Diagnosis and management of ureterovaginal fistula in a resource limited setting: a 12 years’ experience at four fistula surgery centers in Uganda

Abstract

Background: Ureterovaginal fistulae usually follow iatrogenic injury to the ureter during pelvic surgery. This manifests as urine incontinence and results in serious psychosocial effects to the women. Ureterovaginal fistulae unlike vesicovaginal fistulae present challenges in diagnosis and management especially in resource constrained settings. Objective: To describe the magnitude, aetiology, diagnosis, management and outcomes of ureterovaginal fistula at four fistula surgery centres in Uganda over a twelve-year period. Methods: A retrospective review of charts for women who had fistula repair at four regional fistula repair centres in Uganda from 2010 to 2021 was conducted. The diagnosis of ureterovaginal fistula was made clinically using a combination of a history of leakage of urine through the vagina following a pelvic surgery, absence of visible anterior vaginal wall defect on speculum examination, a negative methylene blue dye test, and a three-swab test. All women were managed using open transvesical ureteral reimplantation with or without Boari flap. A ureteral stent and Foley catheter were left in situ for 2 weeks. The outcome of surgery (successful fistula repair with urine continence) was determined at 2 months post-surgery. This was confirmed through a vaginal speculum exam. Results: Overall, there were 477 women who were managed for genito-urinary fistulae during the study period. Approximately 1 in every 10 women with genitourinary fistula had uretero-vaginal fistula (n=47, 9.8%). The mean age of the women with ureterovaginal fistula was 31.9 (SD ±11.8) years. Majority of the ureterovaginal fistulae (n=33, 70.7%) followed caesarean sections done at general hospitals (n=22, 46.8%) by medical officers (n=32, 68.1%). The clinical assessment method used in this study was accurate in diagnosing ureterovaginal fistula. Successful fistula repair with urine continence using the open transvesical ureteral reimplantation was achieved in 45 (95.7%) of the cases. Conclusion: Iatrogenic ureterovaginal fistulae are common in Uganda and most follow caesarean section performed at lower-level health facilities by medical officers. In resource limited settings where advanced diagnostic techniques aren’t available or not affordable, a simple but careful step-wise clinical evaluation described in this study is effective in making a diagnosis. Open transvesical ureteral re-implantation fistula repair technique has a high successful repair rate with urine continence.