Management of urethrovaginal fistulas

Female non-obstetric urogenital fistula repair: long-term patient-reported outcomes and a scoping literature review

OBJECTIVE

To investigate long-term and patient-reported outcomes, including sexual function, in women undergoing urogenital fistula (UGF) repair, addressing the lack of such data in Western countries, where fistulas often result from iatrogenic causes.

PATIENTS AND METHODS

We conducted a retrospective analysis at a tertiary referral centre (2010-2023), classifying fistulas based on World Health Organisation criteria and evaluating surgical approaches, aetiology, and characteristics. Both objective (fistula closure, reintervention rates) and subjective outcomes (validated questionnaires) were assessed. A scoping review of patient-reported outcome measures in UGF repair was also performed.

RESULTS

The study included 50 patients: 17 (34%) underwent transvaginal and 33 (66%) transabdominal surgery. History of hysterectomy was present in 36 patients (72%). The median (interquartile range [IQR]) operating time was 130 (88-148) min. Fistula closure was achieved in 94% of cases at a median (IQR) follow-up of 50 (16-91) months and reached 100% after three redo fistula repairs. Seven patients (14%) underwent reinterventions for stress urinary incontinence after transvaginal repair (autologous fascial slings). Patient-reported outcomes showed median (IQR) scores on the International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms Modules (ICIQ-FLUTS) of 5 (3-7) for filling symptoms, 1 (0-2) for voiding symptoms and 4.5 (1-9) for incontinence symptoms. The median (IQR) score on the ICIQ Female Sexual Matters Associated with Lower Urinary Tract Symptoms Module (ICIQ-FLUTSsex) was 3 (1-5). The median (IQR) ICIQ Satisfaction (ICIQ-S) outcome score and overall satisfaction with surgery item score was 22 (18.5-23.5) and 10 (8.5-10), respectively. Higher scores indicate higher symptom burden and treatment satisfaction, respectively. Our scoping review included 1784 women, revealing mixed aetiology and methodological and aetiological heterogeneity, thus complicating cross-study comparisons.

CONCLUSIONS

Urogenital fistula repair at a specialised centre leads to excellent outcomes and high satisfaction. Patients with urethrovaginal fistulas are at increased risk of stress urinary incontinence, possibly due to the original trauma site of the fistula.

The utility of Martius fat pad in the repair of urogenital fistulae: review of current evidence

OBJECTIVE

To present the contemporary evidence on transvaginal urogenital fistulae (UGF) repair with Martius fat pad (MFP), compared to direct graftless fistula repair.

METHODS

We reviewed all available studies reporting lower UGF repair via the transvaginal approach in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). The primary outcome of interest was the fistula closure rates. When available, patients' baseline characteristics, indications for surgery, and early and late postoperative complications with focus on MFP-related complications are reported.

RESULTS AND DISCUSSION

In obstetric fistulae, tissue interposition has been almost completely abandoned, with contemporary large series reporting closure rates of >90% with graftless repair, even for complex fistulae. Similarly, most simple, non-irradiated iatrogenic fistulae can be closed safely without or with tissue interposition with success rates ranging between 86% and 100%. However, MFP is valuable in fistulae with difficulty achieving tension-free and layered closure, with significant tissue loss, urethral involvement and with poorly vascularised tissues after radiotherapy, with reported success rates between 80% and 97% in those challenging situations.

CONCLUSION

A UGF repair should be individualised after considering the specific characteristics and complexity of the procedure. MFP interposition is probably unnecessary for the majority of low (obstetric) fistulae within otherwise healthy tissues. However, MFP may still have a place to maximise outcomes in low-income settings, in select cases with higher (iatrogenic) fistulae, and in most cases with radiotherapy.

FIGO recommendations: Use of midurethral slings for the treatment of stress urinary incontinence

BACKGROUND

Stress urinary incontinence (SUI) is a global problem. It can significantly adversely impact a woman's quality of life. The use of synthetic mesh in vaginal surgery is controversial, especially when used for pelvic organ prolapse surgery. Although negative effects have been reported, the synthetic mesh midurethral sling (MUS) is considered to be safe and effective in the surgical treatment of SUI.

OBJECTIVES

To provide evidence-based data and recommendations for the obstetrician/gynecologist who treats women with SUI and performs or plans to perform MUS procedures.

METHODS

Academic searches of MEDLINE, the Cochrane Library, Embase, and Google Scholar articles published between 1987 and March 2020 were performed by a subgroup of the Urogynecology and Pelvic Floor Committee, International Federation of Gynecology and Obstetrics (FIGO).

SELECTION CRITERIA

The obtained scientific data were associated with a level of evidence according to the Oxford University Centre for Evidence-Based Medicine and GRADE Working Group system. In the absence of concrete scientific evidence, the recommendations were made via professional consensus.

RESULTS

The FIGO Urogynecology and Pelvic Floor Committee reviewed the literature and prepared this evidence-based recommendations document for the use of MUS for women with SUI.

CONCLUSIONS

Despite the extensive literature, there is a lack of consensus in the optimal surgical treatment of SUI. These recommendations provide a direction for surgeons to make appropriate decisions regarding management of SUI. The MUS is considered safe and effective in the treatment of SUI, based on many high-quality scientific publications and professional society recommendations. Comprehensive long-term data and systemic reviews are still needed, and these data will become increasingly important as women live longer. These recommendations will be continuously updated through future literature reviews.

Anatomical and functional outcomes of non-obstetric urogenital fistula repair

INTRODUCTION AND HYPOTHESIS

Studies on non-obstetric urogenital fistulas (NOUGFs) provide limited information on predictive outcome factors. This study was aimed at specifying and analyzing the risk factors for long-term anatomical and functional results.

METHODS

A cross-sectional study of surgical repair for non-obstetric urogenital fistula was performed. From 2012 to 2020, a total of 479 patients with urogenital fistulas were treated in two tertiary centers. Patients with isolated ureteral fistulas and rectal injuries were excluded. For evaluation of the long-term results, patients with vesicovaginal and urethrovaginal fistulas with at least 12 months of follow-up were identified and contacted by phone and/or examined in the clinic. The anatomical outcome was assessed by resolution of symptoms and/or clinical examination. The Urinary Distress Inventory (UDI-6) was used for the functional outcomes.

RESULTS

Overall, 425 patients were studied (mean age was 49.8; BMI 27.5; mean fistula size 1.4 cm, mean follow-up was 12 months). Vesicovaginal fistula affected 73% of patients. Hysterectomy without radiation was the most common etiology (66.3%), followed by hysterectomy with subsequent radiation (16%) and pelvic radiotherapy (12.2%). The transvaginal approach was used in 54.4%, abdominal in 12.4%, transvesical in 22.4%, and a combined approach in 10.8%. The successful closure rate was 92.9% for primary cases, 71.6% for secondary cases, and 66.7% for radiation fistulas. A high risk for relapse was found for NOUGFs with ureteral involvement (RR 2.5; 95% CI 1.3-4.5; p = 0.003), radiation fistulas (RR 2.1; 95% CI 1.3-3.5, p = 0.003); and combined radiation and hysterectomy cases (RR 2.9; 95% CI 1.8-4.6; p = 0.0001). In multifactorial analysis, fistula size >3.0 cm, pelvic radiation, and previous vaginal surgeries were associated with a higher risk for failure or lower urinary symptoms.

CONCLUSIONS

Factors for successful NOUGF closure are fistula size less than 3.0 cm, absence of pelvic radiation, and previous vaginal surgeries.

Urethrovaginal fistula repair with or without concurrent fascial sling placement: A retrospective review

INTRODUCTION

We sought to review outcomes of urethrovaginal fistula (UVF) repair, with or without concurrent fascial sling placement.

METHODS

All patients diagnosed with UVF at our center from 1988-2017 were included in this study. Patient charts were reviewed from a prospectively kept fistula database, and patient characteristics and surgical outcomes were described. Descriptive statistics were applied to compare complication rates between patients with or without fascial sling placement at the time of UVF repair.

RESULTS

A total of 41 cases of UVF were identified, all of which underwent surgical repair. Median age at diagnosis was 49 years (interquartile range [IQR] 35-62). All patients had undergone pelvic surgery. UVF etiology was secondary to stress urinary incontinence (SUI) surgery in 17 patients (41%) and urethral diverticulum repair in seven patients (17%). The most common presenting symptom was continuous incontinence in 19 patients (46%). Nineteen patients had a fascial sling placed at the time of surgery (46%), with no significant difference in complication rates (26% vs. 23%, p=0.79). Two patients had Clavien-Dindo grade I complications (5%) and one had a grade III complication (2%). Four patients had long-term complications (10%), including urinary retention, chronic pain, and urethral stricture. Two patients had UVF recurrence (5%). Median followup after surgery was 21 months (IQR 4-72).

CONCLUSIONS

UVF should be suspected in patients with continuous incontinence following a surgical procedure. Most UVF surgical repairs are successful and can be done with concurrent placement of a fascial sling.

Vaginal repair of nonradiogenic urogenital fistulas

INTRODUCTION AND HYPOTHESIS

In developed countries urogenital fistulas are rare and usually a complication of surgery or radiation therapy. Surgical repair can be accomplished transvaginally or by laparotomy, laparoscopy, robotic-assisted laparoscopy, or transurethral endoscopy. Closure can be achieved with or without tissue interposition. The vaginal approach is the least invasive and a variety of techniques with or without tissue interpositions and flaps have been described. This study reviews surgical approaches and techniques for the repair of nonradiogenic urogenital fistulas.

METHODS

We identified and reviewed records from all patients treated for urogenital fistulas at our unit between 2008 and 2018. We analyzed fistula location, etiology, type and duration of corrective surgery, length of hospitalization, as well as complication and success rates.

RESULTS

Fifty patients (mean age 52 years) were identified. 49 fistulas were related to previous gynecological surgery, 3 were related to obstetric trauma. Thirty-four patients had vesicovaginal, 11 urethrovaginal, 3 ureterovaginal, and 2 neobladder-vaginal fistulas. Forty-eight patients (96%) were operated on using a vaginal approach; a modified Sims-Simon repair was used in 47 cases (94%). No flaps or tissue interpositions were used. In 48 patients (96%) successful closure was achieved with one operation; the modified Sims-Simon technique was successful in all 47 cases. The median operation time was 40 min (range, 20-100 min); the complication rate was 14%.

CONCLUSIONS

This series demonstrates the feasibility and advantages of vaginal repair of benign gynecological fistulas. The success rate was high and extensive procedures were avoided.

Repair of Iatrogenic Urethral and Bladder Neck Injury Due to Missed Diagnosis of Mayer-Rokitansky-Küster-Hauser Syndrome

Mayer-Rokitansky-Küster-Hauser syndrome is a congenital malformation disorder resulting in agenesis of the proximal vagina, absence of cervix, and variable development of the uterus. This report describes the repair of a complex iatrogenic urethrovaginal injury due to a missed diagnosis of Mayer-Rokitansky-Küster-Hauser. Our treatment utilized a primary urethroplasty through a transvaginal approach with bladder neck reconstruction and a Martius flap for secondary coverage. Urinary continence was restored postoperatively.

The Aetiology, Treatment, and Outcome of Urogenital Fistulae Managed in Well- and Low-resourced Countries: A Systematic Review

CONTEXT

Urogenital fistula is a global healthcare problem, predominantly associated with obstetric complications in low-resourced countries and iatrogenic injury in well-resourced countries. Currently, the published evidence is of relatively low quality, mainly consisting retrospective case series.

OBJECTIVE

We evaluated the available evidence for aetiology, intervention, and outcomes of urogenital fistulae worldwide.

EVIDENCE ACQUISITION

We performed a systematic review of the PubMed and Scopus databases, classifying the evidence for fistula aetiology, repair techniques, and outcomes of surgery. Comparisons were made between fistulae treated in well-resourced countries and those in low-resourced countries.

EVIDENCE SYNTHESIS

Over a 35-yr period, 49 articles were identified using our search criteria, which were included in the qualitative analysis. In well-resourced countries, 1710/2055 (83.2%) of fistulae occurred following surgery, whereas in low-resourced countries, 9902/10398 (95.2%) were associated with childbirth. Spontaneous closure can occur in up to 15% of cases using catheter drainage and conservative approaches are more likely to be successful for nonradiotherapy fistulae. Of patients undergoing repairs in well-resourced countries, the median overall closure rate was 94.6%, while in low-resourced countries, this was 87.0%. Closure was significantly more likely to be achieved using a transvaginal approach then a transabdominal technique (90.8% success vs 83.9%, Fisher's exact test; p=0.0176).

CONCLUSIONS

It is difficult to conclude whether any specific route of surgery has advantage over any other, given the selection of patients to a particular procedure is based upon individual fistula characteristics. However, surgical repair should be carried out by experienced fistula surgeons, well versed in all techniques as the primary attempt at repair is likely to be the most successful.

PATIENT SUMMARY

Urogenital fistulae are a common problem worldwide; however, the available evidence on fistula management is poor in quality. We searched the current literature and identified that 95% of fistulae occur following childbirth in low-resourced countries, whereas 80% of fistulae are associated with surgery in well-resourced countries, where successful repair is also more likely to be achieved. The first attempt at repair is often the most successful and therefore fistula surgery should be centralised to hospitals with the most experience.

Concomitant repair of stress urinary incontinence with proximal urethrovaginal fistula: Our experience

INTRODUCTION

Proximal urethrovaginal fistula (UVF) located close to the bladder neck may cause extensive sphincter damage and is usually associated with continuous incontinence, which may mask the associated stress urinary incontinence (SUI). Simultaneous correction of SUI avoids a second surgery for SUI, which needs dissection in ischemic fields and carries a high risk of failure. The aim of this study is to describe our technique of concomitant repair of SUI with proximal UVF and our results.

METHODS

Between July 2010 and August 2014, 14 patients underwent UVF repair in Jackknife position by the interposition of a Martius flap and simultaneous correction of SUI by modified McGuire pubovaginal autologous fascial sling. The procedure was carried out a minimum of 3 months of presentation and after detailed preoperative evaluation.

RESULTS

After a mean follow-up of 28 months, all 14 patients were continent. None of the patients developed recurrence of the UVF. Two patients presented with retention immediately after catheter removal and clean intermittent catheterization training was given to both of them. Two patients became pregnant during the follow-up period and were advised cesarean section near term.

CONCLUSIONS

Repair of proximal UVF and correction of SUI can be performed in the same session to avoid the operation in an ischemic field.

Transvaginal repair of a urethrovaginal fistula using the Latzko technique with a bulbocavernosus (Martius) flap

INTRODUCTION AND HYPOTHESIS

Urethrovaginal fistula is a rare disorder that may occur following sling procedures for stress urinary incontinence, excision of a urethral diverticulum, anterior vaginal wall repair, radiation therapy, and prolonged indwelling urethral catheter. The most common clinical manifestation is continuous urinary leakage through the vagina, aggravated by an increase in the intra-abdominal pressure. Appropriate management, including timing of the surgical intervention and the preferred technique, remains controversial.

METHODS

This video presentation describes the transvaginal repair of a urethrovaginal fistula using the Latzko technique and a bulbocavernosus (Martius) flap.

RESULTS

The patient's postoperative course was uneventful. At her follow-up visit 2 months later, she was free of urinary leakage, and a pelvic examination revealed excellent healing, with complete closure of the fistula.

CONCLUSIONS

Transvaginal repair using the Latzko technique with a vascular bulbocavernosus (Martius) flap is an effective and safe mode of treatment.

Female Urethral Reconstruction

PURPOSE

Female urethral reconstruction can be used successfully to treat a heterogeneous group of urethral disorders through an expanding number of unique approaches. Understanding the diverse etiologies of female urethral stricture and loss is essential in evaluating and diagnosing patients. Although there is an appreciable body of literature addressing female urethral reconstruction individually, there is a paucity of resources that approach this issue holistically. We discuss the relevant female urethral anatomy, pathophysiology, diagnosis and evaluation of female urethral disorders, and current reconstructive techniques, as well as published outcomes data and potential future directions for female urethral reconstruction.

MATERIALS AND METHODS

We reviewed articles published in English and indexed in the PubMed®, Embase® and Google Scholar™ databases, and consulted textbooks. Key search terms used were female, urethra, urethral reconstruction, urethroplasty, pathology, stricture, vaginal flap, bladder flap, graft, dilation, pubovaginal sling, catheterization, imaging, tissue engineering and bioscaffold. We created a synopsis of relevant articles, including original research studies and reviews.

RESULTS

Urethral tissue loss and strictures are caused by traumatic injuries, iatrogenic injuries and, rarely, infections and malignancies. A comprehensive patient history and physical examination are critical for diagnosis. Flexible cystoscopy, voiding cystourethrography and endovaginal magnetic resonance imaging can help to determine the surgical method of repair. Minimally invasive approaches to female urethral reconstruction are associated with poor outcomes. Definitive treatment options for repair of female urethral stricture include vaginal flap/wall urethroplasty, graft urethroplasty and distal urethrectomy with advancement meatoplasty. Repair techniques for urethral loss include primary closure, vaginal flap/wall urethroplasty and bladder flap urethroplasty. Vaginal flap approaches with well vascularized grafts and buccal mucosal grafts have high success rates. Tissue engineered grafts are being investigated as a novel treatment modality.

CONCLUSIONS

Female urethral reconstruction is complex, and one must carefully evaluate patients afflicted with urethral disorders. Urethral stricture and urethral loss have different etiologies. Variations of a standard approach might best address the condition of an individual patient. Long-term outcomes data are not available for contemporary techniques of female urethral reconstruction. The highest success rates have been reported with vaginal flap and buccal mucosal graft urethroplasty. Further studies focusing on newer reconstruction techniques and long-term outcomes are warranted.

Long-term functional outcomes following non-radiated urethrovaginal fistula repair

OBJECTIVE

To review long-term functional outcomes after urethrovaginal fistula (UVF) repair.

MATERIALS AND METHODS

Following IRB approval, women who underwent transvaginal non-irradiated UVF repair with minimum 6-month follow-up were reviewed. Surgical outcomes were assessed by validated questionnaires: UDI-6, IIQ-7, FSFI and visual analogue scale for QoL. Two groups were compared: (1) synthetic sling-related versus (2) non-sling-related UVF. Descriptive statistics were applied with p < 0.05 for significance.

RESULTS

From 1996 to 2013, 18 patients underwent UVF repair, with a mean age of 46 years (range 20-66), BMI 29 (range 21-42) and mean follow-up at 52 months (range 9-142). Overall repair success rate was 95%. Prior failed UVF repair was recorded in 11 women (61%). Statistical differences noted for Q4: 1.9 versus 0.8 (p = 0.03) and Q5: 1.3 versus 0 (p = 0.02) and VAS between the two groups, favoring the non-sling group; 1.5 (0.6) versus 5 (4) (p = 0.05). No differences in IIQ-7 were noted between the two groups (p = 0.09). Of the 18 patients, 5 remained sexually active and of those, 2 responded to FSFI (40%) with low scores. Reoperation rate was 33% (6 women) with 3 requiring periurethral-bulking agent for recurrent SUI, 2 transurethral laser for residual urethral sling mesh strands and 1 urethral dilation.

CONCLUSION

This large contemporary series of non-radiated UVF indicates a satisfactory outcome in UVF closure repair at a mean 4- to 5-year long-term follow-up, with the synthetic sling-related group performing worse.

Urethrovaginal Fistula in a 5-Year-Old Girl

Urethral fistulas are rare in girls. They occur most of the time during trauma. The case presented here is an iatrogenic fistula. The treatment was simple and consisted of a simple dissection and suture of urethra and vagina.

Large Urethro-Vesico-Vaginal Fistula due to a Vaginal Foreign Body in a 22-Year-Old Woman: Case Report and Literature Review

In the non-industrialized countries of Africa and Asia obstetric fistulas are more frequently caused by prolonged labour, whereas in countries with developed healthcare systems they are generally the result of complications of gynaecological surgery or, rarely, benign pathologies like inflammation or foreign bodies. A 22-year-old woman was brought to the gynaecology clinic because of foul-smelling vaginal discharge. On pelvic examination a ring-like foreign body was impacted between the anterior and posterior vaginal wall. MRI scan confirmed the presence of a cylindrical foreign body in the vagina and the patient revealed that she had 'involuntarily' inserted a plastic bubble bath cap into the vagina. At surgery removal of the cap was difficult and at the end of the manoeuver evidence of a huge urethro-vesico-vaginal fistula occurred. The patient was discharged with bilateral ureteral stents and suprapubic catheter. After 3 months we performed an end-to-end anastomotic urethroplasty to repair the urethral avulsion and restored the bladder/trigonal and vaginal/cervical defects with 3 layers of sutures; 3 months later the patient had no complaints. Complex genital fistulas represent an extremely debilitating morbidity. In our case, a vaginal approach was successful, but the choice between an abdominal or vaginal approach depends on the surgeon's experience and training.

Biologic grafted repair of urethrovaginal fistula and concomitant synthetic sling

The utilization of a biologic graft interposition allows for a successful fistula repair and concomitant synthetic sling without an increase in complications.

Management of urethrovaginal fistulae

PURPOSE OF REVIEW

Urethrovaginal fistulae are a rare condition. It is a conceptual mistake to consider urethrovaginal fistulae to be synonymous with vesicovaginal fistulae. Urethrovaginal fistulae are a different entity requiring special attention and treatment. Due to the wide variety and individuality of the clinical manifestations of these injuries, it is practically impossible to find and create common guidelines for treatment. Taking into account the difficulty of urethrovaginal fistula treatment, we decided to conduct a review of the current literature on this subject.

RECENT FINDINGS

Due to advances in obstetric care, urologists in the developed world encounter urethrovaginal fistulae rarely, and many of the fistulae seen are secondary to vaginal surgery. Surgical treatment procedures include direct primary anatomical repair and interpositional tissue restorations, mainly by Martius flap. Successful direct anatomical repair alone may result in the development of stress urinary incontinence or obstructed voiding in up to 50% of patients. Synthetic tape should be removed during fistula repair, which may lead to the resumption of stress incontinence.

SUMMARY

Prevention of urethrovaginal fistulae can be achieved through both improvements in obstetric care and adequate training in vaginal surgery. The success of any surgical treatment depends on careful patient selection, and assumes knowledge of all possible treatment options. Potential work needs to be directed towards the application of the newest molecular technologies.

Predicting the risk of failure of closure of obstetric fistula and residual urinary incontinence using a classification system

The aim of this study is to assess the possibility of predicting the risk of failure of closure and post-fistula urinary incontinence. Women attending the fistula clinics were assessed pre-operatively, and fistulae were staged prospectively, using a previously published classification system. Assessment for fistula closure and residual urinary incontinence was performed, prior to discharge. Of the 987 women who were assessed, 960 had successful closure of their fistulae. Of those with successful closure, 229 complained of urinary incontinence following surgery. Women with fistulae located closest to the external urinary meatus had the highest rate of urinary incontinence following fistula closure. Women with significant vaginal scarring and circumferential fistulae also had significantly higher rates of urinary incontinence and higher risk of failure of closure. The classification used is able to predict women at risk of post-fistula urinary incontinence and failure of closure.

Predicting the risk of failure of closure of obstetric fistula and residual urinary incontinence using a classification system

The aim of this study is to assess the possibility of predicting the risk of failure of closure and post-fistula urinary incontinence. Women attending the fistula clinics were assessed pre-operatively, and fistulae were staged prospectively, using a previously published classification system. Assessment for fistula closure and residual urinary incontinence was performed, prior to discharge. Of the 987 women who were assessed, 960 had successful closure of their fistulae. Of those with successful closure, 229 complained of urinary incontinence following surgery. Women with fistulae located closest to the external urinary meatus had the highest rate of urinary incontinence following fistula closure. Women with significant vaginal scarring and circumferential fistulae also had significantly higher rates of urinary incontinence and higher risk of failure of closure. The classification used is able to predict women at risk of post-fistula urinary incontinence and failure of closure.