The management of genitourinary fistula in the third millennium

Abstract

BackgroundA vesicovaginal fistula (VVF) is an abnormal fistulous tract between the bladder and vagina, causing continuous loss of urine via the vagina. VVF is a relatively uncommon condition, but there is a drastically higher prevalence in the developing world. Furthermore, iatrogenic postoperative VVF is most common in developed countries, compared to mainly obstetric trauma in developing countries. In this review we focus on the development of current management techniques for VVF.MethodsMedline was searched to identify articles related to urogenital fistulae, including VVF. Based on these reports we focus on the aetiology, clinical presentation, diagnosis and management of VVF. This in-depth review includes the optimal surgical timing, different surgical approaches (including minimally invasive techniques such as laparoscopic and robotic surgery), recommendations for postoperative care, surgical complications, and the need for further research in the use of robotic surgery to treat this condition.ResultsIn all, 60 articles were identified and included in this review; eight were related to the aetiology, 12 to diagnosis, and 40 to the management of VVF. A thorough evaluation of VVF is imperative for planning the repair. Although the surgeonís experience typically influences the surgical approach, special situations will dictate the best approach.ConclusionThe treatment of genitourinary fistulae with robotic assistance continues to develop, but further research is necessary to fully understand the use of this technology.

Incidence, type and management of ureteric injury associated with vesicovaginal fistulas: Report of a series from a specialized center

“…It has been reported that clinical presentation of UVF is subtly different from VVF. Intermittent or position‐related vaginal leakage of urine can be expected with UVF, whereas urine leakage is more constant with pure VVF . In the present cohort, the UVFs were associated with concurrent VVF, which made the clinical picture mixed in nature.…”

“…Other clinical signs of UVF are ileus and abdominal pain consequent to intraperitoneal leak of urine, recurrent ascending urinary tract infections, and renal impairment. Additional clinical signs of VVF can include vulvar irritation and excoriation …”

“…The majority occur consequent to gynecological or other pelvic surgery and/or pelvic radiotherapy for malignancy . The most common surgical procedure leading to VVF formation is hysterectomy, which is reported to account for up to 80% of iatrogenic causes of VVF, with the laparoscopic approach having the highest risk (2.2:1000), and vaginal approach the least risk (0.2:1000) …”

Transvaginal primary layered repair of iatrogenic vesicovaginal fistula

“…Vesicovaginal fistula (VVF) is a direct communication between the bladder and vagina. In high‐income countries, VVF is associated with malignancy, radiation, and pelvic surgery . Classical VVF presentation includes urinary leakage from the vagina, vulvovaginal irritation, and recurrent infections.…”

Latzko Operation for Repair of Posthysterectomy Fistula: Reappraisal of an Exemplary Method

“…The lowest incidence is with transvaginal (0.2:1000) followed by transabdominal (1:1000), and laparoscopic procedures (2.2:1000). 2 Over the last 200 years, multiple repair techniques for VVF have been used. Urologists have utilized abdominal, laparoscopic, and robotic approaches for repair of complex fistulas; these approaches are technically difficult.…”