Urology, KMC and GRH, Chennai
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42. MARTIUS FLAP
Dept Of Urology, KMC and GRH, Chennai
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43. Fibrin glue
Dept Of Urology, KMC and GRH, Chennai
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44. Abdominal Approach
Absolute indications
 The need for concomitant abdominal surgery, such as
augmentation cystoplasty and ureteral reimplantation;
 Inability to adequately expose the fistula vaginally;
 A complex presentation of VVF involving the ureters, bowel,
or other intraabdominal structures;
 Involvement of the VVF with ureteric orifices
Dept Of Urology, KMC and GRH, Chennai
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45. Abdominal Approach
Dept Of Urology, KMC and GRH, Chennai
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46. LAPAROSCOPIC
Dept Of Urology, KMC and GRH, Chennai
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47. ROBOTIC VVF REPAIR
Dept Of Urology, KMC and GRH, Chennai
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48. URINARY CONDUIT
 Multiple fistulae/ Recurrent
 Complete urethral defect
 Fibrosed atrophic bladder
 Unrelenting urinary incontinence
Procedures
 Conduits- ileal bladder
 Orthotopic diversion
Dept Of Urology, KMC and GRH, Chennai
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49. Postoperative
 Bladder drainage – 2 to 3 weeks
 Acidification of urine
 Estrogen replacement therapy
 Control of postoperative bladder spasms
 Antibiotic therapy
 Minimizing Valsalva maneuvers
 Pelvic rest -3 months
 Avoid sex or tampoon for 3 months
Dept Of Urology, KMC and GRH, Chennai
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50. Prognosis
 The success rate of fistula surgery is high overall
95%
 vesico-vaginal fistulas that were associated with
recto-vaginal fistulas or uretero-vaginal fistulas had
even lower rates of successful closure
Dept Of Urology, KMC and GRH, Chennai
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51. Prognosis
The success rate declined with increasing attempts
at closure.
 First attempt 70/82 (85%)
 Second attempt 6/12 (50%)
 Third attempt 2/6 (33%)
Dept Of Urology, KMC and GRH, Chennai
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52. Take home …
 Vesicovaginal Fistula(post-op)
 obstructed labour / TAH- most common causes
 Identification of proper plane between bladder and cervix, sharp
dissection of bladder, care in clamping suturing vaginal cuff (0.2 %)
 postoperative vesicovaginal fistula ; watery vaginal discharge 10
to 14 days after surgery (1st 48 to 72 hours after surgery)
Dept Of Urology, KMC and GRH, Chennai
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53. Take home …
 Vesicovaginal fistula: foley catheter inserted for prolonged drainage
 Up to 15% of fistulas close spontaneously with 4 to 6 weeks of
continuous bladder drainage
 Closure not occurred by 6 weeks operative correction
 3 to 4 monthes from time of diagnosis  reduction of
inflammation and improve vascular supply
 Three-layered closure:
 Bladder mucosa
 Endopelvic fascia
 Vaginal epithelium
Dept Of Urology, KMC and GRH, Chennai
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54. Take home …
 Incidental cystotomy at time of hysterectomy: more
common( than vesicovaginal fistula)
 Repaired correctly, rarely development of fistula
 Now,the trend more towards trans-vaginal (Foley pull) and also
not to excise fistulous tract or vaginal cuff.
 Laparoscopy evolving technique
 Robotic !!
 Individualized treatment.
Dept Of Urology, KMC and GRH, Chennai
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55. Thank You
Dept Of Urology, KMC and GRH, Chennai
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