International Journal of General Medicine

and Pharmacy (IJGMP)

ISSN(P): 2319-3999; ISSN(E): 2319-4006
Vol. 3, Issue 6, Nov 2014, 55-60
© IASET

REPAIR OF LONG STANDING RADIATION INDUCED VESICO-VAGINAL FISTULA: A

CASE REPORT

PRASHANT DINKAR PAWAR1, ATUL JAISWAL2, ABID RAVAL3 & ASHIQ RAVAL4
1
Contract Medical Practitioner, Department of General Surgery, Dr Babasaheb Ambedkar Memorial Hospital,
Central Railway, Byculla, Mumbai, Maharashtra, India
2
Senior Divisional Medical Officer, Department of General Surgery, Dr Babasaheb Ambedkar Memorial Hospital,
Central Railway, Byculla, Mumbai, Maharashtra, India
3
Resident, Department of General Surgery, Dr D Y Patil Medical College and Hospital,
Navi Mumbai, Maharashtra, India
4
Honorary Urologist, Department of General Surgery, Dr Babasaheb Ambedkar Memorial Hospital,
Central Railway, Byculla, Mumbai, Maharashtra, India

ABSTRACT

Vesico-Vaginal Fistula (VVF) is a subtype of female urogenital fistula. It is an abnormal fistulous tract extending
between bladder and vagina that allows continuous involuntary discharge of urine into the vaginal vault. In addition to the
medical sequelae they have profound effect on patient’s emotional well being, therefore requires radical treatment.
Here we report a case of old radiation induced fistula, with complaints of persistent leakage of urine. The patient
underwent surgery for VVF repair which relieved her symptoms.

KEYWORDS: Radiation Induced Fistula, Surgical Management, Vesico-Vaginal Fistula

INTRODUCTION

Vesico-vaginal fistula (VVF), an abnormal passage between the urinary bladder and the vagina that results in the
continuous involuntary discharge of urine into the vaginal vault, is a serious complication of obstructed labour. It is
prevalent in the developing world, with recent estimates suggesting that 2 million women live with fistula, mainly in
sub-Saharan Africa and South Asia.[1] In the developed world, VVF is usually an injury resulting from gynaecologic
surgery. In the United States and the United Kingdom, for example, 70% of fistulae are sequelae of pelvic
surgery,[2] which is in sharp contrast to the statistics in India, where 83% to 93% of fistulae are caused by obstructed or
prolonged labour.[3, 4] Other less common causes of VVF include pelvic malignancy, pelvic irradiation, obstetric trauma
and infection, including tuberculosis [5]. VVFs caused by erosion of a foreign body such as a pessary [6] or vigorous
intercourse [7] have also been reported.

The uncontrolled leakage of urine into the vagina is the hallmark symptom. Patients may complain of urinary
incontinence or an increase in vaginal discharge following pelvic surgery or pelvic radiotherapy with or without antecedent
surgery. The drainage may be continuous; however, in the presence of a very small VVF, it may be intermittent. Increased
postoperative abdominal, pelvic, or flank pain; prolonged ileus; and fever should alert the physician to possible urinoma or
urine ascites and mandates expeditious evaluation. Recurrent cystitis or pyelonephritis, abnormal urinary stream, and
haematuria also should initiate a workup for VVF.

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56 Prashant Dinkar Pawar, Atul Jaiswal, Abid Raval & Ashiq Raval

The time from initial insult to clinical presentation depends on the etiology of the VVF. Approximately 90% of
genitourinary fistulas associated with pelvic surgery are symptomatic within 7-30 days postoperatively. In contrast,
radiation-induced UGFs are associated with slowly progressive devascularization necrosis and may present 30 days to 30
years later. Patients with radiation-induced VVFs initially present with symptoms of radiation cystitis, haematuria, and
bladder contracture [8].

A gynaecologic fistula is classified as simple or complicated [9] and may have important implications for the
surgical approach taken as well as for the prognosis for cure. Although the simple VVFs are usually uncomplicated
surgical cases with good prognosis, complicated VVFs are challenging even for the most experienced and skilled
gynaecologic surgeon. The choice of technique used for fistula repair depends mainly on individual surgeon
preference.[10]

We present a rare case of radiation induced VVF, repaired using an abdominal (Suprapubic)
transperitoneal- transvesical approach.

CASE REPORT

A 60 years old female presented with complaint of continuous leakage of urine from vagina since last 22 years.
She had a history of Carcinoma of cervix, detected 22 years back for which she underwent abdominal hysterectomy with
radiotherapy. She developed the complaint of continuous leakage of urine from vagina during the cycles of radiotherapy
and has been living with the symptoms since then.

Patient’s detailed clinical examination was done. PS findings revealed: presence of urine leak while fistula margins were
not visible, PV findings revealed about 1 cm x 1 cm circular opening palpable 4 cm from vaginal intraiotus over anterior
wall.

Diagnosis of VVF was confirmed on cystoscopy, which revealed an approx. 1 cm x 1cm ovoid fistulous opening
just above the trigone. Abdominal approach for repair of VVF was planned and all the required pre-operative investigation
and anesthetic fitness was done.

PROCEDURE DETAILS

The urinary bladder was approached through infra umbilical incision. The anterior wall of urinary bladder was
identified and opened. The fistula was seen just above the trigone (Figure 1). Both ureteric orifices were cannulated with
feeding tubes (stents) so as to avoid injury to both the Ureters (Figure 2). The urinary bladder was bivalved till Vesico
vaginal fistula. The urinary bladder and vagina were separated. The fistula tract was excised and sent for histopathology
examination. The Vagina was closed horizontally with 3-0 Vicryl on round body needle. The Urinary bladder wall was
sutured vertically with 3-0 Vicryl on round body needle with interrupted sutures after putting Foley’s catheter.
The omentum was interposed between the Urinary bladder and vaginal vault (Figure 3). The drain was kept in cave of
retzius and abdomen was closed (Figure 4). The patient was discharged 7 days post operatively with Foley’s catheter.
The Foley’s catheter was removed after 4 weeks, the patient voided urine normally. Histopathology was reported as:
hyperplastic squamous mucosa with underlying sub epithelial fibrosis.

Impact Factor (JCC): 2.9545 Index Copernicus Value (ICV): 3.0

Repair of Long Standing Radiation Induced Vesico-Vaginal Fistula: A Case Report 57

DISCUSSIONS

The frequency of VVF is largely underreported in developing countries. The predominant cause is prolonged
obstructed labour, while the majority of urogenital fistula in developing countries are consequences of iatrogenic
causes – most common being hysterectomy. [11]

The first basic surgical principles for the repair of VVFs were described in 1663 by Hedrik von Roonhuyse.
In 1834, Jobert de Lamballe published a report of his VVF repairs in which skin flaps were used in the vagina. Later, he
advocated the use of tension-free closures using vaginal-releasing incisions [12]. James M Sims published his famous
discourse on the treatment of VVF in 1852 [13]. Sims emphasized the importance of good exposure, adequate resection of
the fistula and scarred vaginal edges, and the critical importance of continuous postoperative bladder drainage. In 1861,
Maurice Collis was the first to report a layered closure technique [14], and in 1893, Schuchardt described a Para rectal
incision to facilitate improved exposure for the repair of a high VVF [15]. Trendelenberg, in 1881-1890, described a
Suprapubic approach [16] Maisonneuve [17] and Mackenrodt [18] each described the key technique that involves
separating the bladder from the vaginal mucosa and suturing each layer individually. 1942, Latzko published his partial
colpocleisis technique for repair of post hysterectomy VVF, in which he used the resection of scarred vaginal mucosa and a
layered horizontal closure [19].

Imaging investigation for VVF traditionally included IV pyelography, cystography, cystoscopy and use of
contrast media but more recently Transvaginal Sonography has been used.

Surgery is the mainstay of therapy for VVF. The approach used very much depends on the preference and
experiences of surgeon. Both Transvaginal and Trans abdominal approaches have comparable results [20, 21].
Transvesical approach is usually done when fistula is located at the level of ureteral orifice or higher as in our case.
Vaginal approach is ideal for low lying fistula [11]

The use of interposition grafts are likely to contribute towards better outcome. These grafts include omental flaps,
peritoneal flaps and Martius labial flap pads. The results from a cross-section study concluded that low recurrence was
observed with the use of interposition flaps. The most important determinants of successful repair are the principal of
tension free repair, adequate blood supply, prevention of infections and adequate post-op bladder drainage. [11]

REFERENCES

1. United Nations Population Fund. The Second Meeting of the Working Group for the Prevention and Treatment of
Obstetric Fistula. October 30-November 1, 2002; Addis Ababa, Ethiopia.

2. Hilton P. Surgical fistulae. In: Staskin D, Cardozo L. Textbook of Female Urology and Urogynecology. Oxford,
UK: Isis Medical Media; 2001: 691-709.

3. Raut V, Bhattacharya M. Vesical fistulae -- an experience from a developing country. J Postgrad Med.
1993;39:20-21.

4. Sarker B, Ghoshroy S, Saha SK, Mukherjee A, Ganguly RP, Saha S. A study of genitourinary fistulae in North
Bengal. J Obstet Gynecol Ind. 2001;51:165-169.

5. Ba-Thike K, Aye T, Oo N. Tuberculous vesicovaginal fistula. Int J Gynecol Obstet 1992; 37: 127–30

www.iaset.us [email protected]
58 Prashant Dinkar Pawar, Atul Jaiswal, Abid Raval & Ashiq Raval

6. Goldstein I, Wise GJ, Tancer ML. A vesicovaginal fistula and intravesical foreign body: a rare case of the
neglected pessary. Am J Obstet Gynecol 1990; 163: 589–91

7. Sharma SK, Madhusudnan P, Kumar A. Vesicovaginal fistulas of uncommon etiology. J Urol 1978; 137: 280

8. Chapple, Christopher, and Richard Turner Warwick. "Vesico‐vaginal fistula."BJU international 95.1 (2005):
193-214.

9. Kohli N, Miklos JR. Managing vesico-vaginal fistula. Available at:

http://www.womenshealthsection.com/content/urog/urogvvf002.php3. Accessed December 4, 2005.

10. Riley VJ, Spurlock J. Vesicovaginal fistula. Available at: http://www.emedicine.com /med/topic3321.htm. Last
Updated: Mar 5, 2004. Accessed: Dec 4, 2005.

11. Patel MS et al. Vesico-Vaginal Fistula Repair. Gujrat Medical Journal. 2009; 64(2): 94-95

12. Jobert de Lamballe AJ. Balliere, Fils, eds. Traite Des Fistules Vesico-Uterines. Paris, France: 1852.

13. Sims JM. On the treatment of Vesico-vaginal fistula. 1852. Int Urogynecol J Pelvic Floor Dysfunct. 1998;
9(4):236-48. [Medline].

14. Collis M. Further remarks on a new successful mode of treatment for vesicovaginal fistula. Dublin Q J. 1861;
31:302-16.

15. Schuchardt K. Eine neue Methode der Gebarmutterextirpation. Zentralbl Chir. 1893; 20:1121.

16. Trendelenburg F. Discussion zu Helferich. Zuganglichmachung der vorderen Blasenwand. Verbandlung der
Deutsche ges F Chir. 1888; 17:101.

17. Maisonneuve J. Clinique Chirurgicale. Paris, France: 1863:660.

18. Mackenrodt A. Die operative Heilung grosser Blasenscheidenfisteln. Zentralbl Gynakol. 1894; 8:180.

19. Latzko W. Postoperative vesicovaginal fistulas: genesis and therapy. Am J Surg. 1942; 58:211-8.

20. Godwin EE et al. Vesicovaginal and Ureterovaginal fistula: A summary of 25 years of experience. J Uro.
1980;123:370-4

21. Langkilde NC et al. Surgical repair of Vesicovaginal fistulae: A ten years retrospective study. Scand J Urol
Nephrol. 1999;33:100-4.

Impact Factor (JCC): 2.9545 Index Copernicus Value (ICV): 3.0

Repair of Long Standing Radiation Induced Vesico-Vaginal Fistula: A Case Report 59

APPENDICES

VVF URINARY BLADDER

Figure 1

Figure 2

Figure 3

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60 Prashant Dinkar Pawar, Atul Jaiswal, Abid Raval & Ashiq Raval

Figure 4

Impact Factor (JCC): 2.9545 Index Copernicus Value (ICV): 3.0