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    Vesicovaginal fistula (VVF) is an abnormal connection between the bladder and vagina that causes continuous urinary leakage. In developing countries, VVFs are primarily caused by obstructed childbirth, while in developed countries they are usually iatrogenic from gynecologic surgery like hysterectomy. Diagnosis involves examining for urinary leakage from the vagina. Small, uncomplicated VVFs may close with catheterization, but surgery is often needed. Surgical repair aims to close the bladder and vagina in separate layers. A vaginal approach is common for small VVFs, while an abdominal approach is used for more complex cases. Post-operative complications can include bleeding, infection,

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    Vesicovaginal fistula (VVF) is an abnormal connection between the bladder and vagina that causes continuous urinary leakage. In developing countries, VVFs are primarily caused by obstructed childbirth, while in developed countries they are usually iatrogenic from gynecologic surgery like hysterectomy. Diagnosis involves examining for urinary leakage from the vagina. Small, uncomplicated VVFs may close with catheterization, but surgery is often needed. Surgical repair aims to close the bladder and vagina in separate layers. A vaginal approach is common for small VVFs, while an abdominal approach is used for more complex cases. Post-operative complications can include bleeding, infection,

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    513 views24 pages

    Vesicovaginal Fistula: Urology Department

    Uploaded by

    HardiTariqHamma
    Vesicovaginal fistula (VVF) is an abnormal connection between the bladder and vagina that causes continuous urinary leakage. In developing countries, VVFs are primarily caused by obstructed childbirth, while in developed countries they are usually iatrogenic from gynecologic surgery like hysterectomy. Diagnosis involves examining for urinary leakage from the vagina. Small, uncomplicated VVFs may close with catheterization, but surgery is often needed. Surgical repair aims to close the bladder and vagina in separate layers. A vaginal approach is common for small VVFs, while an abdominal approach is used for more complex cases. Post-operative complications can include bleeding, infection,

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    of 24

    VESICOVAGINAL FISTULA

    Urology department
    Prepared by Hardi Tariq Hama
    INTRODUCTION

    • Vesicovaginal fistula (VVF) is an abnormal communication between the


    bladder and vagina.
    • Most common acquired fistula of urinary tract .
    • James Marion Sims published his famous surgical series describing his method of
    surgical treatment of VVF in 1852 by transvaginal approach.
    • The first successful transabdominal approach to VVF repair was reported by
    Trendelenburg in 1888 .
    ETIOLOGY

    • In developing countries the majority are due to obstructed or prolonged


    childbirth

    • In developed countries occur most frequently %75 as a result of


    iatrogenic injury at the time of gynecologic surgery, in particular
    hysterectomy.
    Other causes

    • pelvic surgery or radiotherapy


    • Pessary erosion(foreign body)
    • advanced pelvic malignancy (cervical carcinoma)
    • pelvic endometriosis
    • inflammatory bowel disease
    • Trauma
    • low estrogen states
    • infection (urinary TB)
    • congenital abnormalities
    DIAGNOSIS

    • must be distinguished from other causes of urinary incontinence as well as


    ureterovaginal fistula.
    • main presenting symptom is painless continuous leakage of urine per vagina
    • Different leakage amount  small fistula may cause intermittent and
    positional wetting
    • Patients may also report recurrent cystitis, perineal skin irritation from
    constant wetness, vaginal fungal infections, or rarely pelvic pain .
    • pain is an uncommon finding in patients with VVF unless there is
    considerable skin irritation or the VVF occurred as a result of radiation
    therapy.
    • pelvic examination with a speculum should always be performed in the
    evaluation of VVF.

    • Cystoscopy may directly identify the fistula tract and help determine its
    proximity to the ureteric orifices.

    • In a patient with a history of prior pelvic neoplasia, a biopsy of the


    fistula site is mandatory to rule out recurrent tumor.

    • Vaginoscopy is very helpful in exactly localizing the fistula .


    • retrograde bladder filling with a colored fluid(methylene blue) placement of a tampon into
    the vagina to identify staining may facilitate the diagnosis of a VVF.

    • Testing the creatinine level in either the extravasated fluid or the accumulated ascites and
    comparing this to the serum creatinine level will confirm urinary leakage.

    • testing potassium levels will show higher levels compared with serum levels.

    • ‘3- swab test’: give oral phenazopyridine which turns the urine orange. After 1h, place
    three swabs into the vagina and instil methylene blue into the bladder. If the proximal
    swab turns blue, it indicates VVF; if it is orange, it suggests ureterovaginal fistula.
    • CT urogram and/ or bilateral retrograde pyelograms to assess ureteric involvement or
    coexisting injury.

    • Cystogram: the best test for identifying a bladder fistula (can be done by
    fluoroscopy screening or as a CT cystogram) .

    • A cystogram and/or voiding cystourethrogram (VCUG) and an upper tract study should
    be performed in patients being evaluated for a VVF.

    • Contrast- enhanced CT or MRI if history of previous radiotherapy or


    malignancy.
    Sagittal reconstruction of CT urography demonstrating vesico-vaginal fistula secondary to bladder injury during
    caesarean section. A narrow fistula tract between the vault of the vagina anteriorly and posterior wall of the bladder
    is depicted (arrow).
    Management

    Minimally Vaginal Abdominal


    conservative
    invasive approach approach
    CONSERVATIVE MX

    • Small, uncomplicated VVF may resolve with urethral catheterization, First trial by
    indwelling catheterization and anticholinergic medication for at least 2 to 3 weeks.

    • Before epithelialisation is complete an abnormal communication between viscera will


    tend to close spontaneously, provided that the natural outflow is unobstructed or if urine
    is diverted.

    • most widely accepted for favorable outcome with conservative management is size less
    than 2 to 3 mm.

    • If persist after period of observation , surgery is indicated .


    PRINCIPLES OF VVF REPAIR

    • Good exposure of fistula.


    • Excise devitalized tissue.
    • Removal of any foreign bodies.
    • Dissection to separate vaginal and bladder walls.
    • Watertight closure of the bladder and vagina.
    • Interpositional tissue.
    • Multiple layer closure, tension- free, avoid overlapping suture lines.
    • Good haemostasis.
    • Drainage of urine from the site of surgical repair (catheter, drain,stents).
    MINIMALLY INVASIVE

    • minimally invasive treatment involving disruption of the epithelial layer of the


    fistula tract ,Catheterization may be combined with minimally invasive
    electrocoagulation of the fistula tract.

    • laser welding has been tried with success in a small series of women with fistula
    smaller than 3 mm.
    • Fibrin sealant has been used as an adjunctive measure to treat VVF after
    fulguration The bladder is then drained for several weeks.
    OPERATION

    • About timing ;Findings from uncontrolled case series suggest no


    difference in success rates for early or delayed closure of VVF.

    • When the VVF is identified perioperatively, immediate repair can be


    considered.

    • Repair for Post-operative VVF can be done 3-6 months after the surgery
    or earlier .

    • Repair after radiotherapy is deferred for 6– 12 months.


    VAGINAL APPROACH

    • the fistula tract is incised and closure of the bladder and vagina are
    performed in separate layers. Interpositional tissue (Martius fat pad from
    labia majora) may be mobilized between the bladder and vagina.

    • A vaginal approach can be attempted as soon as 2 to 3 weeks after the


    initial injury, if conservative therapy fails.
    Indications

    • Fistulas less than 3 to 4 cm in diameter


    • Tissues pliable
    • Vaginal size normal or larger than normal
    • No cancerous tissue involved
    • No previous extensive radiotherapy
    The advantages of the transvaginal approach include:
    • Avoidance of an abdominal incision
    • Minimal blood loss
    • Reduced postoperative morbidity
    • Less postoperative discomfort to the patient
    • Decreased length of hospitalization
    ABDOMINAL APPROACH

    • more often used for complex cases.

    • patients with a VVF high in the vagina or if associated with ureteric injury.

    • Suprapubic and urethral catheters are placed for 2– 3wk.

    • Avoid tampons or sexual intercourse for 3 months.

    • a cystogram performed prior to catheter removal.


    ABDOMINAL VERSUS TRANSVAGINAL REPAIR OF
    VESICOVAGINAL FISTULA
    POST- OPERATIVE COMPLICATIONS OF
    VVF

    • vaginal bleeding.
    • Infection.
    • bladder pain, dyspareunia due to vaginal stenosis.
    • graft ischaemia.
    • ureteric injury.
    • fistula recurrence.

    Outcomes
    • Overall success rates for primary VVF repair (via a vaginal or an abdominal
    approach) are >90%.
    REFERENCES

    • Oxford handbook of urology ; (Chapter 5) Urinary


    incontinence and female urology
    • Campbell’s urology book; (part XII 89) Urinary Tract
    Fistulae ; page 2103
    • European association of urology guidelines ; urinary
    incontinence in adult ; page 67
    • Glenn’s urologic surgery ; (chapter 27) vesicovaginal fistula
    THANK YOU

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