570781

research-article2015
URO0010.1177/2051415815570781Journal of Clinical UrologyKiosoglous and Greenwell

Continuing Medical Education

Journal of Clinical Urology

Vesico-vaginal and urethro-vaginal

1–7
© British Association of
Urological Surgeons 2015
fistulae in the developed world Reprints and permissions:
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DOI: 10.1177/2051415815570781
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Anthony J Kiosoglous and Tamsin J Greenwell

Incidence
Vesico-vaginal fistulae (VVF) and urethro-vaginal fistulae 2%25 to 4%.26 Preliminary assessment is particularly
(UVF) are major health issues in developing countries, important for women with post-radiotherapy fistulas as
with in excess of 142,000 women estimated to have VVF only approximately 50% will be suitable for a primary
in Ethiopia alone.1 These are predominantly consequent to VVF repair5 whilst others will benefit from urinary
obstetric trauma (in particular a prolonged obstructed sec- diversion (conduit, neobladder and Mitrofanoff) or
ond stage of labour).2,3 In the developed world VVF and ureterosigmoidostomy.
UVF are rare – with only 120 cases of VVF and 11 of UVF Predisposing factors for iatrogenic VVF include infec-
recorded in the United Kingdom in 2013.4 The majority of tion, diabetes, small vessel disease, pelvic inflammatory
developed world VVF/UVF occur as a complication of disease, endometriosis, and previous radiotherapy or uter-
medical treatment – predominantly but not exclusively fol- ine surgery.27
lowing gynaecological surgery.5 Malignancy is responsible for up to 3% of VVF.
Cervical, vaginal and endometrial tumours are the three
most common tumours resulting in malignant VVF.6 For
VVF aetiology any radiation-induced fistulae it is vital to exclude malig-
The commonest cause of VVF in the developed world is nancy recurrence. A biopsy of the tract is recommended
bladder injury at the time of gynaecological, urological, or prior to considering any definitive management.
other pelvic surgical procedures (Table 1).5–8 Hysterectomy
is the precipitating surgical cause in 63–91% of cases with UVF aetiology
higher rates of VVF following abdominal hysterectomy for
cancer (one in 87) and lowest following vaginal hysterec- In the developed world the risk factors for UVF include
tomy for benign disease (one in 3861).9–11 The incidence of all forms of anterior vaginal wall surgery, in particular,
VVF following hysterectomy overall has been calculated stress urinary incontinence sling or periurethral injection
as 0.001–0.2%.11,12 Other surgical causes of VVF include procedures, anterior wall prolapse repair, and urethral
Caesarean section,5 cervical cerclage,13 vaginal laser sur- diverticulectomy.5,16,28–31
gery,14 midurethral tape surgery,15 intraurethral injections
for stress urinary incontinence16 and nephroureterectomy.5 Pathogenesis of VVF
Other less common causes of VVF are radiotherapy,
retained vaginal pessary for prolapse in older women, It is hypothesised that damage at the time of surgery
retained foreign body in young women/children (often either directly in the form of an iatrogenic cystostomy or
inserted by the child at some remote time of exploration indirectly from ligation and or diathermy of vessels
and forgotten until a VVF results),17–19 chronic infectious
and inflammatory disease,20–22 sexual trauma23 and very Department of Urology, University College Hospital, UK
rarely congenital.24 VVF may occur several decades after
Corresponding author:
the completion of radiation therapy.25 The type (external Tamsin J. Greenwell, Department of Urology, University College
beam and interstitial), dose, and localisation of radiation Hospital, London, UK.
are compounding factors. The incidence can range from Email: [email protected]

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2 Journal of Clinical Urology

Table 1. Causes of VVF. be positional. It is important to distinguish VVF from uri-

nary incontinence secondary to other causes such as stress,
Cause urge and overflow. Other features include recurrent cysti-
Abdominal hysterectomy tis, perineal skin irritation, or rarely pelvic pain.34

Laparoscopic hysterectomy
Presentation
Vaginal hysterectomy
Depending on the aetiology VVF can occur any time from
Caesarean section immediately post-operatively (usually after the removal of
Nephroureterectomy
an indwelling catheter) to several months to years from
such causes as post-pelvic radiotherapy, pelvic malig-
MUS tape nancy, and chronic infective and inflammatory conditions.
Patients with ileus, haematuria, and bladder irritation post-
Retained pessary
hysterectomy have been shown to have a higher risk of
Retained FB developing a VVF.27
Malignancy
Physical examination
Congenital
A vaginal examination with the aid of a Sims speculum
VVF: Vesico-vaginal fistulae; MUS: midurethral sling; FB: foreign body. should be performed. The assessment of the VVF should
include the location, size, and number of fistulae. Any
inflammation or infection should be noted as they may
(resulting in an ischaemic area of bladder wall that in the impact on the timing of surgery and most likely delay
presence of low-grade infection or inflammation and a repair. Factors that may affect approach should be noted
degree of urinary retention will become necrotic) leads to including vaginal anatomy, introital size, VVF depth, asso-
pelvic urinoma formation, which ultimately will drain out ciated prolapse and stress urinary incontinence.
of the vaginal wound.5,27 A fistulous tract develops in time
with continuous drainage.
Imaging
A cystogram, either by computer tomography (CT) or
Classification fluoroscopy, should be performed (Figure 1) to confirm
There are a multitude of VVF classification systems the presence and delineate the position of the VVF. Lateral
described, with the most commonly used being the views are recommended to avoid super-imposition of the
Waaldijk32 and Goh.33 They are designed to allow classifi- bladder and vagina. A benefit of performing a CT urogra-
cation of obstetric VVF in the developing world and have phy (CTU) is that a ureterogram can be provided to exclude
little relevance to the fistulae seen in the developed world. concomitant ureteric involvement – present in approxi-
In practice fistulae are generally described in terms of the mately 12% of VVF patients.35 Voiding or micturition
organ(s) involved, the size of the fistula, the number of cysto-urethrogram (VCUG/MCUG) may be required for
fistulae, and the site of the fistula. For VVF which bladder patients with suspected VVF too small for cystogram to
wall, position of the ureteric orifices, and any bladder neck elucidate. An increase in intra-vesical pressure may be all
involvement are also noted. For UVF it is important to that is required to delineate the fistula. Magnetic resonance
note whether the proximal or distal urethra and any sphinc- imaging (MRI) pelvis, with the introduction of higher
ter are involved. The presence of urinary obstruction, Tesla machines, is more commonly being utilised. T2
infection, malignancy, or any other predisposing factors weighting can diagnose the presence of a VVF, its posi-
need to be recorded. tion, and any upper tract involvement.36

Diagnosis Cystoscopy and vaginoscopy

The use of the endoscope can be both diagnostic and thera-
Clinical features
peutic (Figure 2).
The most common presentation of VVF and UVF is con-
stant urinary incontinence. The amount of leakage and vol-
ume of urine voided can vary considerably depending on
Diagnostic
the size and site of the fistula. It can range from continuous Cystoscopy can confirm the presence, size, number of
leakage (large fistula) to intermittent leakage, which can VVF, and its relation to the ureteral orifices. If the ureteric

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Kiosoglous and Greenwell 3

Figure 2. Cystoscopic appearance of vesical side of vesico-

Figure 1. Computed tomography urography (CTU) showing vaginal fistulae (VVF).
vesico-vaginal fistulae (VVF) with central fistula tract from
posterior wall of bladder to vagina.
may be asymptomatic or present with a splayed stream or
vaginal voiding (urinary incontinence when rising from a
orifice is involved or located very close to the fistulae, re-
seated position after voiding).29
implantation may be required. Biopsies should be taken if
there is a background history of pelvic malignancy, to
exclude recurrence. The passage of a guide wire or ure- Diagnosis
teric catheter through the fistula may aid in confirming its
As for VVF, diagnosis of UVF is made following exami-
presence, as well as its position – although this should be
nation, voiding cystogram and cysto-urethroscopy. MRI
reserved for established VVF only. For the difficult-
and CTU may be of benefit in assessing the whole uri-
to-identify VVF, instilling 100 ml of methylene blue and
nary tract and delineating the fistula tract, an essential
clamping the urinary catheter may allow visualisation by
part of assessment as 20% of patients with a UVF also
direct observation of egress of blue into the vagina or
have a VVF.7
indirectly by identification of blue dye on gauze swabs
inserted into the vagina prior to dye instillation (the three-
swab test).35 Management
Immature VVF may appear as an area of localised bul-
The aims of managing VVF/UVF are to 1) eliminate uri-
lous oedema with obvious or distinct ostia. Mature VVF
nary leakage either by conservative means, or surgically,
may have smooth margins of variable size. There may also
in preferably one procedure; 2) retain normal urinary tract
be associated inflammation with small pits or cavities,
function (with regards to continence and ureteric drain-
together making identification of the VVF extremely
age); and lastly 3) exclude malignancy.
difficult.

Conservative
Therapeutic
As with the management of all fistulae, adequate nutrition,
For small fistulae less than 3 mm in diameter, simple ful- treatment of infection and relief of urinary obstruction
guration may be all that is required.37 If a guide wire or (indwelling catheters or nephrostomy tubes) are essential
ureteric catheter can be inserted through the fistula at the primary management along with exclusion of malignancy.
time of definitive repair, this greatly assists with visualisa- Pads, skin care and regular clinic reviews with the treating
tion of all margins. specialist and continence nurse specialists can provide a
great deal of comfort and reduce the distress suffered by
UVF the patient in this difficult period. Spontaneous healing
may result with the use of indwelling catheters and anti-
Size and location of the fistula along the urethral lumen cholinergic medication within three to six weeks in up to
will determine the symptoms. Proximal urethral fistulae 7%.5,38 Surgical repair will be required if healing has not
may be associated with continuous or stress incontinence. occurred after six weeks of drainage. Unfortunately three
Distal urethral fistulae beyond the sphincteric mechanism weeks is the general limit for early surgical repair, after

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4 Journal of Clinical Urology

which it is best to wait three months before attempting Vaginal repair

definitive surgical repair.39,40
Indications
Surgical VVF may be repaired transvaginally if: 1) there is no absolute
indication for abdominal repair (ureteric injury/small-capacity
In most cases, definitive surgical treatment of VVF/UVF is bladder requiring clam cystoplasty), 2) the vaginal introitus
required. The principles of surgical repair include 1) ade- width versus the depth of the VVF makes it physically possi-
quate exposure of the fistula tract (with or without debride- ble to access the fistula, and 3) it is often best to repair a fistula
ment), 2) removal of any foreign bodies, 3) water-tight vaginally if a previous failed abdominal repair has occurred.
closure of bladder or urethra, 4) multi-layer closure that is
tension free and without overlapping suture lines, 5) use of
well-vascularised interposition flaps/omentum, 6) haemo- Advantages
stasis, 7) appropriate antimicrobial cover, and 8) stenting These include 1) avoiding the need for a laparotomy and
and drainage of the urinary tract with an indwelling cath- its associated morbidities along with those of potentially
eter until healing is presumed or confirmed at cystoure- bi-valving the bladder, 2) less blood loss, 3) reduced post-
throgram to have occurred (generally three weeks), or up operative pain, 4) local interpositional flaps (e.g. Martius
to six weeks. If healing has not occurred by six weeks then fat pad) are adjacent and readily available, 5) anti-inconti-
the procedure is deemed to have failed.5,41 nence or prolapse surgery may be performed at the same
time, and 6) shorter hospital stay and an earlier return to
Who should repair VVF and UVF? normal activities.34,41,55
The best opportunity to repair a VVF/UVF is with the
primary operation.42,43 Failed attempts at repair ulti- Transabdominal
mately produce inflammation, scarring, anatomical dis-
tortion, and compromise potential reconstructive flaps.44
Indications
Repair can still be achieved after several failed proce- These include: 1) high fistula in a deep narrow or a floppy,
dures but each failed repair adversely affects the likeli- capacious vagina making surgical access impossible, 2)
hood of success of the subsequent repair,5,44,45 and repair previously irradiated tissues, 3) ureteric involvement, 4)
by experts in centres of significant experience is the best small-capacity bladder requiring augmentation cysto-
option for all patients. plasty, 5) complex fistulae, and 6) previous failed trans-
vaginal approach.5,34,41
Timing of repair
Classically, the teaching for fistula repair has been to wait
Advantages
several months from time of diagnosis to definitive surgery, These include 1) simultaneous reimplantation of ureter(s)
to allow resolution of tissue inflammation.46–49 However, it may be performed if involved, 2) formation of clam cysto-
is possible, with appropriate case selection, to achieve suc- plasty if indicated, and 3) omentum can be easily harvested
cessful early repair within two to three weeks from the ini- in most patients without additional morbidity or incision.
tial injury. After this, tissue inflammation is best left to
settle and definitive repair attempted after three to six
months depending on degree of inflammation.39,40,50–52
To excise the fistula tract or not?
For more than a century it was the belief that complete
Transvaginal or transabdominal excision of the tract was required.46,49,50 However, it is now
understood that excision is not always necessary, and may
repair?
even compromise repair.9,52,57–59 The disadvantages include
Due to their respective training and experience, it is firstly the creation of a larger tissue defect, and secondly
widely considered that gynaecologists prefer repairing the risk of converting what would be a simple vaginal
VVF transvaginally, and urologists’ preference is transab- repair transvaginally to a transabdominal approach, espe-
dominally.53,54 This difference has narrowed, to the point cially if the VVF is adjacent to a ureteric orifice.
where the majority of cases are now being performed
transvaginally both by urologists and gynaecologists as
per our own practice.55 In the developed world the major-
To insert interposition flaps or not?
ity of cases are amenable to transvaginal repair and it Some surgeons and units advocate the use of interposition
should be possible to close VVF vaginally at least 60–70% flaps 100% of the time45 whilst others do not.60 Clear indi-
of the time.5,41,55–57 cations for their use include 1) irradiated tissue, 2) previous

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Kiosoglous and Greenwell 5

failed repairs, and 3) large fistulae >3 cm.5,44 For those Bladder neck and proximal urethra involvement, lead-
VVF repaired transvaginally, a labial fat pad (Martius flap) ing to sphincteric incompetence, can result in high rates of
or a peritoneal flap is most commonly used. From a transab- stress urinary incontinence (up to 50% in women with
dominal approach, omentum or peritoneum is often used as obstetric fistula) despite successful repair of the
an interpositional flap.61 Greater than 95% success rates VVF.5,41,82,83 The bulbocavernosus muscle has been uti-
have been achieved using a Martius flap for a first-time lised as an anti-incontinence flap/wrap in these situations
repair versus 75% for a simple repair.8,45 with reasonable success.83,84
Other forms of voiding dysfunction may pre-exist with
or occur as a consequence of VVF/UVF and/or its repair
Possible future techniques and have been reported in up to 83%.85 The types of void-
Over the past two decades, successful laparoscopic and ing dysfunction reported include detrusor overactivity in
robotic repair have been achieved.62–68 The indications are 40%, loss of compliance in 17%, detrusor hypocontractil-
as for a transabdominal repair. When compared to an open ity in 16% and bladder outflow obstruction in 4%.
transabdominal repair, robotic and laparoscopic repairs are Urodynamic stress urinary incontinence (USUI) and idio-
associated with less surgical trauma, shorter recovery time, pathic detrusor overactivity (IDO) are more commonly
and lower morbidity; however, these are only case reports associated with bladder neck VVF or UVF.
or case series with a maximum of five only. These tech-
niques should be viewed as experimental and to be under- Conclusion
taken only in centres with both laparoscopic and robotic
urology and fistula repair experience. VVF and UVF are rare in the developed world. They
mainly occur as an adverse consequence of surgical treat-
ment and are the cause of a great deal of emotional and
UVF management psychological stress both for the patient and the responsi-
This can be quite challenging due to factors such as extensive ble surgeon. Medicolegal litigation, often related to delay
tissue defects and lack of local viable tissue for a multi-lay- in diagnosis and/or treatment, is frequently involved. It is
ered repair.69 The use of rotational vaginal wall flaps30 or therefore prudent that timely diagnosis and referral for
Martius Fat Pads70,71 have been described for smaller fistulae. treatment is made to an expert centre with experienced sur-
For larger fistulae, more extensive surgery requiring urethral geons offering high success rates able to offer all aspects
reconstruction may be necessary.72–74 For UVF secondary to and techniques of fistula care.86 We advocate the use of
a foreign body (e.g. a synthetic sling), it is advisable to excise CTUs and T2-weighted MRI of the pelvis for diagnosis
this.75 Distal fistulae that are asymptomatic may be observed and exclusion of upper tract pathology. Fistula biopsies are
or managed via an extended meatotomy.76 important in those cases where malignancy is a high risk.
A transvaginal approach should be performed in most
cases, excluding those with absolute indications for a
Prognosis transabdominal approach.
Success rates from 58% to 98% have been reported5,34,41
Conflicting interests
depending on whether the fistula is simple or complex and
the procedure a primary or secondary (or more) procedure. None declared.
Anatomical closure of a simple VVF repair has been
Funding
reported in more than 85% with either the transvaginal or
transabdominal approach. VVF that are complex, secondary None declared.
to obstetric causes, large or those associated with radiation
therapy generally have lower success rates of between 60% Ethical approval
and 70%.41,77–81 At our institution we have found that 75% Not Applicable.
can be performed transvaginally, with a 87% first-time
repair success rate, and 100% success rate for repeat repair. Guarantor
Martius fat pad interpositions are used for all vaginal repairs. TJG.
For UVF, the success rates are more than 90% for the
primary repair and 98% for a second repair.54 Contributorship
The complications associated with the transvaginal AJK and TJG researched literature. AJK wrote the first draft of
approach include longer operative time, vaginal shorten- the manuscript. TJG reviewed and edited the manuscript and
ing, and marginally higher risk of failure. Those associated approved the final version of the manuscript.
with the transabdominal approach include the morbidity
associated with a laparotomy, greater post-operative pain, Acknowledgements
and longer recovery time. None.

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6 Journal of Clinical Urology

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