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Clinical Case Discussion

Case Discussion: Vesicovaginal Fistula Following a Total Abdominal Hysterectomy: The Case for Abdominal Repair

By: Altaf Mangera and Christopher Chapple

EU Focus, Volume 2 Issue 1, April 2016, Pages 100-102

Published online: 01 April 2016

Abstract Full Text Full Text PDF (1,3 MB)

1. Clinical features

This is an interesting case that is more common than we would wish. This patient has good performance status, good nutrition, few comorbidities, and no previous abdominal surgery. Thus, we suspect that her tissue quality is good, suggesting an optimistic outcome for primary fistula repair. Bilateral retrograde studies showed no residual obstruction of the upper urinary tract, although the fistula is close to the right ureter. The hysterectomy was for benign disease, so no (additional/adjuvant) oncologic treatments are planned.

2. Discussion

The incidence of posthysterectomy vesicovaginal fistulae (VVF) is around 1 in 788 [1] and is higher after hysterectomy for cervical cancer. A concomitant ureterovaginal fistula is found in up to 15% of cases [2]. Patients with surgical complications are commonly distraught, as a routine procedure has resulted in a problem that may be worse than the original symptoms. The initial medical team responsible must be honest, patient, and sympathetic with regard to these feelings. The surgeon dealing with the complication should recognise these concerns and show sympathy regarding the patient's plight. Medicolegal proceedings may have commenced and anything discussed should be documented to allow later scrutiny. The patient and the surgeon would prefer the next surgery to be the last, so it is probably best that only a limited number of specialists manage such patients. With adequate training and experience, such surgeons should be able to quote personal success rates exceeding 90%.

Patients with VVF hope for immediate resolution. However, the surgical repair should not be undertaken until 2–12 wk have passed to allow time for resolution of infection, wound healing, and tissue remodelling). The timing may be further compromised following oncologic surgery, as adjuvant treatments may be necessary and the risk of local recurrence may affect the chances of fistula cure.

When planning repair, a copy of the original operation notes (which may mention difficulties encountered such as adhesions or anatomic variations) should be obtained before taking a comprehensive history and performing an office examination. A cystogram will confirm the diagnosis but may not detail adjacent anatomic relationships. A delayed-phase contrast computed tomography (CT) scan will show a ureterovaginal fistula and will suggest the relationship of the ureter to the pelvic organs and fistula. The soft-tissue resolution of a CT scan is inferior to magnetic resonance imaging. Complete imaging of the upper and lower urinary tract is mandatory. An examination under anaesthesia with cystoscopy will provide an appreciation of the anatomic relationships and tissue integrity, and will allow retrograde examination of the ureters. Small fistulae may be difficult to visualise without methylene blue.

While management options include bladder drainage aimed at spontaneous closure [3], fulguration [4], and fibrin glue [5], surgery represents the main treatment approach. The principles for VVF repair are adequate exposure, tension-free and watertight approximation of the fistula edges, nonoverlapping suture lines, interposition of vascularised tissue, good haemostasis, adequate postoperative bladder drainage, and freedom from infection.

3. Treatment recommendations

Owing to the location of this fistula and its proximity to the right ureter, we suggest transabdominal repair. The vaginal approach is favoured for lower fistulae, and a Martius flap or peritoneal interposition can be used as tissue interposition to fill dead space and bring in a vascularised plane between the two ends of the fistula. Alternatively, Latzko colpocleisis may be used in patients with atrophic tissues [6]. With the transabdominal approach, omentum lends itself very well to vascular interposition, and the bladder is bivalved and inspected from the inside before being repaired according to the principles above [7].

Following cystoscopy and ureteric stenting, we open using a Pfannenstiel incision and release the adipose tissue from the rectus sheath (Fig. 1A). The surgeon needs to ensure that this is carried up to the umbilicus and down to the pubis, dividing the rectus muscle attachment to the pubic bone (Fig. 1B,C). The bladder is bivalved to the fistula and the interior is inspected. The ureteric catheters are pulled out from the urethra and retracted laterally. The plane between the bladder and the vagina is only a few millimetres wide, so it may be useful to insert a finger in the vagina to guide incision. A finger not only allows the surgeon to cut the plane by feel but also applies traction to the vagina, and can be augmented by applying gentle traction to the bladder with stay sutures.

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Fig. 1 (A) Pfannenstiel skin incision with release of adipose tissue from the rectus sheath. (B) Midline incision in the rectus from the umbilicus to the pubic bone (denoted by the arrow). (C) Pictorial representation of the principle.

It is necessary to dissect the fistula circumferentially, and dissection of at least 1 cm caudal to the fistula tract is required [8]. It is imperative to ensure that the ureters have not been involved in the dissection; if the fistula is close to the ureters, the ureteric catheters can be exchanged for stents. Figure 2 shows the vaginal opening, the bivalved bladder, and the ureteric catheters.

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Fig. 2 Vaginal opening (black arrow), the bivalved bladder (white arrow), and the ureteric catheters.

The vaginal opening is closed first (Fig. 3). Then omentum is interpositioned onto the vagina and is sutured 1 cm beyond the closed vaginal incision; this is the reason for dissecting at least 1 cm caudal to the fistula (Fig. 4). A 16F suprapubic catheter is inserted and the bladder is closed in layers. A pelvic drain is also inserted with a fresh 16F urethral catheter. The drain is removed after 3 d and the patient is discharged when mobile. A cystogram is performed at 14 d (Fig. 5). Thereafter, the urethral catheter may be removed, followed by the suprapubic catheter if the patient is voiding urine satisfactorily.

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Fig. 3 Closure of the vaginal opening (black arrow).

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Fig. 4 (A) Omental interposition (black arrow). (B) Pictorial representation of the principle for omental harvest.

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Fig. 5 Postoperative cystogram demonstrating resolution of the fistula. Note the contrast reflux up through the ureters because of in situ ureteric stents.

Conflicts of interest

The authors have nothing to disclose.

References

  • [1] P. Hilton, D.A. Cromwell. The risk of vesicovaginal and urethrovaginal fistula after hysterectomy performed in the English National Health Service—a retrospective cohort study examining patterns of care between 2000 and 2008. Br J Obstet Gynaecol. 2012;119:1447-1454 Crossref
  • [2] W.E. Goodwin, P.T. Scardino. Vesicovaginal and ureterovaginal fistulas: a summary of 25 years of experience. J Urol. 1980;123:370-374
  • [3] R.J. Davits, S.I. Miranda. Conservative treatment of vesicovaginal fistulas by bladder drainage alone. Br J Urol. 1991;68:155-156 Crossref
  • [4] P.N. Dogra, G. Nabi. Laser welding of vesicovaginal fistula. Int Urogynecol J Pelvic Floor Dysfunct. 2001;12:69-70 Crossref
  • [5] S.K. Sharma, K.T. Perry, T.M. Turk. Endoscopic injection of fibrin glue for the treatment of urinary-tract pathology. J Endourol. 2005;19:419-423 Crossref
  • [6] D.Y. Pushkar, V.V. Dyakov, G.R. Kasyan. Management of radiation-induced vesicovaginal fistula. Eur Urol. 2009;55:131-137
  • [7] H.H. Woo, D.J. Rosario, C.R. Chapple. The treatment of vesicovaginal fistulae. Eur Urol. 1996;29:1-9
  • [8] C. Chapple, R. Turner-Warwick. Vesico-vaginal fistula. BJU Int. 2005;95:193-214 Crossref

Footnotes

Department of Urology, Royal Hallamshire Hospital, Sheffield, UK

Corresponding author. Department of Urology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK.

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