- Email: [email protected]
Limited Experience in Early Management of Genitourinary Tract Fistulas
Surgical Techniques in Urology Limited Experience in Early Management of Genitourinary Tract Fistulas Ahmed M. Shelbaia and Nawara M. Hashish Genitourinary tract fistulas commonly occur as a complication of gynecologic operations. Vesicovaginal, ureterovaginal, and uterovesical fistulas are the most common fistulas occurring after these operations. In this study, we report the results of early repair of genitourinary fistulas using a retropubic, extraperitoneal, transvesical approach. TECHNICAL In our study, 20 women with a genitourinary tract fistula (12 with vesicovaginal, 6 with CONSIDERATIONS ureterovaginal, and 2 with uterovesical fistulas) were diagnosed and treated within 2 weeks after a gynecologic operation. RESULTS All patients reported a high quality of life postoperatively. None of the patients had urinary leakage after their fistula repair. Urinary urgency occurred after surgery in 7 patients. No urinary tract infections were reported. Follow-up of the patients showed no incidence of ureteral stricture and preservation of upper urinary tract function. CONCLUSIONS The results of our study have shown that early repair of genitourinary tract fistulas results in a high quality of life, few postoperative complications, and a high success rate and preservation of renal function. UROLOGY 69: 572–574, 2007. © 2007 Elsevier Inc. INTRODUCTION
G
enitourinary tract fistulas commonly occur as a complication of gynecologic operations. Vesicovaginal, ureterovaginal, and uterovesical fistulas are the most common fistulas occurring after these operations. Vesicovaginal fistulas (VVFs) are the most common acquired fistula of the urinary tract. Because fistulas result in considerable patient discomfort, are invariably unexpected, and can be acquired as a result of surgical treatment of an unrelated problem, considerable emotional distress often accompanies the diagnosis and subsequent treatment. The most common causes of VVF differ in different parts of the world. In industrialized countries, the most common cause (75%) is injury to the bladder at gynecologic surgery, usually abdominal hysterectomy, with the remainder due to vaginal hysterectomy or antiincontinence surgery, such as anterior colporrhaphy.1,2 In developing countries, in which routine prenatal obstetric care may be limited, VVFs most commonly occur as a result of prolonged labor, with resulting pressure necrosis to the anterior vaginal wall and underlying trigone of the bladder from the baby’s head. VVF can also result from the use of forceps. Posthysterectomy VVF can result from an unrecognized incidental cystotomy or as a result of tissue necrosis from a suture placed through both the
From the Departments of Urology and Gynecology and Obstetrics, Cairo Univervity Hospitals, Cairo, Egypt Reprint requests: Ahmed Mohamed Shelbaia, M.D., Department of Urology, Cairo University Hospitals, Borg el Atbaa Faisal Street, 5th Floor, Flat 5, Faisal, Giza 12111, Egypt. E-mail: [email protected] Submitted: August 16, 2006; accepted (with revisions): January 22, 2007
572
© 2007 Elsevier Inc. All Rights Reserved
bladder and vaginal wall during closure of the vaginal cuff.3 In this study, we examined the early management and repair of genitourinary tract fistulas and report our evaluation of the operative procedures and results.
MATERIAL AND METHODS Included in this study were 20 women with genitourinary fistulas. These patients were referred from surrounding hospitals. They were examined, evaluated, and underwent surgery at Cairo University Hospitals within 2 weeks after a gynecologic operation. Their age ranged from 20 to 40 years. The patients were evaluated by history taking, clinical examination, and laboratory investigations. A general and local examination was done, and the fistulous opening was examined by palpation and inspected vaginally. Methylene blue or indigo carmine tests were done to confirm the diagnosis and locate the fistula site. All patients underwent intravenous urography and cystoscopy before surgical intervention. All patients received 2 g/day of intravenous ceftriaxone for 2 days preoperatively that was continued for 3 days postoperatively. Subsequently, they received ciprofloxacin oral 500 mg twice daily for 5 days.
SURGICAL TECHNIQUE The patients were placed in the dorsal lithotomy position and examined under anesthesia to confirm the diagnosis and to detect any unexpected pathologic features. Cystoscopy was done before surgery to determine the site and size of the fistula and the relation of the fistula to the ureteral orifices. If fistula was too small, a straight-tip guidewire was passed through the fistula to appear in the vagina. For a VVF, a midline suprapubic incision and 0090-4295/07/$32.00 doi:10.1016/j.urology.2007.01.058
extraperitoneal approach was used to reach the bladder. The bladder was opened anteriorly by longitudinal incision, and both ureters were catheterized. All fistulas ranged from 4F to 14F, and none was close to any ureteral orifice. The fistulous tract was grasped with bladder forceps, and the fistula was completely removed, leaving fresh edges of the urinary bladder and vagina. A wide dissection between the bladder and vagina was done, and the vaginal defect was closed in two layers using 0-0 Vicryl in a transverse line. The first layer was continuous, and the second was interrupted. The urinary bladder was closed in two longitudinal layers using 3-0 Vicryl; the first was continuous and the second interrupted. The bladder closed over a suprapubic cystostomy tube and a urethral catheter was placed. The abdominal wall was closed with a drain in place. The suprapubic catheter was removed on the seventh postoperative day. The drain was removed 2 days later, and the urethral catheter was removed 2 weeks after surgery. The patients were advised to avoid sexual intercourse for 3 months after surgery. For ureterovaginal fistulas, cystoscopy and retrograde pyelography were done before surgical intervention. Follow-up of the patients was done using intravenous urography 6 months after surgical intervention and ultrasonography every 3 months for 2 years.
RESULTS Of the 20 women, 2 had a uterovesical fistula after cesarean section, 12 women had a VVF (2 after prolonged and difficult vaginal delivery, 3 after cesarean section, and 7 after hysterectomy for benign uterine lesions), and 6 had a ureterovaginal fistula (1 after cesarean section and 5 after hysterectomy). Of the 6 women with a ureterovaginal fistula, 2 underwent direct ureterovesical reimplantation, 3 required ureterovesical reimplantation with a psoas hitch, and 1 needed a Boari flap. All patients reported a high quality of life postoperatively. None of the patients had urinary leakage after their fistula repair. Urinary urgency occurred after surgery in 7 patients. No urinary tract infections were reported. Follow-up of the patients showed no incidence of ureteral stricture and preservation of upper urinary tract function.
COMMENT Genitourinary tract fistulas commonly occur as a complication of gynecologic operations. Vesicovaginal, ureterovaginal, and uterovesical fistulas are the most common fistulas occurring after these operations. VVFs are common in developing countries, and many investigators have advocated the use of a support graft for repairing VVFs, especially when complicated by the loss of tissue or exposure to infection or radiotherapy. Many surgeons recommend the use of flaps, with most using a pedicle graft4 (eg, Martius graft brought down from the labium magus in the vaginal repair of fistula.5–7 In the transUROLOGY 69 (3), 2007
abdominal approach, many surgeons use a pedicle omental graft.8 In our study, we performed early management of genitourinary tract fistulas. We also used the standard principles of urinary fistula repair, with scar tissue excision, if present; wide dissection; adequate mobilization; use of delayed absorbable sutures and closure in layers; meticulous hemostasis; and continuous bladder drainage for 2 weeks after surgery. In our study, the success rate was better than that reported by other investigators. Sharma9 reported 25 patients who underwent omental graft placement, of which 21 were successful. Wein et al.10 used the transvesical approach with interposition of peritoneum or omentum in 34 patients, of whom 30 had successful repair. O’Connor11 used a suprapubic transvesical approach for 42 patients, with successful repair in 37. Patil et al.12 used a gracilis graft in 18 patients, with success in 13. Immediate management of VVF has also been reported and proved to be highly effective in terms of closure and continence, preventing the patient from becoming outcast with a progressive downgrade of their condition medically, socially, and mentally.13 In our study, immediate repair of the genitourinary tract fistulas decreased the incidence of scar formation, tissue manipulation, and deep venous thrombosis. We used an extraperitoneal approach, with no intestinal or omental manipulation, which reduced the incidence of complications such as ileus or intestinal obstruction. Our operation avoided complete bisection of the bladder and thus decreases the incidence of infection and ureteral reflux.
CONCLUSIONS The results of our study have shown that immediate repair of genitourinary tract fistulas using this technique is effective and safe, results in a high quality of life, and has a high success rate, with preservation of upper urinary tract function. References 1. Gerber GS, Glenn S, and Schoenberg HW: Female urinary tract fistulas. J Urol 149: 229 –236, 1993. 2. Khan RM, Rasa N, Jehanzai BM, et al: Vesicovaginal fistula: an experience of 30 cases at Ayub Teaching Hospital Abbottabad. J Ayub Med Coll Abbottabad 17: 48 –50, 2005. 3. Goodwin WE, and Scardino PT: Vesicovaginal and ureterovaginal fistulas. J Urol 123: 370 –374, 1980. 4. Waldwick K: Fistula patients, in Waldij K (Ed): The Surgical Management of Bladder Fistula in 775 Women in Northern Nigeria. Nijmegen, The Netherlands, Benda, 1989, pp 32– 41. 5. Zimmen PE, Ganbathi K, and Leach GE: Vesicovaginal fistula repair. Urol Clin North Am 2: 87–99, 1994. 6. Blaivas JG, Heritz DM, and Rominzi LI: Early versus late repair of vesicovaginal fistulas: vaginal and abdominal approaches. J Urol 153: 1110 –1113, 1995. 7. Kesrwani PK, Misra R, Coel A, et al: Vesicovaginal fistula: an unusual complication of VVF (corrected) fistula repair. Inter Urogyn J Pelvic Floor Dysfunct 5: 358 –359, 2004. 8. Turner-Warwick R, and Chapple CR: Obstetric and gynecological injuries of urinary tract: their presentation and management, in
573
Bonner J (Ed): Recent Advances in Obstetric and Gynecology. London, Churchill Livingstone, 1994, pp 211–213. 9. Sharma SK: Pedicled omental graft in repair of large, difficult vesicovaginal fistula. Inter Gynecol Obstet 17: 556 –559, 1980. 10. Wein AJ, Carpincello VL, and Murphy JJ: Repair of vesicovaginal fistula by suprapubic transvesical approach. Surg Gynecol Obstet 150: 57– 60, 1980.
574
11. O’Connor VJ: Review of experience with vesicovaginal fistula repair. J Urol 123: 367–369, 1980. 12. Patil U, Waterhouse K, and Laungani G: Management of 18 difficult vesicovaginal and urethrovaginal fistulas with modified IngelmanSundberg ET Martin operations. J Urol 123: 653– 656, 1980. 13. Waaldijk K: Immediate management of fresh obstetric fistulas. Am Obstet Gynecol 191: 795–799, 2004.
UROLOGY 69 (3), 2007
G
enitourinary tract fistulas commonly occur as a complication of gynecologic operations. Vesicovaginal, ureterovaginal, and uterovesical fistulas are the most common fistulas occurring after these operations. Vesicovaginal fistulas (VVFs) are the most common acquired fistula of the urinary tract. Because fistulas result in considerable patient discomfort, are invariably unexpected, and can be acquired as a result of surgical treatment of an unrelated problem, considerable emotional distress often accompanies the diagnosis and subsequent treatment. The most common causes of VVF differ in different parts of the world. In industrialized countries, the most common cause (75%) is injury to the bladder at gynecologic surgery, usually abdominal hysterectomy, with the remainder due to vaginal hysterectomy or antiincontinence surgery, such as anterior colporrhaphy.1,2 In developing countries, in which routine prenatal obstetric care may be limited, VVFs most commonly occur as a result of prolonged labor, with resulting pressure necrosis to the anterior vaginal wall and underlying trigone of the bladder from the baby’s head. VVF can also result from the use of forceps. Posthysterectomy VVF can result from an unrecognized incidental cystotomy or as a result of tissue necrosis from a suture placed through both the
From the Departments of Urology and Gynecology and Obstetrics, Cairo Univervity Hospitals, Cairo, Egypt Reprint requests: Ahmed Mohamed Shelbaia, M.D., Department of Urology, Cairo University Hospitals, Borg el Atbaa Faisal Street, 5th Floor, Flat 5, Faisal, Giza 12111, Egypt. E-mail: [email protected] Submitted: August 16, 2006; accepted (with revisions): January 22, 2007
572
© 2007 Elsevier Inc. All Rights Reserved
bladder and vaginal wall during closure of the vaginal cuff.3 In this study, we examined the early management and repair of genitourinary tract fistulas and report our evaluation of the operative procedures and results.
MATERIAL AND METHODS Included in this study were 20 women with genitourinary fistulas. These patients were referred from surrounding hospitals. They were examined, evaluated, and underwent surgery at Cairo University Hospitals within 2 weeks after a gynecologic operation. Their age ranged from 20 to 40 years. The patients were evaluated by history taking, clinical examination, and laboratory investigations. A general and local examination was done, and the fistulous opening was examined by palpation and inspected vaginally. Methylene blue or indigo carmine tests were done to confirm the diagnosis and locate the fistula site. All patients underwent intravenous urography and cystoscopy before surgical intervention. All patients received 2 g/day of intravenous ceftriaxone for 2 days preoperatively that was continued for 3 days postoperatively. Subsequently, they received ciprofloxacin oral 500 mg twice daily for 5 days.
SURGICAL TECHNIQUE The patients were placed in the dorsal lithotomy position and examined under anesthesia to confirm the diagnosis and to detect any unexpected pathologic features. Cystoscopy was done before surgery to determine the site and size of the fistula and the relation of the fistula to the ureteral orifices. If fistula was too small, a straight-tip guidewire was passed through the fistula to appear in the vagina. For a VVF, a midline suprapubic incision and 0090-4295/07/$32.00 doi:10.1016/j.urology.2007.01.058
extraperitoneal approach was used to reach the bladder. The bladder was opened anteriorly by longitudinal incision, and both ureters were catheterized. All fistulas ranged from 4F to 14F, and none was close to any ureteral orifice. The fistulous tract was grasped with bladder forceps, and the fistula was completely removed, leaving fresh edges of the urinary bladder and vagina. A wide dissection between the bladder and vagina was done, and the vaginal defect was closed in two layers using 0-0 Vicryl in a transverse line. The first layer was continuous, and the second was interrupted. The urinary bladder was closed in two longitudinal layers using 3-0 Vicryl; the first was continuous and the second interrupted. The bladder closed over a suprapubic cystostomy tube and a urethral catheter was placed. The abdominal wall was closed with a drain in place. The suprapubic catheter was removed on the seventh postoperative day. The drain was removed 2 days later, and the urethral catheter was removed 2 weeks after surgery. The patients were advised to avoid sexual intercourse for 3 months after surgery. For ureterovaginal fistulas, cystoscopy and retrograde pyelography were done before surgical intervention. Follow-up of the patients was done using intravenous urography 6 months after surgical intervention and ultrasonography every 3 months for 2 years.
RESULTS Of the 20 women, 2 had a uterovesical fistula after cesarean section, 12 women had a VVF (2 after prolonged and difficult vaginal delivery, 3 after cesarean section, and 7 after hysterectomy for benign uterine lesions), and 6 had a ureterovaginal fistula (1 after cesarean section and 5 after hysterectomy). Of the 6 women with a ureterovaginal fistula, 2 underwent direct ureterovesical reimplantation, 3 required ureterovesical reimplantation with a psoas hitch, and 1 needed a Boari flap. All patients reported a high quality of life postoperatively. None of the patients had urinary leakage after their fistula repair. Urinary urgency occurred after surgery in 7 patients. No urinary tract infections were reported. Follow-up of the patients showed no incidence of ureteral stricture and preservation of upper urinary tract function.
COMMENT Genitourinary tract fistulas commonly occur as a complication of gynecologic operations. Vesicovaginal, ureterovaginal, and uterovesical fistulas are the most common fistulas occurring after these operations. VVFs are common in developing countries, and many investigators have advocated the use of a support graft for repairing VVFs, especially when complicated by the loss of tissue or exposure to infection or radiotherapy. Many surgeons recommend the use of flaps, with most using a pedicle graft4 (eg, Martius graft brought down from the labium magus in the vaginal repair of fistula.5–7 In the transUROLOGY 69 (3), 2007
abdominal approach, many surgeons use a pedicle omental graft.8 In our study, we performed early management of genitourinary tract fistulas. We also used the standard principles of urinary fistula repair, with scar tissue excision, if present; wide dissection; adequate mobilization; use of delayed absorbable sutures and closure in layers; meticulous hemostasis; and continuous bladder drainage for 2 weeks after surgery. In our study, the success rate was better than that reported by other investigators. Sharma9 reported 25 patients who underwent omental graft placement, of which 21 were successful. Wein et al.10 used the transvesical approach with interposition of peritoneum or omentum in 34 patients, of whom 30 had successful repair. O’Connor11 used a suprapubic transvesical approach for 42 patients, with successful repair in 37. Patil et al.12 used a gracilis graft in 18 patients, with success in 13. Immediate management of VVF has also been reported and proved to be highly effective in terms of closure and continence, preventing the patient from becoming outcast with a progressive downgrade of their condition medically, socially, and mentally.13 In our study, immediate repair of the genitourinary tract fistulas decreased the incidence of scar formation, tissue manipulation, and deep venous thrombosis. We used an extraperitoneal approach, with no intestinal or omental manipulation, which reduced the incidence of complications such as ileus or intestinal obstruction. Our operation avoided complete bisection of the bladder and thus decreases the incidence of infection and ureteral reflux.
CONCLUSIONS The results of our study have shown that immediate repair of genitourinary tract fistulas using this technique is effective and safe, results in a high quality of life, and has a high success rate, with preservation of upper urinary tract function. References 1. Gerber GS, Glenn S, and Schoenberg HW: Female urinary tract fistulas. J Urol 149: 229 –236, 1993. 2. Khan RM, Rasa N, Jehanzai BM, et al: Vesicovaginal fistula: an experience of 30 cases at Ayub Teaching Hospital Abbottabad. J Ayub Med Coll Abbottabad 17: 48 –50, 2005. 3. Goodwin WE, and Scardino PT: Vesicovaginal and ureterovaginal fistulas. J Urol 123: 370 –374, 1980. 4. Waldwick K: Fistula patients, in Waldij K (Ed): The Surgical Management of Bladder Fistula in 775 Women in Northern Nigeria. Nijmegen, The Netherlands, Benda, 1989, pp 32– 41. 5. Zimmen PE, Ganbathi K, and Leach GE: Vesicovaginal fistula repair. Urol Clin North Am 2: 87–99, 1994. 6. Blaivas JG, Heritz DM, and Rominzi LI: Early versus late repair of vesicovaginal fistulas: vaginal and abdominal approaches. J Urol 153: 1110 –1113, 1995. 7. Kesrwani PK, Misra R, Coel A, et al: Vesicovaginal fistula: an unusual complication of VVF (corrected) fistula repair. Inter Urogyn J Pelvic Floor Dysfunct 5: 358 –359, 2004. 8. Turner-Warwick R, and Chapple CR: Obstetric and gynecological injuries of urinary tract: their presentation and management, in
573
Bonner J (Ed): Recent Advances in Obstetric and Gynecology. London, Churchill Livingstone, 1994, pp 211–213. 9. Sharma SK: Pedicled omental graft in repair of large, difficult vesicovaginal fistula. Inter Gynecol Obstet 17: 556 –559, 1980. 10. Wein AJ, Carpincello VL, and Murphy JJ: Repair of vesicovaginal fistula by suprapubic transvesical approach. Surg Gynecol Obstet 150: 57– 60, 1980.
574
11. O’Connor VJ: Review of experience with vesicovaginal fistula repair. J Urol 123: 367–369, 1980. 12. Patil U, Waterhouse K, and Laungani G: Management of 18 difficult vesicovaginal and urethrovaginal fistulas with modified IngelmanSundberg ET Martin operations. J Urol 123: 653– 656, 1980. 13. Waaldijk K: Immediate management of fresh obstetric fistulas. Am Obstet Gynecol 191: 795–799, 2004.
UROLOGY 69 (3), 2007