Diagnosis and management

of genitourinary fistula
JEFFREY L. CORNELLA, M.D.
Mayo Graduate School, Gynecologic Surgery, Mayo Clinic,
Scottsdale
Fistula secondary to neglected obstetrical labor
became uncommon with the advent of modern obstetrical care
in the industrialized world. The goals of modern medicine must
be to provide access to sound obstetrical care and to reduce
iatrogenic fistula rates to the lowest extent possible. Proven
techniques used in a thoughtful manner must be employed to
correct fistulae with minimal recurrence and adverse sequelae.
This chapter discusses genitourinary fistula secondary to operation, obstetrical events, malignancy, and irradiation.
ABSTRACT
ABSTRACT

Key words vesico-vaginal fistula, bladder fistula, vaginal fistula,

genitourinary fistula, bladder injury, uretero-vaginal fistula,
urethro-vaginal fistula

industrialized world. Elkins (2) has noted that serial Mayo

Clinic reviews of vesico-vaginal fistulas have clearly shown the
trends through the decades. In 1920, Judd (3) reported that
39% of fistulas referred to the Mayo Clinic were caused by
obstructed labor. In 1964, Massee et al. (4) noted that 5.7% of
fistulas repaired at the Mayo Clinic occurred after obstetrical
trauma. In 1988, Lee et al. (5) reported that only 3% of fistulas were attributed to obstetrics, none of which resulted from
obstructed labor. The majority of fistulas occurring in industrialized countries are now related to surgery.
Thomson (6) noted that gynecologic surgery is the most common cause of vesico-vaginal fistula in the United States. The bladder is the most common
site of urinary tract injury, occurring in 0.5-1% of patients
undergoing total abdominal hysterectomy (6). Symmonds (7)
noted that 75% of more than 800 fistulas managed over three
decades occurred after hysterectomy, with 50% after simple
hysterectomy. The vast majority of fistulas following hysterectomy are noted to be high in the vaginal vault above the
interureteric ridge and coinciding with the vaginal apex scar.
In addition to this type of supratrigonal fistula, a bladder neck
fistula below the trigone may occur with anterior colporrhaphy or urethral surgery. This type of fistula would be found in
the mid-vaginal vault.
ANATOMIC
ANATOMIC CONSIDERATIONS
CONSIDERATIONS

Surgical technique in extirpative surgery involves identification of vital structures and their subsequent
mobilization from the tissues to be resected. The initial step
in all pelvic operations is identification of the ureters. Symmonds (7) has noted that the simple total abdominal hysterectomy is the most common procedure performed prior to
the occurrence of genitourinary fistula. The time of unrecognized bladder injury is frequently during the dissection of the
bladder base from the underlying cervix and upper vagina. At
hysterectomy, wide, sharp dissection of the bladder from the
cervix and upper vagina is essential. Blunt dissection should
not be performed in this area, as the non-scarred tissue
responds easily to sharp dissection and scarred tissue will predispose to injury of the bladder. The bladder should be dissected one centimeter beyond the planned line of resection
(8). The surgeon must pay careful attention to the fine characteristics of the tissue, ascertaining tissue planes, bladder
thickness, evidence of bladder thinning, and any suggestion of
vascular compromise. Atraumatic handling of bladder tissue
and sparing use of cautery will decrease potential for injury.
Sound surgical principles of exposure, optimal lighting, visualization, and traction should be employed. If there is a question of bladder wall thinning, the bladder may be filled with
indigo-carmine dyed saline to further answer this question. If
reinforcement is required, it should be accomplished with
fine-gauge delayed absorbable sutures, paying attention to
any possibility of vascular compromise and the position of the
PREVENTION
PREVENTION

The goals of modern medicine must be to

provide access to sound obstetrical care and to reduce iatrogenic fistula rates to the lowest extent possible. Proven techniques used in a thoughtful manner must be employed to correct fistulae with minimal recurrence and adverse sequelae.
Gynecologic surgeons must have a historical understanding of
the art of fistula repair. The reader is referred to excellent historical descriptions, which document the evolution of management techniques throughout the decades (1). This chapter
will discuss genitourinary fistula secondary to operation,
obstetrical events, malignancy, irradiation, and foreign bodies. The site, size, and complexity of the fistulas often vary
depending upon the type of etiologic event.
INTRODUCTION
INTRODUCTION

VESICO-VAGINAL
VESICO-VAGINAL FISTULA
FISTULA SECONDARY
SECONDARY TO
TO OPERATIVE
OPERATIVE INJURY
INJURY

Fistula secondary to neglected obstetrical labor became

uncommon with the advent of modern obstetrical care in the
Address correspondence to:
Jeffrey L. Cornella, M.D.
Division of Reconstructive Surgery
Obstetrics and Gynecology
Mayo Clinic Scottsdale
13400 East Shea Blvd., Scottsdale, Arizona 85259, USA
Phone (1 480) 301 8090 Fax (1 480) 3018414
E-mail cornella.jeffrey@mayo.edu

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Chapter 22

absorbable sutures (Figures 1 and 2). A watertight closure

should be confirmed with a fluid-filled bladder. The surgeon
should consider interposition of a protective layer between
the bladder and vagina such as peritoneum or omentum, as
this will reduce the risk of subsequent fistula despite repair
(8). This is important to consider, as repair may not always
result in freedom from subsequent tissue breakdown and fistula formation. In a review of 110 posthysterectomy fistulas
by Tancer (9), 24 fistulas were recognized and repaired at the
time of hysterectomy. The more dependent the opening in
the bladder base, the greater the importance of following
sound principles of multi-layer closure, hemostasis, tissue
interposition, and adequate postoperative bladder drainage.
An in-dwelling Foley catheter should be left in place for ten
days.
Figure 1. A cystotomy is created in the muscularis of the bladder base during a gynecologic
operation. Sharp dissection in the proper plane reduces the incidence of such injury.
(From Lee RA. Atlas of Gynecologic Surgery. Figure 440, Page 303. W.B. Saunders,
Philadelphia, Pennsylvania, 1992. Reprinted by permission of the author and publisher.)

The vaginal approach to hysterectomy less frequently results

in the creation of a fistula, but sound principles of traction,
tissue plane dissection, and observance of fine-tissue characteristics apply as well. A wide anterior vaginal incision, dissection with the scissor tips against the cervix, and traction
superiorly with a Deavor retractor allows delineation of the
ureters. If the tissues are significantly scarred, the surgeon vesicouterine fold of peritoneum. If leiomyomatous disease of
may consider an extraperitoneal cystotomy to aid dissection the uterus or general enlargement results in a high location of
of the bladder base from the underlying tissues with a finger the peritoneal fold, peritoneal entry may be difficult. Entry is
placed into the bladder. The ureters must be re-examined facilitated by transection of the uterosacral ligaments, and, if
before and after tying the cardinal-vascular pedicles to note required, extrafascial transection of the cardinal ligament,
their unobstructed course.
posterior cul-de-sac entry and morcellation of the posterior
corpus will allow descent of the uterus and entry into the
If an opening in the bladder base occurs during a gynecolo- anterior cul-de-sac. The ureters should be palpated and the
gic operation it should be carefully repaired in a double or base of the bladder examined. Scarring along this tissue plane
triple-layer closure with interrupted fine-gauge delayed- from cesarean section or endometriosis requires adherence to
these principles with continuous sharp dissection. We prefer to leave urine within the bladder during this dissection, as an abrupt loss of
fluid would be a further indication of injury.
Thompson (6) suggests selected use of five
milliliters of methylene blue within the bladder with resultant staining of the bladder
mucosa, which would become apparent with
bladder thinning. The cystoscope should be a
part of the instrumentation available during
the vaginal hysterectomy and utilized whenever there is a question of injury or following
placement of Modified McCall support
sutures (10). It should be recognized, however,
that a negative cystoscopy does not replace
examination of the operative field or placement of indigo-carmine or sterile milk into
the bladder to rule-out leakage when injury to
Figure 2. Peritoneum covers a double-layer closure of the bladder muscularis
the bladder is suspected. Injury to the bladder
(From Lee RA. Atlas of Gynecologic Surgery. Figure 441, Page 303. W.B. Saunders, Philadelphia, Pennsylvania, 1992.
at the time of vaginal hysterectomy is supraReprinted by permission of the author and publisher.)
trigonal in the vast majority of instances.

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Diagnosis and management of genitourinary fistula

Laparoscopic hysterectomy or laparoscopic assisted

hysterectomy also risk injury to the bladder and
ureters. The same principles followed during open
surgery to avoid injury must be followed during
laparoscopy and include opening of the broad ligaments and direct identification of the ureters, sharp
bladder dissection from the uterus and cervix. The
ureters should be examined at the end of any laparoscopic pelvic procedure and cystoscopic examination
will allow confirmation of ureteral patency in a patient
who exhibited bilateral ureteral efflux at the beginning
of the operative procedure.
It is important to consider possible risk factors for fistula prior to operation. Tancer (9) cited prior cesarean
section, endometriosis, cervical myoma, prior pelvic radiation, and cold-knife conization as risk factors. Tancer
(9) emphasizes wide mobilization of the bladder to reduce tension on the bladder repair suture line and consideration of an interposition of omental graft. If at all
possible, the multi-layer bladder closure should not directly overly the area of clean-contaminated vaginal cuff.

Figure 3. The usual fistula resulting from operation is located on the posterior wall of the bladder
above the interureteric ridge
(From Lee RA. Atlas of Gynecologic Surgery. Figure 404, Page 280. W.B. Saunders, Philadelphia,
Pennsylvania, 1992. Reprinted by permission of the author and publisher.)

Endometriosis, which obliterates the peritoneal surface of the bladder with dense adhesions to the cervix
and uterus at hysterectomy, should be approached in
an extraperitoneal fashion. The bladder peritoneum is
dissected from the bladder followed by extraperitoneal
dissection of the bladder from the vagina and area of
the cervix. The vagina is then entered anteriorly at the
junction of the cervix and the rectum mobilized inferiorly after incision of the posterior vagina. Depending
upon the extent of disease, the ureters may require dissection and lateral mobilization from the vesicouterine
ligament.
Thompson (6) notes that patients with a history of
subtotal abdominal hysterectomy often have distortion
of the bladder over the area of superior peritoneal closure. At the time of trachelectomy, this area may be
predisposed to injury due to dense attachment of the
bladder to the cervix on more than one plane (6). Careful sharp dissection and separation is required.
The patient who presents with fluid
leaking per vagina following surgery warrants careful
and thorough examination. Fistulas may be noted
immediately following surgery or there may be a delay
of ten to twenty days. Most commonly it is noted in the
first ten to twenty days (6). It is incumbent for every
patient to have a thorough history and examination of
the vaginal vault and pelvis when presenting to the
urologist or gynecologist. The physician should assess
RECOGNITION
RECOGNITION

Figure 4. Sharp dissection or flap-splitting dissection results in mobilization of tissues and decreased
tension on subsequent suture lines
(From Lee RA. Atlas of Gynecologic Surgery. Figure 406 Page 281. W.B. Saunders, Philadelphia,
Pennsylvania, 1992. Reprinted by permission of the author and publisher.)

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for possible urine loss per urethra, urine loss per vagina, or
genito-urinary discharge masquerading as incontinence.
Patients should be examined with bladder filling, stress testing
in the standing and supine positions, careful vaginal examination, and possible dye testing. The vault is carefully examined
with a speculum scrutinizing the vaginal cuff and urethra. In
patients with a history of hysterectomy, a cotton-swab is used
to probe folds at the cuff and the patient is asked to cough
during visualization as a method of increasing bladder pressure. If the patient still has a uterus, the vault is examined for
copious watery discharge passed per endocervical canal. The
amount of the urine loss will depend on the size and location
of the fistula and any concomitant urethral sphincter incompetence. It may also depend on the possibility of bladder irritation and loss secondary to uninhibited bladder contractions.
There have also been patients with occult fistula presenting
with urinary incontinence that have undergone incontinence
operation without recognition of the fistula. Postoperative
continued leakage may be attributed to failed surgery or
detrusor instability and the fistula remains unrecognized. If
the patient gives a history of continuously dripping urine, an
occult fistula should be considered. The patient should undergo
the three-tampon test of Moir (6). Indigo-carmine dyed saline Figure 5. The fistula scar is excised converting the opening into fresh injury
is placed within the bladder and three gauze pledgets are (From Lee RA. Atlas of Gynecologic Surgery. Figure 407, Page 282. W.B. Saunders,
placed within the vagina using a ring forceps. The patient is Philadelphia, Pennsylvania, 1992. Reprinted by permission of the author and publisher.)
asked to walk, take stairs, cough,
do deep-knee bends, and void
over a period of twenty minutes.
The pledgets are then examined.
The lower pledget will be dye
stained from voiding and/or loss
of urine from the urethra. If the
middle pledget is stained in its
upper portion or if the deepest
pledget is stained, a fistula should
be suspected. A colposcopic
examination of the vagina then
follows to inspect the vaginal
apex. If the upper pledget is wet
but not stained, a ureterovesical
fistula should be suspected.
Patients may have an injection of
indigo-carmine intravenously to
aid in the determination of the
presence of a ureterovesical fistula or a complex fistula. A retrograde study of the ureters to rule
out additional fistula should be
performed even if a vesicovaginal
fistula is readily apparent. The
gauze pledget test should be done
Figure 6. The initial suture line consists of 4-0 delayed absorbable suture placed in a extramucosal fashion
in situations where a fistula is sus(From Lee RA. Atlas of Gynecologic Surgery. Figure 408, Page 283. W.B. Saunders, Philadelphia, Pennsylvania, 1992. Reprinted by
pected, but the patient has had a
permission of the author and publisher.)

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Diagnosis and management of genitourinary fistula

negative cystoscopy. Cystoscopy may miss small

fistulas within the bladder that a pledget or tampon test would detect. The practitioner should
consider that multiple fistulae might be present
during examination of the vagina and bladder.
The most important
aspect of fistula management is thoughtful evaluation and assessment of the entire situation
prior to consideration of surgery. Precise assessment of tissue integrity, ureters, bladder, and
urethral sphincteric function is mandatory.
Complex fistulas are not uncommon. In a series
of postsurgical fistulas by Symmonds (7), 10% of
the fistulas were multiple, 10% involved one or
both ureters, and 10% were complex (involving
bowel or ureter in addition to the vesicovaginal
fistula). The surgeon should be cognizant of
bladder capacity, emptying ability, sphincteric
function, presence of multiple fistulae or the
presence of complex fistulae prior to planning
the operative approach. Following such an evaluation the surgeon can then make a decision
regarding timing of the operation, taking into
MANAGEMENT
MANAGEMENT PRINCIPLES
PRINCIPLES

Figure 7. The initial suture line is inverted with similar suture. Each suture line inverting the previous suture
line is placed 3 to 4 mm lateral to the initially closed suture line.
(From Lee RA. Atlas of Gynecologic Surgery. Figure 409, Page 283. W.B. Saunders, Philadelphia, Pennsylvania,
1992. Reprinted by permission of the author and publisher.)

consideration the function of the entire urinary tract,

the medical condition of the patient, the social condition of the patient, and the integrity of the tissues.

Figure 8. The peritoneum is pulled from the posterior surface of the bladder for interposition
between the bladder and vagina
(From Lee RA. Atlas of Gynecologic Surgery. Figure 410, Page 284. W.B. Saunders, Philadelphia,
Pennsylvania, 1992. Reprinted by permission of the author and publisher.)

82

Symmonds (7) stated that in his personal experience

52% of patients had failed attempts at repair prior to
referral. He proposed reasons for repair failure, including premature operative attempt at repair (10-15 days
after the causative operation). Tancer (9) stated that 13
weeks is a reasonable period of time to pass between
surgical injury and fistula repair. Thompson (6) agreed
stating that generally all post-hysterectomy fistulas are
ready for repair by the twelfth postoperative week. This
also allows for the possibility of spontaneous closure,
which may occur in 15-20% of cases (6). Blajvas et al.
(11) state that once local inflammation has resolved
there is no benefit to delaying repairs any further. In
addition, delay may have a devastating social impact
and compound how the patient views her entire medical course regardless of final outcome. Woo et al. (12)
noted that the distress experienced may at times lead to
medicolegal consequence. In the series reported by
Blajvas et al. (11), early repair was defined within twelve
weeks of the date of operation that resulted in the fistula. The number of series with repair less than twelve
weeks after surgery is limited in terms of patient numbers (11). The surgeon should have as a component of

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mation or failed fistula repair. The type of surgical

fistula also affects the timing of repair. Fistulas
after surgery for extensive pelvic malignancy may
require different timing for repair. In Lee et al.s (5)
series of 303 patients, 14% of fistulas followed
treatment of malignant conditions.

Figure 9. The vagina is closed in a transverse fashion

(From Lee RA. Atlas of Gynecologic Surgery. Figure 411, Page 285. W.B. Saunders, Philadelphia,
Pennsylvania, 1992. Reprinted by permission of the author and publisher.)
examination assessment of the tissues, and repair should be
avoided in the presence of apparent inflammation, infection,
or edema (11). Lee et al. (5) has noted in a review of 303
women with fistulae, that the ideal time of repair in a nonirradiated fistula was eight to twelve weeks after fistula for-

Elkins et al. (13) has noted that there are three types
of repairs to manage the fistula tract: excision, freshening the edges without full excision, and wide mobilization of the bladder and vaginal tissues. Collis (14)
first described wide mobilization of tissues in 1861.
Many surgeons through the decades, including Symmonds (8), Lee e. al. (5), and Tancer (15), have emphasized its importance. Symmonds (8) stressed the
importance of tension free closure and adequate
excision of scar in order to decrease risk of failure.
Thompson (6) believes that all simple vesicovaginal
fistulas should be closed via the vagina, yet many
articles in the urologic literature, unlike the gynecologic literature, emphasize primarily an abdominal
or transvesical approach. In Lee et al.s (5) large
series of vesicovaginal fistulas, of which 82% were
postsurgical, 80% were approached vaginally with a
98% cure rate (5).
Elkins et al. (13) described excision of the fistula tract uniformly in small and medium size fistulas. Mayo and Walters (16)
described the multiple-layer closure of the bladder in crossing
directions. Elkins et al. (13) describe its use in small fistulas at
any site. In larger fistulas (>4 cm), crossing closure may not be

Figure 10. A bladder incision

exposes the fistula. The
bladder is elevated and the
rim of the fistulous tract in
the bladder to the vagina is
excised.
(From Lee RA. Atlas of
Gynecologic Surgery. Figure
413, Page 286. W.B. Saunders, Philadelphia, Pennsylvania, 1992. Reprinted by per mission of the author and
publisher.)

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Diagnosis and management of genitourinary fistula

possible and two interrupted transverse lay ers may

be required.
OPERATIVE
OPERATIVE APPROACHES
APPROACHES

The standard vaginal repair of

the supra-trigonal vesicovaginal fistula involves
making an incision about the fistula opening and
extending to a transverse vaginal incision (Figure 3).
The vagina is dissected from the bladder allowing
sufficient mobility for subsequent bladder tensionfree closure (Figure 4). The fistula tract is removed
with sharp dissection followed by closure (Figure 5).
The initial suture layer consists of 4-0 delayed
absorbable suture placed in an extramucosal fashion and extending beyond the opening by 3-4 millimeters (Figure 6). Secondary imbricating suture is
placed in a similar fashion into the bladder muscularis (Figure 7). The closure is tested for watertight
characteristics. Peritoneum may be available to
interpose between the bladder and vagina (Figure
8). The vagina is then sutured closed (Figure 9).
FLAP-SPLITTING CLOSURE

Figure 11. The initial extramucosal closure of the vaginal portion of the fistula followed by a second layer
closure.
(From Lee RA. Atlas of Gynecologic Surgery. Figure 414, Page 287. W.B. Saunders, Philadelphia, Pennsylvania,
1992. Reprinted by permission of the author and publisher.)

A great
deal of the urologic literature on vesicovaginal
fistula repair centers on the abdominal approach.
There are appropriate times to perform an abdominal
approach to fistula, however if this is the surgeons frequent,
ABDOMINAL APPROACH TO SUPRA-TRIGONAL FISTULA

Figure 12. The bladder is closed in an extramucosal fashion and the stents removed.
(From Lee RA. Atlas of Gynecologic Surgery. Figure 415, Page 287. W.B. Saunders,
Philadelphia, Pennsylvania, 1992. Reprinted by permission of the author and publisher.)

84

primary choice, it may reflect unfamiliarity with the vaginal

route. The latter offers less morbidity, decreased hospitalization, and a shortened recovery time. The abdominal
approach may be required for complex fistula, the multipleoperated fistula with significant scarring, fistula in the irradiated patient, or other mitigating factors which may prohibit a vaginal approach. The abdominal route may also be
considered when the relative position of the ureters to the
fistula is seen as problematic, although many of these situations can be approached from below with or without the use
of ureteral stents. In 1913, Legueu (17) described the
abdominal technique which bivalves the superior bladder
wall to the level of the fistula modifying the techniques of
Trendelenburg and Dittel. OConor et al. (18) recommended
stay-sutures in the bladder wall every few centimeters to aid
with exposure. The fistula tract is excised and the vagina and
bladder are closed separately in layers (Figures 10 and 11).
Stents may be placed following the incision cystotomy and
removed during closure of the bladder (Figure 12). Peritoneum or omentum may be interposed between the vagina
and bladder (Figure 13). In addition, bladder mucosa autograft tissue may also be utilized in abdominal repair. Brandt
et al. (19) described 80 women with postsurgical fistulas who
were treated by interposition of bladder mucosa as a free
graft into the fistula tract between the closed vagina and the
bladder. The posterior bladder wall is sutured over the graft.
The graft is harvested from a site at the bladder dome that
is then fulgurated. Removal of the scarred fistula tract pro-

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The method extended from a modification of Simons colpocleisis described in

1856 (17). Fritsch and subsequently
Latzko made the assertion that a modification was appropriate in women who
had undergone hysterectomy (17). In
1913, Latzko (17) recommended the
operation as the simplest and surest
procedure for vaginal fistulas following
hysterectomy. Latzkos (17) modification was to allow no vaginal mucous
membrane between the edges of the
suture line and the fistulous opening.
This avoided the diverticulum caused
by leaving an immediate ring of intact
mucosa surrounding the fistula, within
the surrounding denuded tissue in the
Simon procedure. Latzko (17) noted
that the anterior and posterior vaginal
walls are normally in contact, so there
was very little tension on suture lines.
Falk and Kurman (20) and separately
Figure 13. Omentum is interposed between the bladder and vagina in the area of fistula closure
Tancer (15) have reported fairly exten(From Lee RA. Atlas of Gynecologic Surgery. Figure 418, Page 289. W.B. Saunders, Philadelphia, Pennsylvania, 1992.
sively on the Latzko procedure noting
Reprinted by permission of the author and publisher.)
cure rates consistent with standard closure of postsurgical vesicovaginal fistula.
Tancer (9) reported 107 patients who
ceeds harvesting of the graft. Brandt et al. described a suc- underwent the Latzko repair for posthysterectomy fistula
cess rate of 96.3% using this technique.
with a cure rate of 92%.
Following abdominal fistula repair a suprapubic catheter is
inserted and retained for ten to fourteen days. Blajvas et al.
(11) described 24 consecutive fistulas
repaired with a combination of
abdominal and vaginal approaches.
He stated that he prefers the vaginal
approach to fistula repair and indicated that the abdominal route is
chosen for induration exceeding two
centimeters around the fistula, fistulas involving the ureters, or inadequate vagina exposure. The transvesical or open abdominal route has a
success rate which approaches or is
commensurate with the vaginal route
(11). Occasionally a combined abdominal and transvaginal approach to
fistula may be required to close the
vaginal aspect of the fistula tract.

There is more urinary tract literature on laparoscopic injury than laparoscopic repair of such
LAPAROSCOPIC CONSIDERATIONS

Figure 14. A skin flap is placed into the va gina. Alternatively, a Martius flap may be
utilized via a tunnel into the vaginal
wound.
(From Lee RA. Atlas of Gynecologic
Surgery. Figure 403, Page 279. W.B. Saun ders, Philadelphia, Pennsylvania, 1992.
Reprinted by permission of the author and
publisher.)

The Latzko operation

involves a partial colpocleisis of the
vaginal apex surrounding the fistula.
LATZKO TECHNIQUE

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Diagnosis and management of genitourinary fistula

injury. Proven techniques of exposure, identification, and

traction should be maintained during operation regardless of
whether the patient has undergone laparotomy or laparoscopic surgery. Stapling devices along the cardinal-vascular
pedicle must be avoided if the patient has not had complete
delineation of the ureters and separation from the tissue to
be clamped. Considering the fact that this requires ligation of
the uterine vessels above the ureter in order to allow such
delineation, the use of stapling devices are essentially obviated in this area. The same principles of sharp dissection
required in open dissection must be utilized for mobilization
of the bladder from the cervix and vagina. A one-centimeter
area of endopelvic fascia must be developed. Uterine manipulators, which facilitate such dissection, should be utilized.
Hemostasis must be maintained and the ureters re-examined
at the conclusion of the procedure. Cystoscopy may be performed to check the function of the ureters and the integrity
of the bladder. Ureteral stents or lighted ureteral catheters
are usually not helpful and do not relieve the necessity of
ureteral identification and mobilization.
Kadar and Lemmerling(21) have reported two cases of urinary
fistulas related to ureteral injury after laparoscopic assisted
hysterectomy attributed to ureteral injury at cuff closure via
the vagina. There is no place for laparoscopic division of the
cardinal-vascular pedicle, partial or complete, without the
careful ureteral dissection described above. This dissection is
essentially commensurate with total laparoscopic hysterectomy.
Quinlan et al. (22) reported eight bladder lacerations during
173 laparoscopic assisted hysterectomies in a university-affiliated private hospital. All were exposed and repaired vaginally.
Lee et al. (23) reported six cases of urinary bladder injury in
422 cases of laparoscopic assisted hysterectomy.
Some authors have reported laparoscopic repair of vesicovaginal fistula (24). This may be useful in vesicocutaneous fistula, but its use in vesicovaginal fistula seems unnecessary and
cumbersome given the exposure achieved via a transvaginal
repair.
One of the most useful adjunctive operative
techniques is the performance of a tissue flap or graft to provide blood supply and in some instances tissue mass, to the
repair of genitourinary fistula. The graft is not a compensation for a non-water tight closure in a moderately small postsurgical fistula. If the amount of vascularized tissue surrounding a fistula is adequate, the same surgical principles of a
watertight, low-tension closure required in the techniques
described above are sought prior to placing a graft. The multiple-operated fistula, the post-irradiation fistula, the postsurgical fistula over four centimeters in diameter, or large-tissue loss fistulas from pressure necrosis would benefit from
flap placement. If the patient does not have bladder or vagiFLAPS AND GRAFTS

86

nal tissue available to result in primary closure, a myocutaneous flap is required.

The types of flaps available include bulbocavernosus fat pad
or Martius flap, rectus abdominus, gracilis muscle, and vulvar
skin flaps (25-26). One of the most commonly used flaps is the
modified Martius flap. The Martius flap brings adjacent
blood supply and/or tissue to the site of fistula repair (27). It
may also be harvested with a myocutaneous component in
cases of urethral or vaginal tissue loss.
Symmonds (28) described a myocutaneous labia majora skin
flap for reconstruction of the urethra. Due to the dual blood
supply of the bulbocavernosus and its attached fat pad by the
internal and superficial external pudendal arteries, the
myocutaneous flap can also be transected superiorly or inferiorly. Hoskins describes a technique of myocutaneous flapplacement, which emphasizes attachment of the harvested
skin island to the underlying fat pad. Multiple interrupted
sutures are used to prevent avulsion of the delicate cutaneous
vessels, which supply the skin (26).
Kanavel (29) described the repair of a large pelvic cavity with
the use of rectus muscle. Salup et al. (30) described use of a
pedicled myofascial rectus abdominal flap for the repair of a
postirradiation vesicovaginal fistula. Fascia was left attached
to the muscle flap and subsequently used to close a vaginal
defect. The defect subsequently epithelialized with a normal
vaginal mucosa on visual inspection.
In a retrospective study, Evans et al. (31) have found that
patients receiving interposition flaps at abdominal repair of fistulas had a greater success rate than those without such flaps.
An additional recent retrospective study has advocated Martius
flap placement in vaginal approaches for similar reasons (32).
Although obstetric fistulas are uncommon
in the industrialized world, the same does not hold true for
the developing world. Fistula formation from obstructed labor and resultant tissue necrosis is a major medical problem
in many developing countries. Arrowsmith et al. (33) notes
that Africa has the highest maternal mortality rate of any region in the world. In Nigeria, the maternal mortality was
reported to be 1,050 per 100,000 births in a university teaching hospital with a vesicovaginal fistula rate of 350 per
100,000 deliveries (33). This compares with a maternal mortality rate of eight per 100,000 births in the United States and
a low rate of obstetric fistula.
OBSTETRIC
OBSTETRIC FISTULA
FISTULA

Arrowsmith et al. (33) emphasized the field injury that occurs

with obstetric fistula and the focal injury that occurs with the
majority of postsurgical fistulas. This may result in multiple
birth-related injuries in addition to the fistula, such as urinary

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Chapter 22

incontinence, hydronephrosis, renal failure, adverse rectal

sequelae, vaginal stenosis, osteitis pubis, and foot-drop.
Repair of massive fistulas involves advancement of the anterior bladder wall into the vagina for closure or creation of a
neo-urethra (34). Complications may include continued
incontinence, small bladder capacity with bladder instability,
and urethral or vaginal stenosis.
Kelly (35) reported on 564 vesicovaginal fistulas and 121 combined vesicovaginal and recto-vaginal fistulas, the majority of
which were from the Addis Ababa Fistula Hospital. The mean
length of the labor of the African patients who sustained the
fistulae was 3.7 days, with a range of one to seven days; and the
percentage of complicated fistulas was 70.4%. Urethral reconstruction was required in 11.2% of the 685 vesicovaginal fistula patients in the series. Reimplantation of the ureter into the
bladder was required in 5.8% of patients. A Martius pedicle
graft was used to support the repaired fistula in 504 patients
(73.6%) and a gracilis muscle flap was utilized in 28 (4.1%).
This series by Kelly (35) illustrates many aspects of obstetric
fistula including the amount of tissue damage that can be
encountered as well as the fact that the vaginal approach is the
most appropriate route for repair. Elkins et al. (13), in his
series of obstetric fistulas has stated that the transvaginal
approach can repair almost all fistulas and the transabdominal
approach rarely, if ever, offered better exposure and was
always associated with a marked increase in operative time
and bleeding.
Emembolus (36) retrospective study of 115 pregnant patients
with fistulae was conducted to determine the factors associated with improved pregnancy outcome.
The successful repair of fistula was associated with a reduced abortion rate (4.0%),
incidence of premature rupture of the
membranes (1.3%), perinatal mortality
(13.0%), and an increased mean fetal
birthweight.
Obstetrical fistulas involving significant urethral damage
develop during prolonged compression of
the tissue at the pelvic outlet. The proximal
urethra is more commonly damaged than
the urethral meatus (34). Hamlin and
Nicholson (37) reported the incidence of
complete loss of the urethra to be as high
as 5 to 6% of all obstetrical fistulae in
Africa. Hamlin stated that these difficult
fistulas are remarkable for entire loss of
the urethra and complete or almost complete ablation of the vagina due to scarring.
URETHROVAGINAL
URETHROVAGINAL FISTULA
FISTULA

CME Journal of Gynecologic Oncology 2002; 7:7 890

Figure 15. A linear

loss of the urethral
floor. An incision is
made in the vaginal
wall mucosa adjacent
to the defect.
(From Lee RA. Atlas
of Gynecologic Surgery. Figure 394, Page
275. W.B. Saunders,
Philadelphia, Pennsylvania, 1992. Reprinted
by permission of the
author and publisher.)

Neo-urethras can be constructed from either vaginal or vesical flaps. Elkins et al. (34) reported use of a modification of
neo-urethra construction from a vesical advancement flap.
He noted that Tanagho and Smith developed the method
from earlier work by Flocks and Culp. The bladder is separated from the vaginal wall posteriorly. The anterior and lateral fistula edges are dissected from the pubic bone beneath

Figure 16. The vaginal mucosa is mobilized laterally and a portion of the
roof of the remaining urethra is mobilized for reconstruction.
(From Lee RA. Atlas of Gynecologic
Surgery. Figure 395, Page 275. W.B.
Saunders, Philadelphia, Pennsylvania,
1992. Reprinted by permission of the
author and publisher.)

87

Diagnosis and management of genitourinary fistula

Figure 17. A number 10 urethral catheter is placed into

the bed of the urethral roof to
aid in approximation of freed
tissue edges. An initial suture
line of 4-0 delayed absorbable
suture approximates the periurethral tissue. A second
suture line follows.
(From Lee RA. Atlas of Gyne cologic Surgery. Figure 396,
Page 276. W.B. Saunders, Phi ladelphia, Pennsylvania, 1992.
Reprinted by permission of the
author and publisher.)

the arch of the pubic ramus. The anterior bladder wall is dissected free and advanced into the vagina for urethral tubularization. Eighteen out of twenty patients in Elkin et al.s (34)
report experienced closure of the fistula. Reflective of the difficulty of the repair in achieving function in the majority of
patients, only eleven patients experienced complete recovery
of genitourinary function. Problems which may persist after
surgery include urinary incontinence, vaginal stenosis, amenorrhea, and dyspareunia.
In developed countries, urethral fistulas may result from foreign body necrosis, traumatic forceps deliveries, direct injury
in urologic endoscopy, vaginal surgeries, and urethral surgeries such as diverticulum removal. Symmonds and Hill (38)
reported on 50 patients with traumatic loss of much or all of
the urethral floor and bladder neck. This group of patients
had been subjected to 94 unsuccessful operations. Surgical
reconstruction consisted of creating a small-caliber neourethra from contractile tissue in the urethral roof and reinforcement of the anterior vaginal wall by a myocutaneous
labial skin flap similar to that described by Noble (39) (Figures
15-18). A percentage of these patients were anticipated to
have a delayed urethrovesical suspension. Forty-four percent
of the patients in the series had a myocutaneous flap or bulbocavernosus muscle flap. Twenty patients required a second-

88

Figure 18. The third layer of sutures is placed into the cervicopubic fascia to plicate the
urethra and bladder neck further
(From Lee RA. Atlas of Gynecologic Surgery. Figure 397, Page 277. W.B. Saunders,
Philadelphia, Pennsylvania, 1992. Reprinted by permission of the author and publisher.)

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Chapter 22

stage urethrovesical suspension. Seventy-four percent of patients (39) were cured and eight percent were greatly improved over a five to fifteen year follow-up.
Lee et al. (5) reported 53 patients with urethrovaginal or urethrovesicovaginal fistulas during a period of review from 19701985. Sixteen patients were referred for injury sustained from
anterior colporrhaphy, thirteen from diverticulectomy, six
from radiation therapy, three from vaginal hysterectomy and
repair, three from forceps rotation, three from trauma, and
the remainder from miscellaneous procedures. Fourteen of
these patients had failed one attempt at repair and two
patients had failed two attempts at repair prior to their referral. Forty-seven (92%) fistulas were repaired on the initial
attempt and four were successfully repaired on the second
vaginal operation. During the 15-year period of this report,
24,883 patients underwent major gynecologic operations by
the division of gynecologic surgery at the Mayo Clinic. Only
five patients developed fistulas (0.020%) of which three were
urethrovaginal. Only one patient developed a ureterovaginal
fistula, which was a result of a radical hysterectomy for postirradiation recurrent squamous cell carcinoma of the cervix.

As tissue damage and endarteritis increase, the conditions

favoring conventional repair decrease. Multiple biopsies of
radiation induced partially-necrotic lesions may predispose to
the development of fistula. Often diversion is needed to allow
healing or is required as the definitive management of radiation-induced fistulas.
Boronow (42) notes five essential steps in the management of
radiation-induced fistulas. These include exclusion of the
diagnosis of recurrent malignancy, avoidance of surgery during acute necrosis, diversion of fecal stream in cases of concomitant rectovaginal fistula, increasing the blood supply by
the use of grafts or flaps, and proper closure of the fistula.
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RADIATION
RADIATION INDUCED
INDUCED FISTULAS
FISTULAS

CME Journal of Gynecologic Oncology 2002; 7:7 890

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