Arch Gynecol Obstet (2015) 292:245–253 DOI 10.1007/s00404-015-3760-8
NEWS AND VIEWS
Vesicovaginal fistulas: a gynecological experience in 41 cases at a German pelvic floor center Christl Reisenauer1
Published online: 23 May 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose Etiology, diagnosis and management of vesicovaginal fistulas in women referred to the German pelvic floor center Tuebingen over a 9-year period of time were analyzed. Methods Records of 41 consecutive women suffering from vesicovaginal fistulas between February 2006 and February 2015 were reviewed retrospectively. Results In the German case series presented, the most common etiology of vesicovaginal fistulas was total abdominal hysterectomy. Other causes, in descending order of frequency, were abdominal radical hysterectomy, endometriosis surgery, total laparoscopical hysterectomy, vaginal hysterectomy, surgical treatment for ovarian cancer, radiotherapy, supracervical laparoscopic hysterectomy, surgery for genital malformation, cesarean section and forceps delivery. The transvaginal approach, for surgical fistula treatment, was primarily adopted whenever the primary or recurrent fistula was accessible vaginally because of its minimally invasive nature and low morbidity. The vesicovaginal fistula cure rate was 97.5 %. 36 out of 41 vesicovaginal fistulas were closed transvaginally. In one case, the postradiation vesicovaginal fistula could not be cured and the patient required urinary diversion. Conclusion To avoid repeated surgeries, fistula management in specialized centers is advantageous.
Keywords Vesicovaginal fistula Transvaginal fistula repair Martius flap Abdominal fistula repair Omentum majus flap Bioimplant
Introduction Vesicovaginal fistulas (VVF) constitute distressing complications of gynecologic and obstetric procedures with devastating effects on patients‘ quality of live. Fistula treatment often poses a challenge for urogynecologists. Due to advances in obstetric care, genital fistulas are rare in industrialized countries and are attributed to pelvic surgery and hysterectomy in particular [1]. This article deals with etiology, diagnosis and management of VVF in women referred to the Department of Obstetrics and Gynecology Tuebingen over a 9-year period of time.
Materials and methods Records of 41 consecutive women suffering from VVF and referred to the division of Urogynecology between February 2006 and February 2015 were reviewed retrospectively. This project was approved by the local ethics committee. The patients’ characteristics are summarized in Table 1.
Results & Christl Reisenauer [email protected] 1
Department of Obstetrics and Gynecology, University Hospital Tuebingen, Calwerstrasse 7, 72076 Tuebingen, Germany
In total, 112 women with genital fistulas were referred to the Department of Obstetrics and Gynecology of the University Hospital Tuebingen between February 2006 and February 2015. 41 (36.6 %) out of these 112 women, aged
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Table 1 Patients’ characteristics Case number
Women’s age at the time of the fistula diagnosis
Previous surgery
Fistula characteristics/ treatment at other hospitals
Fistula treatment at our department
1.
48
10/2005 total abdominal hysterectomy (TAH) (uterine fibroids)
Primary fistula
Transvaginal multilayer closure 2/2006
3/2005 laparoscopically assisted vaginal hysterectomy (LAVH) (uterine fibroids) (intraoperatively bladder injury)
Recurrent fistula
5/2006 total abdominal hysterectomy (TAH) (uterine fibroids)
Primary fistula 3 mm, supratrigonal
Transvaginal multilayer closure 11/2006
2.
3.
47
35
5 mm, supratrigonal
15 mm, trigonal
Transvaginal multilayer closure 5/2006
Laparoscopic fistula repair 3/2005
4.
61
8/2006 abdominal radical hysterectomy (ARH) (cervical cancer)
Primary fistula 10 mm, supratrigonal
Transvaginal multilayer closure 11/2006
5.
31
6/2007 endometriosis surgery with partial cystectomy
Recurrent fistula
Transvaginal multilayer closure with Martius flap interposition 2/2008
40 mm, supratrigonal Laparoscopic fistula repair 7/2007 Abdominal fistula repair 7/2007 Transvaginal fistula repair (10/ 2007; 11/2007)
6.
48
9/2008 total abdominal hysterectomy (TAH) (uterine fibroids)
Primary fistula 10 mm, supratrigonal
Transvaginal multilayer closure 11/2008
(intraoperatively bladder injury) 7.
34
10/2008 endometriosis surgery with partial cystectomy
Recurrent fistula 10 mm, supratrigonal 4 laparoscopic fistula repairs 10/2008–2/2008
8. 9.
10.
11.
81 50
47
12
Transvaginal multilayer closure with Martius flap interposition 2/2009
8/2009 radiochemotherapy (cervical cancer)
Primary fistula
Urinary diversion 2/2009
6/2009 abdominal radical hysterectomy (ARH) (cervical cancer)
Primary fistula
2/2010 total abdominal hysterectomy (TAH) (uterine fibroids)
Recurrent fistula
6/2010 vaginal reconstruction in woman presenting genital malformation
Primary fistula 3 mm, supratrigonal
Transvaginal multilayer closure 6/2010
30 mm, supratrigonal 10 mm, supratrigonal
20 mm, supratrigonal abdominal transvesical fistula repair 4/2010
Transvaginal multilayer closure 8/2009 Transvaginal multilayer closure with Martius flap interposition 5/2010
12.
47
6/2010 total abdominal hysterectomy (TAH) (uterine fibroids)
Primary fistula 15 mm, trigonal
Transvaginal multilayer closure 8/2010
13.
36
4/2010 endometriosis surgery with partial cystectomy
Primary fistula
Spontaneous closure 8/2010
6/2010 total laparoscopic total hysterectomy (TLH)
Primary fistula
14.
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44
5 mm, supratrigonal 10 mm, supratrigonal
Transvaginal multilayer closure with Martius flap interposition 9/2010
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Table 1 continued Case number
Women’s age at the time of the fistula diagnosis
Previous surgery
Fistula characteristics/ treatment at other hospitals
Fistula treatment at our department
15.
62
10/2009 abdominal radical hysterectomy (ARH) (endometrial cancer) 10/2010 abdominal radical hysterectomy (ARH) (endometrial cancer)
Primary fistula
Transvaginal multilayer closure with Martius flap interposition 1/2011 Transvaginal multilayer closure with Martius flap interposition 2/2011
16.
17.
57
37
3/2007 abdominal radical hysterectomy (ARH) (cervical cancer) (intraoperatively bladder injury)
18.
19.
20.
21.
22.
23..
24.
25.
26.
40
56
55
35
36
44
36
47
52
10 mm, trigonal Primary fistula 10 mm, supratrigonal Recurrent fistula 3 mm, supratrigonal Abdominal fistula repair with omentum majus flap 3/2007 Abdominal fistula repair 2/2009
6/2011 endometriosis surgery with partial cystectomy
Primary fistula
1986 abdominal radical hysterectomy (ARH) and radiotherapy (cervical cancer)
Primary fistula (2010)
6/2011 total abdominal hysterectomy (TAH) (uterine fibroids)
Primary fistula
2/2012 total vaginal hysterectomy (TVH) (bleeding disorders)
Primary fistula
12/2011 forceps delivery for prolonged and difficult delivery
Primary fistula
3/2012 total laparoscopic hysterectomy (TLH) (intraoperatively bladder injury)
Primary fistula
1992 total abdominal hysterectomy (TAH)
Primary fistula
(intraoperatively bladder injury) 2/2012 laparoscopically assisted vaginal hysterectomy (LAVH) (uterine fibroids) 4/2011 total abdominal hysterectomy (TAH) (uterine fibroids)
Transvaginal multilayer closure with Martius flap interposition 4/2011
10 mm, trigonal
5 mm, supratrigonal
5 mm, supratrigonal
10 mm, supratrigonal
30 mm, supratrigonal
20 mm, supratrigonal
3 mm, supratrigonal
Recurrent fistula 20 mm, supratrigonal Abdominal transvesical fistula repair 3/2012 Primary fistula 10 mm, trigonal
Transvaginal multilayer closure with Martius flap interposition 10/2011 Transvaginal multilayer closure with Martius flap interposition 10/2011 Transvaginal multilayer closure 11/2011 Transvaginal multilayer closure 4/2012 Abdominovaginal multilayer closure with omentum majus flap interposition 4/2012 Transvaginal multilayer closure 6/2012
Transvaginal multilayer closure and anterior colporrhaphy 6/2012 Transvaginal multilayer closure with Martius flap interposition 8/2012 Transvaginal multilayer closure 9/2012
(intraoperatively bladder injury) 27.
58
1998 total vaginal hysterectomy (TVH) (bleeding disorders) (intraoperatively bladder injury)
Recurrent fistula 4 mm, supratrigonal Abdominal fistula repair with omentum majus flap 1998
Transvaginal multilayer closure with Martius flap interposition 11/2012
Transvaginal fistula repair 1998
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Table 1 continued Case number
Women’s age at the time of the fistula diagnosis
Previous surgery
Fistula characteristics/ treatment at other hospitals
Fistula treatment at our department
28.
51
9/2012 total abdominal hysterectomy (TAH) (uterine fibroids)
Recurrent fistula
Transvaginal multilayer closure with Martius flap interposition 2/2013
4/2013 total laparoscopic hysterectomy (TLH)
Primary fistula
2/2012 total abdominal hysterectomy (TAH) (bleeding disorders)
Recurrent fistula 5 mm, supratrigonal
29. 30.
65 48
10 mm, supratrigonal Abdominal fistula repair 12/2012 5 mm, supratrigonal
Abdominal fistula repair 3/2012
Transvaginal multilayer closure 7/2013 Transvaginal multilayer closure with Martius flap interposition 10/2013
Abdominal fistula repair with omentum majus flap 4/2012 Abdominal fistula closure 4/2012 31.
32.
33.
57
75
79
2011 ovarian cancer surgery with partial cystectomy
Primary fistula
1996 abdominal radical hysterectomy (ARH) and radiotherapy (endometrial cancer)
Primary fistula 15 mm, trigonal
Transvaginal multilayer closure with Martius flap interposition 2/2014
1985 abdominal radical hysterectomy (ARH) and radiotherapy (endometrial cancer)
Primary fistula
Latzko operation 3/2014
20 mm, trigonal
transvaginal multilayer closure with bioimplant (SurgisisÒ) interposition 8/2014
7/2013 ovarian cancer surgery with partial cystectomy
Recurrent fistula
12 mm, supratrigonal
Transvaginal multilayer closure with Martius flap interposition 12/2013
urinary diversion 4/2015 34.
59
5 mm, trigonal
Transvaginal multilayer closure 5/2014
Transvaginal fistula repair 11/2013 Transvaginal fistula repair with Martius flap 2/2014 35.
36.
37.
38.
39.
123
36
45
55
36
33
2006 abdominal radical hysterectomy (ARH) and radiotherapy (cervical cancer) 1/2014 total abdominal hysterectomy (TAH) (uterine fibroids)
Primary fistula 20 mm, trigonal
Primary fistula 5 mm, supratrigonal
10/2014 laparoscopic supracervical hysterectomy (LSH) and cervicosacropexy
Primary fistula
10/2014 total laparoscopic hysterectomy (TLH) (uterine fibroids)
Primary fistula
9/2014 cesarean section for obstructed labor
Recurrent fistula
(intraoperatively bladder injury)
Abdominal fistula repair 9/2014
10 mm, supratrigonal
40 mm, supratrigonal
25 mm, supratrigonal
Transvaginal multilayer closure with Martius flap interposition 6/2014 Transvaginal multilayer closure 8/2014 Abdominal cervix extirpation and vesicovaginal fistula closure with Omentum majus flap interposition, left ureteroneostomy 12/2014 Transvaginal multilayer closure 1/2015 Abdominovaginal multilayer closure with Omentum majus flap interposition 1/2015
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Table 1 continued Case number
Women’s age at the time of the fistula diagnosis
Previous surgery
Fistula characteristics/ treatment at other hospitals
Fistula treatment at our department
40.
48
12/2014 total abdominal hysterectomy (TAH) (uterine fibroids)
Primary fistula
Transvaginal multilayer closure with bioimplant (SurgisisÒ) interposition 2/2015
12/2014 abdominal radical hysterectomy (ARH) (endometrial cancer)
Primary fistula
41.
48
45 mm, supratrigonal
20 mm, supratrigonal
Transvaginal multilayer closure 2/2015
(intraoperatively bladder injury)
12–81 years, suffered from vesicovaginal fistulas. 2 VVF were of obstetric etiology, 26 occurred after surgeries for benign gynecologic disease and 13 were induced by surgeries for gynecologic malignancies (8/13), radiotherapy (1/ 13) or by a combined therapy of surgery and radiation (4/13). As to the 26 VVF that resulted as complication of surgeries for benign gynecological disease, the most common surgery was hysterectomy (21/26) followed by endometriosis surgery (4/26), and one VVF resulted after surgery for genital malformation. The occurrence of VVF following hysterectomy varied according to abdominal, laparoscopic or vaginal approach: 12 followed total abdominal hysterectomy (TAH), 4 total laparoscopic hysterectomy (TLH), 2 laparoscopically assisted vaginal hysterectomy (LAVH), 2 total vaginal hysterectomy (TVH) and 1 followed laparoscopic supracervical hysterectomy (LSH) and cervicosacropexy. Uterine fibroids were the most common indication for hysterectomy. The 13 VVF that occurred after treatment of genital malignancies were caused by abdominal radical hysterectomy (ARH) (6/13), abdominal radical hysterectomy (ARH) combined with radiotherapy (4/13), radiotherapy (1/13) and surgery for ovarian cancer (2/13). The 2 VVF with obstetric etiology in one case followed a forceps delivery for prolonged and difficult delivery and in another case a cesarean section for obstructed labor. In both cases, the patients gave birth to their second child, after a previous elective cesarean section. 30 out of 41 VVF were primary fistulas whereas 11 out of 41 VVF were recurrent fistulas after one to six previous attempts at repair. The patients with VVF were diagnosed with urine leaking through the vagina during vaginal examination. In very small fistulas (Fig. 1), filling the bladder with a dilute solution of Indigo carmine was helpful for diagnosis. Cystoscopy identified the location of the fistula in the bladder wall. The most common location of VVF was found between the vaginal cuff and the supratrigonal posterior wall of the bladder.
Fig. 1 Vesicovaginal fistula located at the anterior vaginal wall
If ultrasonography of the kidneys—done in every patient—revealed upper urinary tract dilation it was followed by a pyeloureterogram for ureteric injury diagnosis. After resolution of local inflammation, infection and edema of the tissue surrounding the fistula, the fistula closure was performed (Fig. 2). Continuous suprapubic drainage of the bladder was used only in patients with VVF located supratrigonally, as urine leakage through the vagina continues in patients where the fistula is located intratrigonally. In one case, the VVF closed spontaneously after 12 weeks of suprapubic bladder drainage. The fistula was of small diameter (5 mm) and detected immediately after its occurrence. In 5 cases, the fistula diameter was \5 mm and in 19 cases the fistula diameter ranged between 5 and 10 mm. 17 patients had a fistula size [10 mm, the largest fistula was 45 mm. 9 VVF were located intratrigonally (Fig. 3) and 32 supratrigonally. We preferred the transvaginal approach. The vaginal repair techniques used were the Latzko procedure [2] and a
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Fig. 2 Vesicovaginal fistula after hysterectomy between the vaginal cuff and the supratrigonal bladder wall a two weeks after hysterectomy, transvaginal view; b two weeks after hysterectomy, cystoscopic view; c three months after hysterectomy, transvaginal view; d three months after hysterectomy, cystoscopic view
Fig. 3 Vesicovaginal fistula located between the anterior vaginal wall and the trigonum of the bladder a transvaginal view; b cystoscopic view
multilayered closure after trimming the scarred bladder edges of the fistula with or without interposition of Martius flap [3] or a bioimplant. When transabdominal transperitoneal repair was used, it comprised the mobilization of the bladder from the uterus and the vagina, the bladder closure in two layers and the interposition of an omentum majus flap between the uterus/vagina and the bladder. If cystoscopy showed a close proximity of a fistula to the ureteric orifices, ureteral stents were inserted preoperatively. In ten patients, ureteral stents were placed on one (3/10) or both sides (7/10). The ureteral stents were removed 4 weeks postoperatively. Bladder drainage was done in all cases for a period of 3 weeks postoperatively. Two bowel injuries happened during catheter placement. Both patients had extensive
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abdominal surgeries for endometriosis with partial cystectomy prior to fistula repair leading to bowel adhesions to the bladder. Due to the high risk of bowel injury in one patient after ovarian cancer surgery, we used a transurethral bladder drainage. 36 VVF were approached transvaginally, 2 were approached abdomino-vaginally and 1 VVF was approached abdominally. In the cases of vaginal approach, a multilayer closure was used in 16 women, a multilayer closure with Martius flap interposition also in 16 women, a multilayer closure with bioimplant interposition (SurgisisÒ, Cook Medical, Bloomington, IN, USA) in 2 cases and the Latzko procedure in 1 case. The VVF occurring 29 years after radiotherapy was closed twice, first using the Latzko procedures
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and after recurrence 5 months later, the VVF was treated using bioimplant. Due to the inability to obtain proper exposure of the fistula tract transvaginally, the abdominovaginal approach with multilayer closure and omentum majus flap interposition was used in both women with vesicovaginal fistulas after obstetric traumas. In both cases, the uterus was preserved. The patient with the vesicovaginal fistula after the supracervical hysterectomy and cervicosacropexy was treated by transabdominal approach. The cervix was removed and the fistula was closed using a multilayer closure with an omentum majus flap interposition. Ureteroneostomy was needed due to an associated left ureteral obstruction. 5 patients were presented with VVF 2 months, 8 and 18, 24 and 29 years after radiation. In one patient, the VVF occurred 29 years after radiation. As the tissue was rigid, the fistula was closed first using the Latzko procedure. 5 months later a recurrence occurred and then the fistula was closed by using a bioimplant (SurgisisÒ, Cook Medical, Bloomington, IN, USA). The fistula again recurred 8 months later and a urinary diversion was necessary. In one case, due to the progress of cervical cancer 2 months after radiochemotherapy, a palliative urinary diversion was performed. In all other cases, the fistulas after radiation were cured. In 9 of 41 women with VVF, intraoperative bladder lesions occurred during the pelvic surgery prior to the fistula development. In 6 of 41, a partial bladder resection was performed for endometriosis treatment and to achieve maximal cytoreduction in advanced ovarian cancer patients. Success of the procedure was defined if the patient was leakage free in the follow-up period. All patients with VVF resulting as a complication of surgeries for benign gynecological disease and after obstetric injuries were cured postoperatively. In one fistula patient, the healing occurred spontaneously. Two women suffering from VVF after radiotherapy for malign gynecologic disease required a urinary diversion. In one case, the urinary diversion was needed due to cancer recurrence and in the other one following two VVF recurrences due to tissue rigidity after radiation.
Discussion The majority of VVF in the present series of patients occurred up to 6 weeks postoperatively as complications of gynecologic surgery. Gynecological surgeries were more frequently associated with the development of VVF than with obstetric causes, due to advances in obstetric care in industrialized countries.
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In literature, it is assumed that urogenital fistulas originate from dissection of the bladder, from sutures incorporated into the bladder, or from direct injuries to the lower urinary tract [4, 5]. Immediate postoperative VVF presentation occurs when there is direct injury to the bladder during surgery [6]. Delayed presentation can occur when there is an ischemic necrosis and progressive devitalization of the posterior wall of the bladder [7]. Extensive dissection, clamp injury, inclusion of bladder wall during uterine closure, and diathermic cauterization can result in devascularization of the bladder [8]. In the present case series, bladder injury occurred incidentally in 9 women during pelvic surgery prior to fistula development. Furthermore, in 6 cases a partial bladder resection was performed for endometriosis treatment and for achieving maximal cytoreduction in a patient with advanced ovarian cancer before fistulas occurred. Duong et al. reported 34 incidental cystotomies during 1317 hysterectomies, 4 patients (11.7 %) developing a VVF [9]. In a nationwide cohort study, Forsgren et al. observed that the highest overall fistula rates were after laparoscopic and total abdominal hysterectomy, among older women, and during the first year after surgery. Furthermore, they found that the rate of fistula disease was higher in women who had total abdominal hysterectomy than those who had a vaginal hysterectomy [10]. In the German case series presented, the most common etiology of vesicovaginal fistulas was total abdominal hysterectomy. Other causes, in descending order of frequency, were abdominal radical hysterectomy, endometriosis surgery, total laparoscopical hysterectomy, laparoscopically assisted vaginal hysterectomy, total vaginal hysterectomy, surgical treatment for ovarian cancer, radiotherapy, laparoscopical supracervical hysterectomy, surgery for genital malformation, cesarean section and forceps delivery. Hilton et al. showed that among 343771 women undergoing elective hysterectomies in the English National Health Service hospitals between 2000 and 2008, the overall rate of vesicovaginal and urethrovaginal fistula was 1 in 788 (0.13 %) within 1 year after surgery [11]. The rate varied by indication and procedure, being highest following radical hysterectomy for cervical cancer (1 in 87) and lowest following vaginal hysterectomy for prolapse (1 in 3861). Total abdominal hysterectomy resulted in an estimated fistula rate of 1 in 540 and 1 in 2279 for subtotal abdominal hysterectomy. In the presented case series, postoperative fistulas had appeared days after surgery, while radiation-induced fistulas had occurred up to 29 years after treatment. In accordance with the literature, radiation-induced fistulas can occur even 20–30 years after the end of treatment [12]. The majority of our patients had suprapubic bladder drainage after the vesicovaginal fistula diagnosis. A
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spontaneous closure of the fistula during bladder drainage was observed in one case only. The fistula was located supratrigonally in the posterior bladder wall, the urine was completely drained and the patient became continent during the drainage of the bladder. Those patients with vesicovaginal fistulas located within the trigonum lost urine despite the suprapubic bladder drainage. Spontaneous closure of small VVF after catheter drainage alone has been reported. Of 151 VVF, three (2 %) were successfully managed by catheterization in one series [8]. Thompson et al. reported a spontaneous fistula healing rate after bladder drainage of at most only 15–20 % of cases, when the fistula is simple and of small size [13]. In another series, four patients who developed a fistula after abdominal and vaginal hysterectomy were treated with bladder drainage for periods of 19–54 days; all remained dry after the removal of the catheter [14]. It has been suggested that if healing has not occurred within 4 weeks, it is unlikely that a fistula will close spontaneously [15]. The insertion of a suprapubic catheter for bladder drainage can present a risk of bowel injuries, especially after previous extensive surgeries. Due to extensive surgeries for endometriosis treatment prior to VVF development, bowel injuries during suprapubic catheter insertion happened in our case series. This risk has to be weighed against the advantages of a continuous bladder drainage using a suprapubic catheter and needs to be discussed with the patient. Alternatively a transurethral catheter can be used for bladder drainage. 39 out of our 41 patients underwent surgical VVF management: 36 patients by a transvaginal approach, 1 woman by an abdominal approach and 2 VVF were approached abdomino-vaginally. All repairs were done by the same surgeon (CR). Nesrallah et al. reported 100 % success rate with transperitoneal O’Connor procedure and described it as a gold standard for supratrigonal fistulas [16]. In the present case series, on the contrary, vaginal approach was primarily adopted even if the VVF was located supratrigonal because of its minimally invasive nature and low morbidity. In our opinion, a tension-free fistula closure after adequate mobilization of the bladder from the vagina and uterus is essential for cure of the fistula. Abdominal repair was used in the presented case series when the fistula was inaccessible to vaginal approach. Obstetrical fistulas are most often the result of prolonged and obstructed labor. Ischemia of the soft tissue between the vagina and the urinary tract due to compression of the fetal head or direct tearing of the same soft tissue during precipitous deliveries are responsible for the obstetrical vesicovaginal fistulas [17]. This seems to be the reason for the VVF in our patient after forceps delivery, especially following an elective cesarean section.
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The second patient developed a fistula after incidental injury of the bladder during cesarean section for obstructed labor. In her case also an elective cesarean section preceeded. Prolonged and obstructed labor preceding cesarean section can enhance the vulnerability to injury during cesarean delivery. During initial fistula examination, precise evaluation of the upper urinary tract is necessary to accurately define the extent of the fistula tract. It has been demonstrated that concomitant ureteral involvement is estimated to complicate 10–15 % of vesicovaginal fistulas [18]. In our series, in one of 41 cases a concomitant ureteral obstruction was seen. The success rate of unradiated vesicovaginal fistula repair varies between 70 and 100 % and the success rate of radiation-induced vesicovaginal fistula repairs is between 40 and 100 % [19]. In our series, 39 out of 41 women with vesicovaginal fistulas were treated surgically, 38 out of these 39 successfully, two needed a urinary diversion. One patient needed urinary diversion because of progress of cervical cancer, the other one did when she showed a recurrence after Latzko procedure and after fistula closure with interposition of a bioimplant due to the rigidity of the fistula surrounding tissue. Using the Hospital Episode Statistics database, Cromwell et al. have demonstrated an overall failure rate of surgical treatment for lower urinary–genital tract fistula (re-operation rate) of 12 % and a high rate of urinary diversion (24 %). Cure rates varied between 50 and 100 % and were higher in units undertaking less than 3 operations per year. For better results, they recommend a greater centralization of fistula management [20]. Our review showed this as well since one patient was referred to us after six unsuccessful VVF surgeries at another hospital.
Conclusion Management of vesicovaginal fistulas must be tailored to the individual case. The majority of vesicovaginal fistulas can be treated successfully by vaginal approach. Fistula management in specialized centers is advantageous. Conflict of interest
None.
References 1. Lee RA, Symmonds RE, Williams TJ (1988) Current status of genitourinary fistula. Obstet Gynecol 72:313–319 2. Latzko W (1942) Postoperative vesicovaginal fistulas; genesis and therapy. Am J Surg 58:211–228 3. Martius H (1928) Die operative Wiederherstellung der vollkommen fehlenden Harnro¨hre und des Schliessmuskels derselben. Zentralbl Gynak 52:480–486
Arch Gynecol Obstet (2015) 292:245–253 4. Eilber KS, Kavaler E, Rodriquez LV, Rosenblum N, Raz S (2003) Ten-year experience with transvaginal vesicovaginal fistula repair using tissue interposition. J Urol 169:1033–1036 5. Flynn MK, Amundsen CL (2004) Delayed presentation and successful repair of a recurrent vesicivaginal fistula after hysterectomy and primary and primary abdominal repair. Int Urogynecol J Pelvic Floor Dysfunct 15:53–55 6. Alkatib M, Franco AVM, Fynes MM (2005) Vesicouterine fistula following Caesarean delivery—ultrasound diagnosis and surgical management. Ultrasound Obstet Gynecol 26:183–185 7. Porcaro AB, Zicari M, Zecchini Antoniolli S, Pianon R, Monaco C, Migliorini F, Longo M, Comunale L (2002) Vesicouterine fistulas following caesarean section: report on a case, review and update of the literature. Int Urol Nephrol 34(3):335–344 8. Tancer ML (1992) Observations on prevention and management of vesicovaginal fistula after total hysterectomy. Surg Gynecol Obstet 175(6):501–506 9. Duong TH, Gellasch TE, Adam LA (2009) Risk factors for the development of vesicovaginal fistula after incidental cystotomy at the time of a benign hysterectomy. Am J Obstet Gynecol 201:512.e1–512.e4 10. Forsgren C, Lundholm C, Johansson ALV, Cnattingius S, Altman D (2009) Hysterectomy for benign indications and risk of pelvic organ fistula disease. Obstet Gynecol 114:594–599 11. Hilton P, Cromwell D (2012) 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. BJOG 119:1447–1454
253 12. Zoubek J, McGuire EJ, DeLancey JO (1989) The late occurrence of urinary tract damage in patients successfully treated by radiotherapy for cervical carcinoma. J Urol 141:1347–1349 13. Thompson JD (1992) Operative injuries to the ureter prevention, recognition and management. In: Thompson JD, Rock JA (eds) TeLinde‘s operative gynecology, 7th edn. JB Lippincott, Philadelphia, pp 759–783 14. Davits RJ, Miranda SI (1991) Conservative treatment of vesicovaginal fistulas by bladder drainage alone. Br J Urol 68(2):155–156 15. Gerber GS, Schoenberg HW (1993) Female urinary tract fistulas. J Urol 149(2):229–236 16. Nesrallah LJ, Srougi M, Gittes RF (1999) The O’Connor technique: the gold standard for supratriginal vesicovaginal fistula repair. Urology 161(2):566–568 17. Tebeu PM, Fomulu JN, Khaddaj S, de Bernis L, Delvaux T, Rochat CH (2012) Risk factors for obstetric fistula: a clinical review. Int Urogynecol J 23(4):387–394. doi:10.1007/s00192011-1622-x 18. Goodwin WE, Scardino PT (1980) Vesicovaginal and ureterovaginal fistulas: a summary of 25 years of experience. J Urol 123(3):370–374 19. Angioli R, Penalver M, Muzii L, Mendez L, Mirhashemi R, Bellati F, Croce C, Panici PB (2003) Guidelines of how to manage vesicovaginal fistula. Oncoloy Hematol 48:295–304 20. Cromwell D, Hilton P (2012) Retrospective cohort study on patterns of care and outcomes of surgical treatment for lower urinary-genital tract fistula among English National Health Service hospitals between 2000 and 2009. BJU Int 111:257–262
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NEWS AND VIEWS
Vesicovaginal fistulas: a gynecological experience in 41 cases at a German pelvic floor center Christl Reisenauer1
Published online: 23 May 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose Etiology, diagnosis and management of vesicovaginal fistulas in women referred to the German pelvic floor center Tuebingen over a 9-year period of time were analyzed. Methods Records of 41 consecutive women suffering from vesicovaginal fistulas between February 2006 and February 2015 were reviewed retrospectively. Results In the German case series presented, the most common etiology of vesicovaginal fistulas was total abdominal hysterectomy. Other causes, in descending order of frequency, were abdominal radical hysterectomy, endometriosis surgery, total laparoscopical hysterectomy, vaginal hysterectomy, surgical treatment for ovarian cancer, radiotherapy, supracervical laparoscopic hysterectomy, surgery for genital malformation, cesarean section and forceps delivery. The transvaginal approach, for surgical fistula treatment, was primarily adopted whenever the primary or recurrent fistula was accessible vaginally because of its minimally invasive nature and low morbidity. The vesicovaginal fistula cure rate was 97.5 %. 36 out of 41 vesicovaginal fistulas were closed transvaginally. In one case, the postradiation vesicovaginal fistula could not be cured and the patient required urinary diversion. Conclusion To avoid repeated surgeries, fistula management in specialized centers is advantageous.
Keywords Vesicovaginal fistula Transvaginal fistula repair Martius flap Abdominal fistula repair Omentum majus flap Bioimplant
Introduction Vesicovaginal fistulas (VVF) constitute distressing complications of gynecologic and obstetric procedures with devastating effects on patients‘ quality of live. Fistula treatment often poses a challenge for urogynecologists. Due to advances in obstetric care, genital fistulas are rare in industrialized countries and are attributed to pelvic surgery and hysterectomy in particular [1]. This article deals with etiology, diagnosis and management of VVF in women referred to the Department of Obstetrics and Gynecology Tuebingen over a 9-year period of time.
Materials and methods Records of 41 consecutive women suffering from VVF and referred to the division of Urogynecology between February 2006 and February 2015 were reviewed retrospectively. This project was approved by the local ethics committee. The patients’ characteristics are summarized in Table 1.
Results & Christl Reisenauer [email protected] 1
Department of Obstetrics and Gynecology, University Hospital Tuebingen, Calwerstrasse 7, 72076 Tuebingen, Germany
In total, 112 women with genital fistulas were referred to the Department of Obstetrics and Gynecology of the University Hospital Tuebingen between February 2006 and February 2015. 41 (36.6 %) out of these 112 women, aged
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Table 1 Patients’ characteristics Case number
Women’s age at the time of the fistula diagnosis
Previous surgery
Fistula characteristics/ treatment at other hospitals
Fistula treatment at our department
1.
48
10/2005 total abdominal hysterectomy (TAH) (uterine fibroids)
Primary fistula
Transvaginal multilayer closure 2/2006
3/2005 laparoscopically assisted vaginal hysterectomy (LAVH) (uterine fibroids) (intraoperatively bladder injury)
Recurrent fistula
5/2006 total abdominal hysterectomy (TAH) (uterine fibroids)
Primary fistula 3 mm, supratrigonal
Transvaginal multilayer closure 11/2006
2.
3.
47
35
5 mm, supratrigonal
15 mm, trigonal
Transvaginal multilayer closure 5/2006
Laparoscopic fistula repair 3/2005
4.
61
8/2006 abdominal radical hysterectomy (ARH) (cervical cancer)
Primary fistula 10 mm, supratrigonal
Transvaginal multilayer closure 11/2006
5.
31
6/2007 endometriosis surgery with partial cystectomy
Recurrent fistula
Transvaginal multilayer closure with Martius flap interposition 2/2008
40 mm, supratrigonal Laparoscopic fistula repair 7/2007 Abdominal fistula repair 7/2007 Transvaginal fistula repair (10/ 2007; 11/2007)
6.
48
9/2008 total abdominal hysterectomy (TAH) (uterine fibroids)
Primary fistula 10 mm, supratrigonal
Transvaginal multilayer closure 11/2008
(intraoperatively bladder injury) 7.
34
10/2008 endometriosis surgery with partial cystectomy
Recurrent fistula 10 mm, supratrigonal 4 laparoscopic fistula repairs 10/2008–2/2008
8. 9.
10.
11.
81 50
47
12
Transvaginal multilayer closure with Martius flap interposition 2/2009
8/2009 radiochemotherapy (cervical cancer)
Primary fistula
Urinary diversion 2/2009
6/2009 abdominal radical hysterectomy (ARH) (cervical cancer)
Primary fistula
2/2010 total abdominal hysterectomy (TAH) (uterine fibroids)
Recurrent fistula
6/2010 vaginal reconstruction in woman presenting genital malformation
Primary fistula 3 mm, supratrigonal
Transvaginal multilayer closure 6/2010
30 mm, supratrigonal 10 mm, supratrigonal
20 mm, supratrigonal abdominal transvesical fistula repair 4/2010
Transvaginal multilayer closure 8/2009 Transvaginal multilayer closure with Martius flap interposition 5/2010
12.
47
6/2010 total abdominal hysterectomy (TAH) (uterine fibroids)
Primary fistula 15 mm, trigonal
Transvaginal multilayer closure 8/2010
13.
36
4/2010 endometriosis surgery with partial cystectomy
Primary fistula
Spontaneous closure 8/2010
6/2010 total laparoscopic total hysterectomy (TLH)
Primary fistula
14.
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44
5 mm, supratrigonal 10 mm, supratrigonal
Transvaginal multilayer closure with Martius flap interposition 9/2010
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Table 1 continued Case number
Women’s age at the time of the fistula diagnosis
Previous surgery
Fistula characteristics/ treatment at other hospitals
Fistula treatment at our department
15.
62
10/2009 abdominal radical hysterectomy (ARH) (endometrial cancer) 10/2010 abdominal radical hysterectomy (ARH) (endometrial cancer)
Primary fistula
Transvaginal multilayer closure with Martius flap interposition 1/2011 Transvaginal multilayer closure with Martius flap interposition 2/2011
16.
17.
57
37
3/2007 abdominal radical hysterectomy (ARH) (cervical cancer) (intraoperatively bladder injury)
18.
19.
20.
21.
22.
23..
24.
25.
26.
40
56
55
35
36
44
36
47
52
10 mm, trigonal Primary fistula 10 mm, supratrigonal Recurrent fistula 3 mm, supratrigonal Abdominal fistula repair with omentum majus flap 3/2007 Abdominal fistula repair 2/2009
6/2011 endometriosis surgery with partial cystectomy
Primary fistula
1986 abdominal radical hysterectomy (ARH) and radiotherapy (cervical cancer)
Primary fistula (2010)
6/2011 total abdominal hysterectomy (TAH) (uterine fibroids)
Primary fistula
2/2012 total vaginal hysterectomy (TVH) (bleeding disorders)
Primary fistula
12/2011 forceps delivery for prolonged and difficult delivery
Primary fistula
3/2012 total laparoscopic hysterectomy (TLH) (intraoperatively bladder injury)
Primary fistula
1992 total abdominal hysterectomy (TAH)
Primary fistula
(intraoperatively bladder injury) 2/2012 laparoscopically assisted vaginal hysterectomy (LAVH) (uterine fibroids) 4/2011 total abdominal hysterectomy (TAH) (uterine fibroids)
Transvaginal multilayer closure with Martius flap interposition 4/2011
10 mm, trigonal
5 mm, supratrigonal
5 mm, supratrigonal
10 mm, supratrigonal
30 mm, supratrigonal
20 mm, supratrigonal
3 mm, supratrigonal
Recurrent fistula 20 mm, supratrigonal Abdominal transvesical fistula repair 3/2012 Primary fistula 10 mm, trigonal
Transvaginal multilayer closure with Martius flap interposition 10/2011 Transvaginal multilayer closure with Martius flap interposition 10/2011 Transvaginal multilayer closure 11/2011 Transvaginal multilayer closure 4/2012 Abdominovaginal multilayer closure with omentum majus flap interposition 4/2012 Transvaginal multilayer closure 6/2012
Transvaginal multilayer closure and anterior colporrhaphy 6/2012 Transvaginal multilayer closure with Martius flap interposition 8/2012 Transvaginal multilayer closure 9/2012
(intraoperatively bladder injury) 27.
58
1998 total vaginal hysterectomy (TVH) (bleeding disorders) (intraoperatively bladder injury)
Recurrent fistula 4 mm, supratrigonal Abdominal fistula repair with omentum majus flap 1998
Transvaginal multilayer closure with Martius flap interposition 11/2012
Transvaginal fistula repair 1998
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Table 1 continued Case number
Women’s age at the time of the fistula diagnosis
Previous surgery
Fistula characteristics/ treatment at other hospitals
Fistula treatment at our department
28.
51
9/2012 total abdominal hysterectomy (TAH) (uterine fibroids)
Recurrent fistula
Transvaginal multilayer closure with Martius flap interposition 2/2013
4/2013 total laparoscopic hysterectomy (TLH)
Primary fistula
2/2012 total abdominal hysterectomy (TAH) (bleeding disorders)
Recurrent fistula 5 mm, supratrigonal
29. 30.
65 48
10 mm, supratrigonal Abdominal fistula repair 12/2012 5 mm, supratrigonal
Abdominal fistula repair 3/2012
Transvaginal multilayer closure 7/2013 Transvaginal multilayer closure with Martius flap interposition 10/2013
Abdominal fistula repair with omentum majus flap 4/2012 Abdominal fistula closure 4/2012 31.
32.
33.
57
75
79
2011 ovarian cancer surgery with partial cystectomy
Primary fistula
1996 abdominal radical hysterectomy (ARH) and radiotherapy (endometrial cancer)
Primary fistula 15 mm, trigonal
Transvaginal multilayer closure with Martius flap interposition 2/2014
1985 abdominal radical hysterectomy (ARH) and radiotherapy (endometrial cancer)
Primary fistula
Latzko operation 3/2014
20 mm, trigonal
transvaginal multilayer closure with bioimplant (SurgisisÒ) interposition 8/2014
7/2013 ovarian cancer surgery with partial cystectomy
Recurrent fistula
12 mm, supratrigonal
Transvaginal multilayer closure with Martius flap interposition 12/2013
urinary diversion 4/2015 34.
59
5 mm, trigonal
Transvaginal multilayer closure 5/2014
Transvaginal fistula repair 11/2013 Transvaginal fistula repair with Martius flap 2/2014 35.
36.
37.
38.
39.
123
36
45
55
36
33
2006 abdominal radical hysterectomy (ARH) and radiotherapy (cervical cancer) 1/2014 total abdominal hysterectomy (TAH) (uterine fibroids)
Primary fistula 20 mm, trigonal
Primary fistula 5 mm, supratrigonal
10/2014 laparoscopic supracervical hysterectomy (LSH) and cervicosacropexy
Primary fistula
10/2014 total laparoscopic hysterectomy (TLH) (uterine fibroids)
Primary fistula
9/2014 cesarean section for obstructed labor
Recurrent fistula
(intraoperatively bladder injury)
Abdominal fistula repair 9/2014
10 mm, supratrigonal
40 mm, supratrigonal
25 mm, supratrigonal
Transvaginal multilayer closure with Martius flap interposition 6/2014 Transvaginal multilayer closure 8/2014 Abdominal cervix extirpation and vesicovaginal fistula closure with Omentum majus flap interposition, left ureteroneostomy 12/2014 Transvaginal multilayer closure 1/2015 Abdominovaginal multilayer closure with Omentum majus flap interposition 1/2015
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Table 1 continued Case number
Women’s age at the time of the fistula diagnosis
Previous surgery
Fistula characteristics/ treatment at other hospitals
Fistula treatment at our department
40.
48
12/2014 total abdominal hysterectomy (TAH) (uterine fibroids)
Primary fistula
Transvaginal multilayer closure with bioimplant (SurgisisÒ) interposition 2/2015
12/2014 abdominal radical hysterectomy (ARH) (endometrial cancer)
Primary fistula
41.
48
45 mm, supratrigonal
20 mm, supratrigonal
Transvaginal multilayer closure 2/2015
(intraoperatively bladder injury)
12–81 years, suffered from vesicovaginal fistulas. 2 VVF were of obstetric etiology, 26 occurred after surgeries for benign gynecologic disease and 13 were induced by surgeries for gynecologic malignancies (8/13), radiotherapy (1/ 13) or by a combined therapy of surgery and radiation (4/13). As to the 26 VVF that resulted as complication of surgeries for benign gynecological disease, the most common surgery was hysterectomy (21/26) followed by endometriosis surgery (4/26), and one VVF resulted after surgery for genital malformation. The occurrence of VVF following hysterectomy varied according to abdominal, laparoscopic or vaginal approach: 12 followed total abdominal hysterectomy (TAH), 4 total laparoscopic hysterectomy (TLH), 2 laparoscopically assisted vaginal hysterectomy (LAVH), 2 total vaginal hysterectomy (TVH) and 1 followed laparoscopic supracervical hysterectomy (LSH) and cervicosacropexy. Uterine fibroids were the most common indication for hysterectomy. The 13 VVF that occurred after treatment of genital malignancies were caused by abdominal radical hysterectomy (ARH) (6/13), abdominal radical hysterectomy (ARH) combined with radiotherapy (4/13), radiotherapy (1/13) and surgery for ovarian cancer (2/13). The 2 VVF with obstetric etiology in one case followed a forceps delivery for prolonged and difficult delivery and in another case a cesarean section for obstructed labor. In both cases, the patients gave birth to their second child, after a previous elective cesarean section. 30 out of 41 VVF were primary fistulas whereas 11 out of 41 VVF were recurrent fistulas after one to six previous attempts at repair. The patients with VVF were diagnosed with urine leaking through the vagina during vaginal examination. In very small fistulas (Fig. 1), filling the bladder with a dilute solution of Indigo carmine was helpful for diagnosis. Cystoscopy identified the location of the fistula in the bladder wall. The most common location of VVF was found between the vaginal cuff and the supratrigonal posterior wall of the bladder.
Fig. 1 Vesicovaginal fistula located at the anterior vaginal wall
If ultrasonography of the kidneys—done in every patient—revealed upper urinary tract dilation it was followed by a pyeloureterogram for ureteric injury diagnosis. After resolution of local inflammation, infection and edema of the tissue surrounding the fistula, the fistula closure was performed (Fig. 2). Continuous suprapubic drainage of the bladder was used only in patients with VVF located supratrigonally, as urine leakage through the vagina continues in patients where the fistula is located intratrigonally. In one case, the VVF closed spontaneously after 12 weeks of suprapubic bladder drainage. The fistula was of small diameter (5 mm) and detected immediately after its occurrence. In 5 cases, the fistula diameter was \5 mm and in 19 cases the fistula diameter ranged between 5 and 10 mm. 17 patients had a fistula size [10 mm, the largest fistula was 45 mm. 9 VVF were located intratrigonally (Fig. 3) and 32 supratrigonally. We preferred the transvaginal approach. The vaginal repair techniques used were the Latzko procedure [2] and a
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Fig. 2 Vesicovaginal fistula after hysterectomy between the vaginal cuff and the supratrigonal bladder wall a two weeks after hysterectomy, transvaginal view; b two weeks after hysterectomy, cystoscopic view; c three months after hysterectomy, transvaginal view; d three months after hysterectomy, cystoscopic view
Fig. 3 Vesicovaginal fistula located between the anterior vaginal wall and the trigonum of the bladder a transvaginal view; b cystoscopic view
multilayered closure after trimming the scarred bladder edges of the fistula with or without interposition of Martius flap [3] or a bioimplant. When transabdominal transperitoneal repair was used, it comprised the mobilization of the bladder from the uterus and the vagina, the bladder closure in two layers and the interposition of an omentum majus flap between the uterus/vagina and the bladder. If cystoscopy showed a close proximity of a fistula to the ureteric orifices, ureteral stents were inserted preoperatively. In ten patients, ureteral stents were placed on one (3/10) or both sides (7/10). The ureteral stents were removed 4 weeks postoperatively. Bladder drainage was done in all cases for a period of 3 weeks postoperatively. Two bowel injuries happened during catheter placement. Both patients had extensive
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abdominal surgeries for endometriosis with partial cystectomy prior to fistula repair leading to bowel adhesions to the bladder. Due to the high risk of bowel injury in one patient after ovarian cancer surgery, we used a transurethral bladder drainage. 36 VVF were approached transvaginally, 2 were approached abdomino-vaginally and 1 VVF was approached abdominally. In the cases of vaginal approach, a multilayer closure was used in 16 women, a multilayer closure with Martius flap interposition also in 16 women, a multilayer closure with bioimplant interposition (SurgisisÒ, Cook Medical, Bloomington, IN, USA) in 2 cases and the Latzko procedure in 1 case. The VVF occurring 29 years after radiotherapy was closed twice, first using the Latzko procedures
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and after recurrence 5 months later, the VVF was treated using bioimplant. Due to the inability to obtain proper exposure of the fistula tract transvaginally, the abdominovaginal approach with multilayer closure and omentum majus flap interposition was used in both women with vesicovaginal fistulas after obstetric traumas. In both cases, the uterus was preserved. The patient with the vesicovaginal fistula after the supracervical hysterectomy and cervicosacropexy was treated by transabdominal approach. The cervix was removed and the fistula was closed using a multilayer closure with an omentum majus flap interposition. Ureteroneostomy was needed due to an associated left ureteral obstruction. 5 patients were presented with VVF 2 months, 8 and 18, 24 and 29 years after radiation. In one patient, the VVF occurred 29 years after radiation. As the tissue was rigid, the fistula was closed first using the Latzko procedure. 5 months later a recurrence occurred and then the fistula was closed by using a bioimplant (SurgisisÒ, Cook Medical, Bloomington, IN, USA). The fistula again recurred 8 months later and a urinary diversion was necessary. In one case, due to the progress of cervical cancer 2 months after radiochemotherapy, a palliative urinary diversion was performed. In all other cases, the fistulas after radiation were cured. In 9 of 41 women with VVF, intraoperative bladder lesions occurred during the pelvic surgery prior to the fistula development. In 6 of 41, a partial bladder resection was performed for endometriosis treatment and to achieve maximal cytoreduction in advanced ovarian cancer patients. Success of the procedure was defined if the patient was leakage free in the follow-up period. All patients with VVF resulting as a complication of surgeries for benign gynecological disease and after obstetric injuries were cured postoperatively. In one fistula patient, the healing occurred spontaneously. Two women suffering from VVF after radiotherapy for malign gynecologic disease required a urinary diversion. In one case, the urinary diversion was needed due to cancer recurrence and in the other one following two VVF recurrences due to tissue rigidity after radiation.
Discussion The majority of VVF in the present series of patients occurred up to 6 weeks postoperatively as complications of gynecologic surgery. Gynecological surgeries were more frequently associated with the development of VVF than with obstetric causes, due to advances in obstetric care in industrialized countries.
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In literature, it is assumed that urogenital fistulas originate from dissection of the bladder, from sutures incorporated into the bladder, or from direct injuries to the lower urinary tract [4, 5]. Immediate postoperative VVF presentation occurs when there is direct injury to the bladder during surgery [6]. Delayed presentation can occur when there is an ischemic necrosis and progressive devitalization of the posterior wall of the bladder [7]. Extensive dissection, clamp injury, inclusion of bladder wall during uterine closure, and diathermic cauterization can result in devascularization of the bladder [8]. In the present case series, bladder injury occurred incidentally in 9 women during pelvic surgery prior to fistula development. Furthermore, in 6 cases a partial bladder resection was performed for endometriosis treatment and for achieving maximal cytoreduction in a patient with advanced ovarian cancer before fistulas occurred. Duong et al. reported 34 incidental cystotomies during 1317 hysterectomies, 4 patients (11.7 %) developing a VVF [9]. In a nationwide cohort study, Forsgren et al. observed that the highest overall fistula rates were after laparoscopic and total abdominal hysterectomy, among older women, and during the first year after surgery. Furthermore, they found that the rate of fistula disease was higher in women who had total abdominal hysterectomy than those who had a vaginal hysterectomy [10]. In the German case series presented, the most common etiology of vesicovaginal fistulas was total abdominal hysterectomy. Other causes, in descending order of frequency, were abdominal radical hysterectomy, endometriosis surgery, total laparoscopical hysterectomy, laparoscopically assisted vaginal hysterectomy, total vaginal hysterectomy, surgical treatment for ovarian cancer, radiotherapy, laparoscopical supracervical hysterectomy, surgery for genital malformation, cesarean section and forceps delivery. Hilton et al. showed that among 343771 women undergoing elective hysterectomies in the English National Health Service hospitals between 2000 and 2008, the overall rate of vesicovaginal and urethrovaginal fistula was 1 in 788 (0.13 %) within 1 year after surgery [11]. The rate varied by indication and procedure, being highest following radical hysterectomy for cervical cancer (1 in 87) and lowest following vaginal hysterectomy for prolapse (1 in 3861). Total abdominal hysterectomy resulted in an estimated fistula rate of 1 in 540 and 1 in 2279 for subtotal abdominal hysterectomy. In the presented case series, postoperative fistulas had appeared days after surgery, while radiation-induced fistulas had occurred up to 29 years after treatment. In accordance with the literature, radiation-induced fistulas can occur even 20–30 years after the end of treatment [12]. The majority of our patients had suprapubic bladder drainage after the vesicovaginal fistula diagnosis. A
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spontaneous closure of the fistula during bladder drainage was observed in one case only. The fistula was located supratrigonally in the posterior bladder wall, the urine was completely drained and the patient became continent during the drainage of the bladder. Those patients with vesicovaginal fistulas located within the trigonum lost urine despite the suprapubic bladder drainage. Spontaneous closure of small VVF after catheter drainage alone has been reported. Of 151 VVF, three (2 %) were successfully managed by catheterization in one series [8]. Thompson et al. reported a spontaneous fistula healing rate after bladder drainage of at most only 15–20 % of cases, when the fistula is simple and of small size [13]. In another series, four patients who developed a fistula after abdominal and vaginal hysterectomy were treated with bladder drainage for periods of 19–54 days; all remained dry after the removal of the catheter [14]. It has been suggested that if healing has not occurred within 4 weeks, it is unlikely that a fistula will close spontaneously [15]. The insertion of a suprapubic catheter for bladder drainage can present a risk of bowel injuries, especially after previous extensive surgeries. Due to extensive surgeries for endometriosis treatment prior to VVF development, bowel injuries during suprapubic catheter insertion happened in our case series. This risk has to be weighed against the advantages of a continuous bladder drainage using a suprapubic catheter and needs to be discussed with the patient. Alternatively a transurethral catheter can be used for bladder drainage. 39 out of our 41 patients underwent surgical VVF management: 36 patients by a transvaginal approach, 1 woman by an abdominal approach and 2 VVF were approached abdomino-vaginally. All repairs were done by the same surgeon (CR). Nesrallah et al. reported 100 % success rate with transperitoneal O’Connor procedure and described it as a gold standard for supratrigonal fistulas [16]. In the present case series, on the contrary, vaginal approach was primarily adopted even if the VVF was located supratrigonal because of its minimally invasive nature and low morbidity. In our opinion, a tension-free fistula closure after adequate mobilization of the bladder from the vagina and uterus is essential for cure of the fistula. Abdominal repair was used in the presented case series when the fistula was inaccessible to vaginal approach. Obstetrical fistulas are most often the result of prolonged and obstructed labor. Ischemia of the soft tissue between the vagina and the urinary tract due to compression of the fetal head or direct tearing of the same soft tissue during precipitous deliveries are responsible for the obstetrical vesicovaginal fistulas [17]. This seems to be the reason for the VVF in our patient after forceps delivery, especially following an elective cesarean section.
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The second patient developed a fistula after incidental injury of the bladder during cesarean section for obstructed labor. In her case also an elective cesarean section preceeded. Prolonged and obstructed labor preceding cesarean section can enhance the vulnerability to injury during cesarean delivery. During initial fistula examination, precise evaluation of the upper urinary tract is necessary to accurately define the extent of the fistula tract. It has been demonstrated that concomitant ureteral involvement is estimated to complicate 10–15 % of vesicovaginal fistulas [18]. In our series, in one of 41 cases a concomitant ureteral obstruction was seen. The success rate of unradiated vesicovaginal fistula repair varies between 70 and 100 % and the success rate of radiation-induced vesicovaginal fistula repairs is between 40 and 100 % [19]. In our series, 39 out of 41 women with vesicovaginal fistulas were treated surgically, 38 out of these 39 successfully, two needed a urinary diversion. One patient needed urinary diversion because of progress of cervical cancer, the other one did when she showed a recurrence after Latzko procedure and after fistula closure with interposition of a bioimplant due to the rigidity of the fistula surrounding tissue. Using the Hospital Episode Statistics database, Cromwell et al. have demonstrated an overall failure rate of surgical treatment for lower urinary–genital tract fistula (re-operation rate) of 12 % and a high rate of urinary diversion (24 %). Cure rates varied between 50 and 100 % and were higher in units undertaking less than 3 operations per year. For better results, they recommend a greater centralization of fistula management [20]. Our review showed this as well since one patient was referred to us after six unsuccessful VVF surgeries at another hospital.
Conclusion Management of vesicovaginal fistulas must be tailored to the individual case. The majority of vesicovaginal fistulas can be treated successfully by vaginal approach. Fistula management in specialized centers is advantageous. Conflict of interest
None.
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