Bladder Fistulas and Ureteral Injuries

Vol. 96, Nov. Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright @ 1966 by The Williams & Wilkins Co.

BLADDER FISTULAS AND URETERAL INJURIES WILLIAM C. BOWN The cases herein reviewed were done in small community hospitals where the urologist was his own resident and intern. Falk states, "Since any one gynecologist sees this condition infrequently, he must at least have the knowledge of techniques which allow for quick and easy completion, even without his having had previous experience with such an injury or its repair." The urologist sees this condition even more rarely. The purpose of my paper is 1) to discuss the problems encountered, and 2) to make some suggestions about technique. The urologist is ideally equipped to handle these cases since he intentionally creates fistulas in either the bladder or ureter as a part of his daily work, and they always heal. Furthermore, he understands the mechanics of care of the catheter whether it is used in the urethra or in the suprapubic region. Some of these cases which were closed primarily by competent gynecologists and surgeons were failures because the operators did not recognize the signs of a malfunctioning catheter. During a 12-year period beginning 1952, more than 2800 abdominal hysterectomies (according to our record rooms) resulted in 12 vesicovaginal fistulas and 9 ureteral injuries. The incidence of bladder injury is 0.4 per cent, and of ureteral injury 0.3 per cent. In the more than 1200 vaginal hysterectomies, the incidence was less than 0.1 per cent. Other procedures that produced vesicovaginal fistulas were a Watkins interposition operation, a caesarian section resulting in a cervicovesicovaginal fistula, an excision of an anterior vaginal wall cyst, two colporrhaphies, and a transurethral resection for an atonic cord bladder. Forceps extractions produced 4 vesicovaginal fistulas, only one of which was immediately recognized and successfully repaired. This was a linear tear involving the bladder floor, vesical neck and urethra. Recognition of the other 3 fistulas was made only after the patients had returned home without a Foley catheter. Accepted for publication January 26, 1966. Read at annual meeting of Mid-Atlantic Section, American Urological Association, Inc., Washington, D.C., November 3-6, 1965.

During the hospital stay, all of these patients had trouble with the Foley catheter, and its malfunction was often expressed as "voiding around the catheter." This actually represented efflux of urine through an unrecognized fistulous opening into the vagina. The urologist would certainly have been suspicious of a rent in the bladder when the nursing staff noted "catheter not functioning properly, patient voiding around same." This fact seems important because the first 7 days postpartum offer an opportune time to repair these defects. During this period there is good vascularity and edema which make for easy separation of the layers and subsequent accurate approximation. The forceps injury is usually off the midline, linear with sharp margins. If the damage is due to pressure necrosis, the fistula will appear after the tenth day, and it will be ultimately larger in diameter and central in position. Of the 11 fistulas repaired suprapubically, 2 cases required transperitoneal approaches. In one, the greater omentum was freed to the hepatic flexure and brought down the lateral gutter to fill a large defect between the anterior rectal wall and bladder floor. This fistula was huge, and resulted from the combined effects of radiation therapy and hysterectomy for carcinoma of the cervix. Of the 9 fistulas repaired vaginally, one was due to an abdominal hysterectomy and one to a vaginal hysterectomy. Two were repaired by ureteral transplant to the colon because of complete loss of bladder floor with the ureters visible on the margins of the fistula when seen vaginally. These were done early in the series. One was repaired by ileal loop after over-ambitious efforts of a urologist to resect a bladder neck for an atonic cord bladder. This fistula, which was huge, could probably have been repaired by filling the defect in the bladder floor with greater omentum, but the patient had an irreconcilable cord bladder which would not have functioned, so the ureters were placed in an isolated segment of ileum. 706

BLADDER FISTULAS AND UHETERAL I:t-T,JURIES

No attempt at repair was made in one case because of the patient's terminal ,state. Of the 24 cases, there was one failme, and this represented my first case: a urethrovaginal fistula which occurred after a Kelly plication for stress incontinence. The purse-string suture u.sed to support the \'esicourethral a.ngle became a seton, and the bladder floor, vcsical neck and proximal portion of Lhe urethra sloughed away. It took three additional repairs to close this defect. In figure 1, the artist has outlined with a circular dotted line the approxirnate position of the cervix and the Yaginal stump following total hysterectomy. It is in this arna that fistulas due to abdominal hysterectomies are found, lie high in the vault, are ahrn,ys anterior to the scar, and for this reason are morc readily accessible way of either the hansvesical or transperitoneal route The linear line on the right represents the lateral position of fistulas due to forceps application. Some of these are difficult because in the process of healing they become attached to the pubic ramus. Their dissection is facilitated by mcising lateral to the labia minora and sharply

FIG. L Conventional s1.raight lrnudh,d blade is used for preliminary incisions.

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freeing the adhesions from the ramw,. Blceding i, brisk on occasion, but it usually U1 pressure. The fistula, in the midlinc 1s just about at the point where pressure necrosis due to produces its damage. Those fistulas arising from vaginal procedures, including rnginal tomies, are located in this same area, and an, easily handled by the vaginal route. The technique of repairing a fi.stula is fournfod upon complete and thorough ~eparation of iJw adhesions binding bladdcr and vagina, atraumatic tissuc handling employing skin hooks and dissection, accurate hemostasis, and finally care ful watertight approximation of one of the tw() aforementioned layers using cot.ton sutmrs in one of the layers. Falk st.ates: "In separating the vagina from the bladder wall, all fascia should be left with the bladder to aid in the closure. Again, all a.utliorities agree that a proper watertight closure of the bladder wall is essential to the cure of nal fistula. Again, if the bladder wall can be mobilized and closed without tension, success ,s It is not necessary to close the layer," Prior to dissection of the fistula (fig. 1) 11 prostatic tractor is placed in the blaclclcr for the purpose of bringing the tract closer to the opera.. tor as well as immobilizing the area for the preliminary incisions. These are on the side closest to the urethral meatus, at least. 1.5 cm away from thc fistulous tract, and carried down through vaginal mucosa and fascia. No at this point is made to delineate bladder wall from vagina, but one is careful not to carry the incision so deep as to include vesical mucosa The incision is then carried down arnuud the: fistulous tract posteriorly to a point at least 1.ii cm. 1elow the opening, and the is r;om pleted about the fistulous tract on the side. The prostatic tractor fixes the field for th,, prelim.inary incisions. The 45-clegree blade and scissors facilitate cutting the adhesions perpendicular to thcir course and minimize buttonholing of the bladder wall. The skin hooks are used to tent the vagina during tbe laternl dissection. The bayonet forceps are used to grasp the during suturing. See figure 2. With the preliminary incisions made, the dissection laterally of the fistulous tract

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Skin hooks are used for tissue retraction and dissection is made easy by using a 45-degree angle scissors and a 45-degree Bard Parker blade loaded with a No. 11 stylet point (fig. 3, A, B). In many

instances these adhesions will extend at least another 1 to 2 cm. peripheral to the fistulous tract. Often they are more easily felt than seen, but be assured that once all adhesions uniting the fistula

a

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LC

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Fm. 2. Basic instruments

Fm. 3. A, B, use of 45-degree blade. C, D, vertical mattress sutures (cotton) in bladder tied on vaginal side (watertight) with chromic on vaginal layer for apposition.

BLADDER FISTULAS AND URETERAL IN"JURIES

have been divided, 1) the fistula will be much larger than the original, and 2) one will be able to bring the bladder wall to the midline without tension and any tenting of the vaginal wall. A well-developed layer of bladder and its fascia will be present which will permit the easy application of cotton mattress sutures without tension (fig. 3, C). No attempt should be made to close or free the vesical mucosa since the properly placed mattress sutures will bring the bladder wall with , its fascia to the midline and accomplish a watertight closure. Since there has been complete and careful separation of vaginal mucosa from bladder wall and its fascia, the vaginal wall will fall in place and need only be held in apposition by either absorbable or non-absorbable sutures. Note in figure 3, D that the suture lines do not lie in apposition, but are purposely placed at right angles. The prostatic retractor is removed and replaced with an appropriately sized Foley catheter for continuous drainage. Since watertight closure has been obtained, there is no need to impose upon the patient a prone position on the Bradford frame. For the next 7 to 10 days the only need is for the operator to be certain that the Foley catheter perfectly drains the bladder. A suprapubic Foley catheter placed through a stab cystotomy is a preferred method of drainage when the fistula lies close to the vesicourethral angle.

FIG. 4-. Transvesical approach: Begin closure of bladder.

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Fm. 5. Transperitoneal dissection of fistula.

In many instances following abdominal hysterectomy it is difficult to free the posterior vaginal wall by reason of its intimate association in scar with the anterior rectal wall. For this reason, I feel that the operator should approach these fistulas using either the transvesical or transperitoneal route. Figure 4 illustrates careful dissection of bladder wall from vaginal mucosa. The vaginal wall has been closed with cotton mattress sutures. When one cannot close the posterior vaginal wall in the manner demonstrated here, the operator must depend on a perfect closure of a welldefined bladder wall. In this instance, the bladder wall after adequate immobilization is closed with interrupted mattress sutures of cotton tied so that they will in no way extrude into the vesical lumen and provide a nidus for stone. Closure of the vesical mucosa is not necessary, but closing it with a fine atraumatic plain catgut suture is not harmful. It has been my experience that once the bladder wall has been adequately approximated, the vesical mucosa will naturally fall in place. Russell states, "Closure of the bladder should be as perfect as possible, and closure of the vagina is an entirely secondary consideration." An alternative method particularly suited to large defects is to repair the fistula by way of the transperitoneal route (fig. 5). The peritoneal flap in the cul-de-sac is opened, and by means of sharp and blunt dissection the bladder wall is freed up around the fistulous tract. The attach-

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ment incorporating anterior and posterior vaginal wall is transected and allowed to drop down into the vaginal vault. Then a primary closure of freshly incised bladder wall is performed.

Fm. \l. Post-radi:1tion fistul:1 rep:1ired transperitone:1lly.

In defects which are huge and cannot be closed, the greater omentum can be detached from the transverse colon to the right gastroepiploic artery, and this rich vascular mass brought down the lateral gutter. Its distal end is easily placed beneath the repair for the rich blood supply that it offers and for the added protection of separating vaginal cuff from partially reapproximated bladder wall. It is held in place by four mattress sutures to bladder wall. Figure 6 is the 6-month postoperative urogram of a woman who had a vesicovaginal fistula admitting 5 fingers with both ureters visible on the margin. At operation the margins of the fistulous tract were examined for residual carcinoma and found to be negative. There was no possibility of completely closing the defect in the bladder floor. Greater omentum was taken down and placed as a plug between the anterior rectal wall and the deficient bladder floor. Mattress sutures in four quadrants were used to hold the omentum in place and the defect closed primarily. Of 13 ureteral injuries, 6 were recognized immediately and repaired over a T-tube with primary healing. T-tubes were used 4 times in delayed cases with no failures. Most ureteral injuries were caused by failure to identify and trace the ureter. Some occurred as a result of aberrant blood supply, and some as a result of sudden, frightening blood loss and an attempt to control hemorrhage. In reviewing the operative records of these cases there has been severe bleeding, poor mobilization of bladder and ureter or no identification of the ureter. In some instances, the ureter has

Fm. 7. Modifications of T-tube

BLADDER FISTULAS AND URETERAL INJURIES

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FIG. 8. Intraperitoneal repair of ligated ureter

been distorted from its normal course by intraligamentary disease. In a few instances, the low ureteral blood supply arises as a branch of the uterine artery without normal anastomosis with the remainder of the ureteral blood supply. If the uterine artery is ligated lateral to this branch, low ureteral necrosis can be expected. The average points of damage are at the infundibulopelvic ligament and the crossing of the ureter beneath the uterine artery. I use a short arm T-tube in the ureter with one exception (fig. 7). If the injury is within 2 cm. of the bladder, the distal end must extend well into the bladder for fixation. Ten ureteral injuries were repaired over a T-tube without stricture at the site of anastomosis. The T-tube should be made of soft latex rubber, and I modify the long-arm Cattell tube. It should fit loosely in the ureteral lumen. The common sizes are Nos. 8 to 12. The arms have been cut short and the ends have been beveled to minimize trauma to the mucosa. The proximal arm has been fenestrated to increase drainage, and at the base of the T, a wedge has been cut for easy removal. The T-tube is above the anastomosis because an automatic decompression of the urinary tract will be provided if the anastomosis

FIG. 9. Ureteroneocystotomy at infunbidulopelvic ligament.

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fails. Conversely, if the anastomosis is adequate, the ureterotomy will close in 36 hours after the removal of the tube. The ends of the ureter are cut obliquely and held in place by 4-0 chromic sutures, one placed in each quadrant. This anastomosis must be supported with cotton sutures binding periurcteral fascia to deep pelvic fascia. If ureteral damage is recognized within the first 3 days following abdominal hysterectomy, one has an excellent opportunity to repair the defect promptly. The original wound must be re-opened and the approach niade intraperitoneally. Since the gynecologist has already n10bilized the bladder during the hysterectomy, it is an easy matter to enter it through a stab wound and move the bladder wall over the index finger to the infundibulopelvic ligament (fig. 8). The perivesical fascia and bladder wall can be tacked for support to the infundibulopelvic ligament (fig. 8, A). Then a conventional end-to-end anastomosis between proximal ureter and bladder wall is performed and splinted with a T-tube (fig. 8, B).

Figure 9 represents the 6-month postoperative result of the procedure illustrated in figure 8. It shows the asymmetry of the bladder as a result of bringing it to the infundibulopelvic ligament and the absence of obstruction at the ureteroneocystotomy. When ureteral damage is recognized after the third postoperative day, prompt decompression of the upper urinary tract is indicated. In figure 10, A the ureter was transected and urine drained per vagina on the tenth postoperative day. The defect is identified and the fistulous tract drains into the vagina with the dye outlining the contour of the vagina rather than the bladder. After waiting 3 months, continuity was re-established over a T-tube. The T-tube was re1noved after 17 days. Figure 10, B is the postoperative urogram showing no obstruction existing at the site of the end-to-end ureteral anastomosis. Figure 11 pictures the 3-month postoperative urogram of a woman who suffered a 6 cm. loss of left ureter as a result of a resection for carcinoma

FIG. 10. A, ureter in discontinuity at Mackenrodt's ligament. B, 3-month post-nreteral anastomosis

:BLADDER FIS'l'ULAS AND URETERAL INJURIES

All T-tube anastomoses have healed without strictures. The T-tube should hav,: short arms be placed above the obliquely cut uretera1 anastomosis. All anastomoses of ureter must supported by adjacent fascia_ Vesical injuries due to vaginal should be repaired vaginally_ Other vaginai injuries due to gynecological procedures, , For etc. lend themselves to easy vaginal the urologist, vesical injuries due to abdominal hysterectomy should be approached cally via the transperitoneal or transvesical rnvk, Greater omentum is a natural viable which can be used to fill in the defects in bladder floors. The freely mobilized bladder following dominal hysterectomy can be moved to thn infundibulopelvic ligament and correct a uretera] injury_ The T-tube is a splint only and should be short arm to avoid ureteral stricture. The anastornotas must be supported with periureteral fascia. The preferred method of diversion suprapubic. YVhcn operating diversion is easily accomplished through a trocar. A prone position of the patient is not neeessar_y if diversion is provided suprapubically. Fw. 11. Note rigidii:y and. medial deviation of low ureter as it crosses common iliac artery.

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Swede St., Norristown, ,Annsi11.i;a:nw. TmFEilENCES

of the descending colon_ The left kidney and upper ureter were mobilized which permitted anastomo-sis above the bifurcation of the common iliac 11·ith a prnximal T--tube. In order to support the anastomosis, the periureteral faseia was tacked to the common iliac artery. COKCLUSIONS

Twenty-four vesicovaginal fistulas have been with one failure, the only case in whicb the patient was placed in a prone position post-

FALK,

H. C.: Urologic Injuries rn

Philadelphia: F. A. Davis Co., F. C., PE"IG, B . .'\.ND WA'1'EHHOUSE, .K.: °E1'perimental studies on repair of injured ureter, Arch. Surg., 90: 298-30.5, 1905. M1cr-L-\.ELS, J. P.: of L1ret.era.l bloud and its bearing on necrosis of the ureter lowing the Wertheim opera,tion. 8urg., Gynee & Obst., 86: :10-44, 1948. lviorn, .f. C.: The ·vesico-Vaginal Fistula.. London· Tindall and Cox, HJ6L HAMM,

RussELL,

C. S. · Vesico-\'aginal :Fistulas and

Related .ivfatters. Springfield, Illinois. Cr1a.rle2 C. Thomas, 1902. WALTEns, V\T.: Omental flap in the transperitons,d repair of recurring vesicovaginal fistuhcl'. Surg., Gynec. & Obst., 64: ?4 75, rn,;7_