Long-term functional outcomes following nonradiated vesicovaginal repair

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.

Early bladder dysfunction after vesicovaginal fistula repair: A prospective comparative analysis of transvaginal, open, and laparoscopic abdominal approaches

INTRODUCTION

We aim to compare the clinical and urodynamic profile of lower urinary tract symptoms (LUTS) in patients undergoing laparoscopic, open transabdominal, and laparoscopic transabdominal vesicovaginal fistulae (VVF) repair at 3 months of repair, that is, in early postoperative period.

MATERIALS AND METHODS

Fifty-one consecutive patients with endoscopically confirmed VVF were enrolled in our study over 2 years. Malignant fistulae, radiation-induced, and complex fistulae were excluded after cross-sectional imaging. All patients underwent a postoperative assessment for the success of the repair. Then at 3 months, they completed the American Urological Association Symptom Score questionnaire and underwent a dual channel pressure-flow urodynamic study. The results of transvaginal, laparoscopic, and open transabdominal repairs were compared.

RESULTS

All patients belonged to the Indian Caucasian race. The mean age was 35.43 ± 6.63 years. Thirty-two patients had supratrigonal and 19 had trigonal fistulae. Laparoscopic transabdominal repair was done in 15 patients, open transabdominal repair in 22 patients, and transvaginal repair in 14 patients. Forty-six patients reported some LUTS at a median follow-up of 5.83 ± 2.37 months postoperatively. Only 18 (35.2%) of these patients had moderate to severe symptoms The postoperative bladder dysfunction rates in open transabdominal, transvaginal and laparoscopic transabdominal groups were 36.4%, 28.6%, and 20%, respectively. Twenty-seven patients (52.9%) had some urodynamic abnormality, that is, small capacity (5), high voiding pressures (14), genuine stress incontinence (3), and poor compliance (3). Bladder capacity was a significant predictor of bladder dysfunction in our patients.

CONCLUSIONS

In our study, all three surgical approaches were associated with bladder dysfunction, however, it was the least in the laparoscopic transabdominal approach. Postoperative bladder capacity is a significant predictor of bladder dysfunction.

Quality of life, voiding & sexual dysfunction following robot-assisted vesicovaginal fistula repair: a tertiary care centre experience

Robot-assisted VVF (RA-VVF) repair has the advantage of small cystotomy, precise dissection and minimal surrounding tissue trauma. Translation of this to better functional outcomes is not studied so far. This study aims to evaluate the quality of life, voiding, and sexual dysfunction following robot-assisted VVF repair. Women with successful RA-VVF repair were screened using UDI-6, IIQ-7, FSFI, and WHOQOL-BREF questionnaires. The preoperative assessment was done in the prospective cohort only. Of the 75 women who underwent RA-VVF repair, 47 were enrolled, 33 in retrospective, and 14 in a prospective cohort. Overall, 28 (60%) women had urinary complaints with a median UDI-6 total score of 4 (0-100) and  IIQ-7 score (0-23) in 5 (10%) women. However, UDS (15 women) showed no DO with cystometric capacity (352 ± 98.12) ml and normal compliance in 14 (93%) women. Mean BOOI and DCI were 11.90 ± 7.01 and 44.25 ± 8.60 respectively, with PdetQmax ranging from 17 to 44. None had difficulty in voiding (Qmax 13.85 ± 4.90). Twenty (43%) women were sexually active, and 2 had sexual dysfunction (FSFI score < 26.55). Quality of life was "good" to "very good" in all domains (score > 90) except for the social domain. The prospective cohort showed significant improvement in UDI-6 score (p < 0.05), IIQ-7 score (p < 0.05), and quality of life (p < 0.05) postoperatively. RA-VVF repair results in minimal voiding dysfunction and significant improvement in overall quality of life. For sexual dysfunction assessment, a longer follow-up is required.

Vesico-Vaginal Fistula in Females in 2010-2020: a Systemic Review and Meta-analysis

INTRODUCTION

In the Western world today, urogenital fistula, including vesicovaginal fistula (VVF), is rare. However, while it remains significant in developing parts of the world due to prolonged and obstructed labor, in this study, we systematically reviewed the existing literature, discussing VVF occurrence, its etiology, and outcomes.

MATERIAL AND METHODS

We used electronic databases to search relevant articles from 2010-2020. The screening was performed with the help of Covidence. Relevant data from included studies were extracted in excel sheets, and final analysis was done using CMA-3 using proportion with 95% confidence interval (CI).

RESULTS

Fifteen studies reported the VVF among the fistula series. The pooled result showed 76.57% cases of VVF (CI, 65.42-84.96), out of which 27.54% were trigonal, 55.70% supra-trigonal, and the rest with a varied description like circumferential, juxta-cervical, juxta-urethral. Obstetric etiology was commonly reported with 19.29% (CI, 13.26-27.21) with cesarean section and 31.14% (CI, 18.23-47.86) with obstructed labor. Hysterectomy was the commonly reported etiology among gynecological etiology (46.52%, CI; 36.17-57.19). Among different surgical treatments employed for fistula closure, 49.50% were by abdominal approach (CI, 37.23-61.82), and 42.31% by vaginal approach (CI, 31.82-53.54). Successful closure of fistula was reported in 87.09% of the surgeries (CI, 84.39-89.38).

CONCLUSION

The vesicovaginal fistula is the most common type of genitourinary fistula. Major causes of fistula are gynecological surgery, obstructed labor, and cesarean section. The vaginal approach and abdominal are common modalities of repair of fistula with favorable outcomes in the majority of the patients.

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.

Evaluation of surgical approaches for vesicovaginal fistulae repair: the case for transvaginal repair as the gold standard

INTRODUCTION AND HYPOTHESIS

To highlight the success rates of two approaches of transvaginal vs. transabdominal closures for the vesicovaginal fistula (VVF) repair and to investigate the patient, fistula, and surgical factors relevant to surgical characteristics and successful outcomes.

METHODS

Retrospective analysis of 66 consecutive patients who underwent VVF repair between 2005 and 2020. Fistula profile, operative data, and postoperative outcomes were analyzed. Primary outcome was success rate with regard to surgical approach. Secondary outcomes were to compare patients' and surgical characteristics with regard to surgical approach and correlate these characteristics relevant to surgical outcomes.

RESULTS

A total of 66 women with a median age of 47 (27-82) years were included. Most (93.9%) of the VVFs were secondary to gynecological procedures. Thirteen (19.7%) patients had previous VVF repair. The median time from onset of leakage to surgical repair was 120 days. Forty-nine patients underwent transvaginal repair, whereas 17 (25.7%) women had abdominal repair. The success rates of transvaginal and abdominal techniques were 98% and 82%, respectively. Transvaginal approach had a significantly shorter operative time, less intraoperative blood loss, reduced hospital stay, and lower complication rates (p < 0.005). Age and time to surgery were positively and significantly correlated with surgical time [r (p value): 0.392 (0.003), (0.0386 (0.01)] and estimated blood loss [0.388 (0.002 and 0.410 (0.001)], respectively.

CONCLUSION

Transvaginal repair of VVF is a technically feasible and successful approach with significantly better operative parameters and lower complications. Despite varied etiology and different surgical approach, age and time to surgery are the main factors that correlate with operative time and blood loss.

Clinical outcome and quality of life after gracilis muscle transposition for fistula closure over a 10-year period

PURPOSE

Gracilis muscle transposition (GMT) is an established surgical technique in the treatment of anorectal fistulas and fistulas to the vagina and the urinary system when previous closure options have failed. There is little evidence on the success rate of this procedure in the long term.

METHODS

This is a follow-up study on all patients undergoing GMT over a 10-year period at a tertiary referral center for complex fistulas. Postoperative function and quality of life were evaluated by standardized questionnaires (Wexner score, Fecal Incontinence Quality of Life Score (FIQL), SF-12 and a brief questionnaire designed for this study). Sexual function was evaluated by the Female Sexual Function Index (FSFI) and the International Index of Erectile Function.

RESULTS

Forty-seven gracilis muscle transpositions (GMT) in 46 patients were performed. Most treated patients had (neo-)-rectovaginal fistulas (n = 29). An overall fistula closure was achieved in 34 of 46 patients (74%): in 25 cases primarily by GMT (53%) and in nine patients with persistent or recurrent fistula by additional surgical procedures. A clinically apparent relapse occurred on average 276 days (median: 180 days) after GMT (mean follow-up 73.4 months).

CONCLUSION

GMT in our hands has a primary closure rate of 53%, and after further procedures, this rises to 74%. Fecal continence is impaired in patients having undergone GMT. The overall quality of life in patients after GMT is only slightly impaired, and sexual function is severely impaired in female patients.

Update on vesicovaginal fistula: A systematic review

Objective: To conduct a systematic review of the literature on vesicovaginal fistula (VVF), including reporting on the aetiology, in both developed and underdeveloped countries; diagnosis; intraoperative prevention; and management.

Methods: We conducted a systematic review of the literature on VVF through the PubMed and the Cochrane Library according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search was conducted from 1985 to 2018 in English, using the keywords ‘fistula’ and ‘vesicovaginal fistula’. Prospective studies were preferred; however, retrospective studies and case reports were used when no prospective studies were available. All authors’ extracted relevant data related to the proposed review of VVF and carefully examined collected articles.

Results: In all, 116 relevant articles were identified and 43 articles were included in this systematic review. The outcome of surgical reconstruction was >90%, but the outcome may be suboptimal in radiotherapy (RT)-induced VVFs. Absolute indications for an abdominal approach included: ureteric involvement, the need for concomitant bladder augmentation, severe vaginal stenosis, and an inability to tolerate the dorsal lithotomy position (e.g. due to muscular spasticity). Typically, it was recommended to wait at least 3 months to allow the inflammatory response to subside before definitive surgery. Early fistula repair can be performed in the absence of infection and in patients who have not received pelvic RT.

Conclusion: VVF is rare in developed countries. Surgical treatment is the primary method of repair. The outcome of surgical reconstruction exceeds 90%, but the outcome may be suboptimal in RT-induced VVFs.

Abbreviations: PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RT: radiotherapy; (S)UI: (stress) urinary incontinence; UVF: ureterovaginal fistula; VVF: vesicovaginal fistula

The medium- to long-term functional outcomes of women who have had successful anatomical closure of vesicovaginal fistulae

Context:

While much has been published on vesicovaginal fistula (VVF), little is known about the urinary, bowel, and sexual functional outcomes following successful anatomical closure.

Aims:

We assessed the medium- to long-term urological, sexual, and bowel function outcomes following the successful anatomical closure of VVF.

Patients and Methods:

We conducted interviews with 36 women (median age – 47.5 years) who had successful anatomical closure of their VVF (28 vaginally and 8 abdominally) with a median of 40.5 months earlier. All completed validated questionnaires on urinary (Urogenital Distress Inventory-6 [UDI-6] and Incontinence Impact Questionnaire-7 [IIQ-7]), bowel (low anterior resection syndrome [LARS] score), and overall function (EQ5D). Sexually active patients completed the pelvic organ prolapse/urinary incontinence sexual questionnaire (PISQ-12). All women also completed these questionnaires retrospectively for their status immediately before VVF repair. Functional outcomes were compared with preoperative function, and outcomes of those women having vaginal repair were compared with those having abdominal repair. Statistical analysis was by Student's t-test and Mann–Whitney U-test.

Results:

Median UDI-6 and IIQ-7 scores (low score is better) reduced significantly (P ≤ 0.01) from 16.5 and 25.5 preoperatively to 4 and 2.5 postclosure. Median LARS score was not significantly altered. Sexual function was restored in 67.6% while overall function postclosure was good (PISQ12 – low score better). Both EQ5D (low score better) and health thermometer (high score better) medians were significantly improved (P < 0.01) from 9 and 25 to 6 and 75 postclosure, respectively. There was no significant difference in the medium- to long-term outcomes of women who had had vaginal repair of their VVF and those who had had abdominal repair.

Conclusions:

Successful repair of VVF results in medium- to long-term significant improvement in urinary symptoms and distress, general well-being, and quality of life with no long-term adverse effects on bowel function regardless of route of repair. Sexual function is restored in 67.6%.

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.