Urogynecological Fistula Repair Techniques

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

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

Genito-urinary fistulae
An abnormal fistulous tract extending
between the urinary tract and the cervix, uterus
, fallopian tube, vagina, vaginal cuff that allows
the continuous involuntary passage of urine into
the vagina.
Chennai
3

Vesicovaginal fistula (VVF)
• VVF is the most common acquired fistula of the urinary tract.
• The majority of UGFs in developed countries are a
consequence of gynecological surgery
• incidence rate of VVF after total abdominal hysterectomy
(TAH) is 0.5-1%
(Bladder injuries are atleast 3 times common during abdominal hysterectomy compared
with vaginal hysterectomy.)
• Post-hysterectomy VVFs result most commonly from an
incidental unrecognized iatrogenic cystotomy near the
vaginal cuff
Chennai
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Etiology
• Urology & gynaecology procedures
• Retroperitoneal, vascular or pelvic surgery
• Infectious or inflammatory disorders
• Foreign bodies ,neglected pessaries
• Congenital VVF
• Sexual trauma
• Vaginal laser procedures
• Traumatic-External violence
• Malignancy---cervical,vaginal,endometrial
• Radiation
Chennai
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Obstetric bladder injury
 Incidence
1/10,000 deliveries
14/10,000 caesarean
1/100 Gynaec surgeries
2.5/100 Cystocele Repair
Chennai
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• In developing countries, the predominant
cause of VVF is prolonged obstructed labor
(97%).
• The frequency of VVF is largely underreported
in developing countries.
Chennai
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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 by
compression between
pubic symphysis and
presenting part.
Chennai
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RISK FACTORS
 Intraoperative bladder injury
( AAST grade of the bladder trauma is the strongest predictor of subsequent VVF)
 Prior uterine surgery
 Endometriosis
 Infection
 Diabetes
 Arteriosclerosis
 Pelvic inflammatory disease
 Prior radiotherpy
Chennai
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Factors in prevention
 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
10

Clinical features
• The uncontrolled leakage of urine into the
vagina is the hallmark symptom
• Increase in vaginal discharge
• The drainage may be continuous; however, in
the presence of a very small UGF, it may be
intermittent
• Recurrent cystitis or pyelonephritis, abnormal
urinary stream, and hematuria
Chennai
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• Pain is 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
• Incidence varies with the type, dose, and location of
the radiation
Chennai
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• Obstetric fistulae tend to be larger and located
distally in the vagina and may involve large
portions of the bladder neck and proximal
urethra
Chennai
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Differential diagnosis
• ureterovaginal fistulas
(- most common presenting symptom is the onset of constant
urinary incontinence 1 to 4 weeks after surgery
- normal voiding pattern)
• CT,RGU,IVU - diagnostic
Chennai
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DD post hysterectomy clear vaginal
discharge
• VVF
• Post hysterectomy pseudoincontinence
• Fallopian tube fluid drainage
• Lymphatic fistula
• Urinary loss detrusor instability or poor compliance
• Ectopic ureteral discharge
• Ureterovaginal fistula
• Spontaneous vaginal secretions
Chennai
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Evaluation
• Any fluid collection tested for urea, creatinine,
or potassium to diagnose GUF
• Urine culture and sensitivity
• In patients with a h/o local malignancy, a
biopsy of the fistula tract
Chennai
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Vaginal speculam inspection
• Assessment of tissue mobility;
• Accessibility of the fistula to vaginal repair;
• Determination of the degree of tissue
inflammation, edema, and infection;
• Possible association of a rectovaginal fistula.
Chennai
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DOUBLE DYE or TAMPON TEST
• Bladder can be filled with methylene blue in
retrograde fashion
• Placement of tampons in tandem in the
vaginal vault and staining of the tampons by
methylene blue may help locate fistulas.
Chennai
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– Staining of the apical tampon implicate the vaginal
apex or cervix/uterus/fallopian tube fistula
– staining of a distal tampon implies urethral fistula
– If the tampons are wet but not stained, oral
phenazopyridine (Pyridium) or intravenous indigo
carmine can be used to rule out a ureterovaginal,
ureterouterine, or ureterocervical fistula.
Chennai
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Imaging Studies
– IVU is necessary to R/o ureteral injury or fistula ,
12% of VVFs have associated ureteral fistulas
– voiding images may be necessary in some patients
with small fistulae to demonstrate the VVF.
– If suspicion is high for a ureteral injury or fistula and
the IVU is negative, RetroGradePyelogram should be
performed at the time of cystoscopy.
– Delayed CT visualization of contrast within the
vagina is considered highly suspicious for VVF in the
majority of cases
Chennai
20

• 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.
• Cross-sectional imaging may also be helpful in
assessing for recurrent malignant disease in
those with such a history.
Chennai
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Cystogram in VVF
Chennai
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Chennai
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Cystoscopy
• To assure bilateral ureteral patency
• To look for suture placement in the bladder or
urethra
• To determine the location, number and
proximity to ureteric orifices,
• To identify and remove calculi or sutures
Chennai
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Chennai
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Chennai
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Conservative management
• VVF diagnosed within the first few days of
surgery, a transurethral or suprapubic catheter
should be placed and maintained for atleast 2-3
wks along with anti-cholinergics.
• Small fistulae (< 2-3mm) may resolve or
decrease
• if no improvement is observed after 30 days, a
VVF is not likely to resolve spontaneously
Chennai
28

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.
Chennai
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Principles of fistula management
 Adequate nutrition
 Elimination of infection
 Unobstructed urinary tract drainage or
stenting
 Removal or bypass of distal urinary tract
obstruction
Chennai
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Timing of repair
• Longer intervals are universally accepted as the standard care in infected
or irradiated tissue
• uncomplicated postgynecologic urinary fistulae may be repaired as soon
as they are identified and confirmed
• uncomplicated VVF after 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 VVFs after vaginal
hysterectomy.
• Conversely, if an abdominal approach is being considered after a
particularly difficult or complicated abdominal surgery that resulted in the
VVF (e.g., complicated by abscess, urinoma), then a delay may be
warranted to allow resolution of active inflammation.
Chennai
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• first successful transabdominal approach to
VVF repair was reported by Trendelenburg in
1888,
• concept of an interpositional flap was first
reported in 1928 by Martius,
Chennai
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Surgical principles
Adequate exposure,
Removal of foreign
bodies
Carefull dissection
watertight closure
Use vascularised
healthy tissue flaps
Multiple layer closure
Tension free non
overlapping suture
Adequate urinary tract
drainage or stenting
Treat infections
haemostasis
Chennai
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Surgical Techniques of repair
1. vaginal approach,
2. abdominal approach,
3. electrocautery,
4. fibrin glue,
5. endoscopic closure using fibrin glue with or
without adding bovine collagen,
6. laparoscopic approach,
7. interposition flaps or grafts.
Chennai
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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%
Chennai
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Vaginal approach
Absolute contraindications:
 concomitant presence of fistulas with other
abdominopelvic organs, such as ureters and
small and large bowel,
Multiple VVFs.
Chennai
36

Flap-splitting techniques
• vaginal wall is incised circumferentially around
the fistula and widely dissected from the
underlying endopelvic fascia in a standard
anterior colporrhaphy technique
• Leaving the tract unresected, the bladder is
closed tension-free, in 2 layers
• The surgery is completed with the vaginal
closure over the bladder defect.
Chennai
37

Vaginal cuff excision
• The vaginal mucosa is denuded circumferentially for a
radius of 3-5 mm from the vaginal cuff, including the
fistula.
• This incision is then extended obliquely to the
bladder wall so as to resect the fistulous tract and
vaginal cuff scar in a funnel-shaped specimen.
• First, the bladder is closed
• the subvaginal pubocervicovaginal fascia is then
closed in 2 layers
• vaginal wall closure.
Chennai
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Retraction including ring retractor, vaginal speculum, and Foley catheter in
the VVF tract.
A Foley catheter is seen in the VVF tract providing traction on the vaginal
cuff.
Chennai
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Mobilization
of anterior vaginal wall
flap. Lateral flaps are
developed as well,
thereby isolating the
VVF tract
Chennai
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Mobilization of posterior vaginal wall flap
Chennai
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Initial layer of closure is
performed without
excising the edges of the
fistula tract.
Chennai
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The perivesical fascia is closed with Lembert-type sutures. This line of closure
is perpendicular to the initial suture line.
Chennai
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The vaginal wall flaps are advanced to avoid overlapping suture lines
Chennai
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Latzko technique
– Vaginal mucosa is sharply denuded in a circular fashion at a
distance of 1.5 cm from the fistula opening.
– The fistula at the bladder mucosa is not disturbed.
– A double row of sagittally oriented sutures is placed in the
raw surfaces on either side of the fistula, with the second
row imbricating the first
– Suturing of the vaginal wall providing a third layer of
closure.
– The vaginal wall in contact with the bladder becomes the
posterior vesical wall and eventually is reepithelialized with
transitional epithelium
Chennai
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Advantages of transvaginal aproach for post hysterectomy
VVF
1. Avoidance of laparotomy & its morbidity
2. Short operating time
3. Brief inpatient stay
4. Minimal post op pain
5. Minimal blood loss
6. No need for wide openning or bivalving bladder
7. Not compromised by prior surgery
8. Concomitant prolapse surgery possible
9. Local inter positional flap available
10. 3 to 4 layer closure is possible
11. If failure occurs abdominal approach possible
Chennai
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Abdominal approach
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
Chennai
47

Abdominal approach
• Suprapubic Transvesical technique
 The posterior wall of the bladder is dissected free as
much as possible.
 The bladder then is bivalved at the dome. This
incision is extended posteriorly to the level of the
fistula.
 Complete exicision of fistulous tract.
Chennai
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• Ureteral orifices and the location of fistula(s) are
identified, and ureteral catheters are placed
• The fistula tract and scarred and necrotic tissue are
resected.
• Dissection of the posterior wall of the bladder from
the underlying endopelvic fascia and vagina is
completed.
• The bladder and vagina are closed in separate layers.
• Commonly, peritoneal or interposition grafts are
added.
Chennai
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Chennai
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Chennai
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Adjunctive techniques for VVF repair
1. Tissue interposition
2. Martius flap
3. Peritoneal flap
4. Greater omental flap
5. Gracilis muscle flap
6. Labial myocutaneous flap
7. Seromuscular intestinal flap
8. Rectus abdominis flap
Chennai
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Tissue interposition
Helpful in complex fistulas
 Recurrent fistulas
 Post radiotherapy
 Ischemic or obstetric fistulas
 Large fistulas
 Difficult or tenuous closure due to poor tissue
quality
Chennai
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Interposition flaps or grafts
• They increase success by enhancing granulation
tissue formation,
• Increasing neovascularity to the area,
• obliterating dead space.
• They provide a barrier layer between the
bladder suture line and the vaginal suture line.
Chennai
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Vaginal approach interposition grafts or flaps
• Martius flap
• Gracilis muscle flap
• Peritoneal flap
Chennai
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Martius flap
• In first described procedure - bulbocavernosus muscle
and its overlying fibroadipose tissue
• In their modification, only the fibroadipose tissue in
the labium majus was isolated. It was composed of
fibrous septa, round ligament, and a superficial fibrous
layer; it did not contain bulbocavernosus muscle
• Triple blood supply to this tissue and the
bulbocavernosus muscle (dorsally via internal pudendal
artery ,ventrally via external pudendal artery, laterally
via obturator artery)
Chennai
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Chennai
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Chennai
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Abdominal approach interposition grafts or
flaps
• Omental J flap
• Peritoneal flap
• Rectus abdominis muscle flap
• Autologous bladder mucosa interposition graft
• Human dura mater interposition graft
• Broad ligament flaps
Chennai
59

Postoperative
• Bladder drainage – atleast 2 wks
• Acidification of urine to diminish risks of cystitis,
mucus production, and formation of bladder calculi
• Estrogen replacement therapy
• Anti-cholinergics- Control of postoperative bladder spasms
• Antibiotic therapy
• Minimizing Valsalva maneuvers
• Pelvic rest
Chennai
60

Prognosis
• The success rate of fistula surgery is high -
overall 95%
• Urethrovaginal fistulas -94%
• midvaginal vesicovaginal fistulas - 71%
• vesico-vaginal fistulas that were associated
with recto-vaginal fistulas or uretero-vaginal
fistulas had even lower rates of successful
closure
Chennai
61

Electrocautery
• used in a highly selected patient group
• small in size, identified as either pinhole
openings or bladder mucosal dimples.
• Fulguration with a Bugbee electrode and
placement of a large Foley catheter for a
minimum of 2-3 weeks.
• worthy of historical interest only.
Chennai
62

Laser technique
• Reports of successful closure of a radiation-
induced and markedly fibrosed VVF measuring
5 mm
• Laser welding in the repair of a 3-mm VVF in
the supratrigonal area of the bladder.
• Nd-Yag laser to fulgurate the fistula opening
and the full tract
Chennai
63

Laparoscopic approach
• cystoscopy, catheterization of the fistula tract,
• dissection of the bladder from the vagina,
• laparoscopic cystotomy,
• excision of the tract,
• adequate dissection of the bladder from the
vaginal wall,
• cystotomy, and colpotomy closure with
interposition of a flap of healthy tissue.
Chennai
64

Transurethral suture cystorrhaphy (TUSC)
• small uncomplicated vesicovaginal fistulas with
a maximum of 5-6 mm,
• Advantages
1. minimal intervention,
2. outpatient setting,
3. reduced operating time,
4. reduced morbidity.
Chennai
65

 suprapubic visualization with a shorter
scope such as an arthroscope,
 Large-caliber sheaths used transurethrally to
allow passage of relatively large curved
needles, self-righting needle driver, and
adequate fulguration of the fistula tract and
the surrounding bladder mucosa
Chennai
66

Ureterovaginal fistula
• The most common cause is surgical injury to
the distal ureter, with gynecologic procedures
being by far the most common
• The incidence of iatrogenic ureteral injury
during major gynecologic surgery is 0.5% to
2.5%
Chennai
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Chennai
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Modes of injury :
• Ureteral laceration or transection,
• blunt avulsion,
• crush injury,
• partial or complete suture ligation, and,
• ischemia caused by operative devitalization of
the ureteral vascular supply and/or cautery
injury
Chennai
69

• In the deep pelvis, the ureter passes at the
lateral edge of the uterosacral ligament and
ventral to the uterine artery, and then passes
just lateral to the cervix and fornix of the
vagina
• Any injury to the ureter that exposes the
ureteral lumen (i.e., laceration) or results in
delayed necrosis of a portion of the ureter (i.e.,
suture ligation) and subsequent urinary
extravasation may lead to a fistula
Chennai
70

A sequence of events in ureterovaginal fistula
• urinary extravasation from the ureteral injury,
• urinoma formation,
• subsequent extension along nonanatomic
planes created during surgery,
• and eventual drainage through the vaginal
incision or an ischemic area of the vaginal cuff
Chennai
71

Clinical features /Diagnosis
• The most common presenting symptom is the
onset of constant urinary incontinence 1 to 4
weeks after surgery
• in the setting of continuous urine leakage from
a ureterovaginal fistula, patients will continue to
report normal voiding habits because bladder
filling is maintained from the contralateral,
presumably undamaged, upper urinary tract
Chennai
72

Retrograde pyelogram demonstrates a distal ureteral stricture
with a small fistula tract (white arrow) with contrast in the
vagina (black arrows) superimposed on contrast in the bladder
from the contralateral retrograde ureterogram.
Chennai
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Faint and subtle opacification of the vagina (white arrows) is
somewhat obscured by bladder filling (bladder edge indicated
by black arrows) on this oblique image
Chennai
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VESICOUTERINE FISTULA
CAUSES
• Commonly, following Caesarian Section
• Previous traumatic (difficult) forceps delivery
• Migration of (Perforated) Intrauterine
Contraceptive Device
Chennai
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CLINICAL PRESENTATION
• Typically, Cyclic Hematuria (Menouria, Vesical
menstruation)
• Lochiauria (Urethral passage of Lochia)
• In some reported cases, Urinary Incontinence (vaginal
leakage of urine) when fistula involves isthmus region
(VESICOCERVICAL FISTULA)
• Herniation of the Amniotic sac through Uterovesical
fistula
• Infertility, Amenorrhea
Chennai
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• Youssef syndrome describes the presenting
symptom complex of vesicouterine fistula:
menouria, cyclic hematuria with associated
apparent amenorrhea, infertility, and urinary
continence in a patient who has undergone
prior low-segment cesarean section
Chennai
79

DIAGNOSIS
• Cystoscopy, Cystogram, Hysterosalpingogram
• Transabdominal/Transvaginal Sonogram
• Exclusion of other Genitourinary fistula like Vesico
Vaginal Fistula or Uretero Vaginal Fistula by DOUBLE
DYE TEST (i.e., intravesical instillation of Methylene
Blue+Oral adm. Of Pyridium)
• SALINE INFUSION SONOHYSTEROGRAM (SIS) +
ENDOVAGINAL SONOGRAM
Chennai
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Chennai
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Sonohysterography
• A cannula is introduced into the cervical canal after
expellingair from it with saline
• The endovaginal probe is introduced into the vagina.
• Saline is injected into the cannula, and simultaneously
the uterus is scanned in the longitudinal plane.
• The saline freely entering the urinary bladder in a jet
through the deficiency in the myometrium, confirms
the vesicouterine fistula
Chennai
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83
Chennai
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MANAGEMENT
Conservative approach:
• i) Cystoscopic fulguration,
• ii) Cyclic combine hormonal therapy with continuous
catheterization,
• iii) Spontaneous resolution by continuous catheterization
Chennai
84

Surgical approach:
• i) Transabdominal transperitoneal repair of
fistula with/without Hysterectomy,
• ii) Fistula repair with Omental interposition or
Myouterine flap,
• iii) Vaginal repair in cases of previous subtotal
hysterectomy Dept Of Urology, KMC and GRH,
Chennai
85

Urethrovaginal Fistula
Etiology:
• obstructed labor with or without associated VVF
• feminizing genital reconstructions in children with
ambiguous genitalia and surgical repairs of cloacal
malformations
• female-to-male reconstruction
• bulking agents or synthetic slings for SUI
• Trauma—including inappropriate catheterization and
foreign bodies
Chennai
86

symptoms
• a large urethrovaginal fistula can cause continuous
urine drainage.
• Proximal fistulae can be associated with stress
incontinence, or, if they are located at the bladder
neck, continuous incontinence may result.
• Distal fistulae beyond the sphincteric mechanism
may be completely asymptomatic or splayed urinary
stream
Chennai
87

- diagnosis of
urethrovaginal
fistula can often be
made on physical
examination and
cystourethroscopy
- voiding
cystourethrography is
most useful .
Chennai
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• Distal fistulae without associated voiding symptoms or incontinence may
be observed or, alternatively, can be managed with an extended
meatotomy
• repair of urethrovaginal fistulae is conceptually very similar to the vaginal
flap repair of VVF
• Various types of soft-tissue flaps are often an important component of a
successful urethrovaginal fistula repair because fistula excision and vaginal
flap advancement have been historically associated with a high rate of
failure
• SUI may persist after repair of urethrovaginal fistulae. Whether repair of
SUI should be done concomitantly with the fistula surgery or should be
deferred until after repair of the fistula is controversial!
(SUI associated with distal urethrovaginal fistula can be repaired
concomitantly)
Chennai
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Thank You….
Chennai
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