Original Paper

Treatment modalities and outcome for Ureterovaginal fistula

inflicted in obstetrical and gynaecological practice

List of the contributors

 Dr Ghazi Khan FCP

Registrar Urology dept

Shaikh Zayed Hospital Lahore

 Dr Farah Yousaf

ex Associate Prof Gynae Obstetrics

Post graduate Medical Institute Lahore

 Dr Muhammad Muzammil Tahir

Asisstant Professor Urology

Shaikh Zayed Hospital Lahore

 Prof Dr Sajjad Husain

Prof of Urology/Principle

Punjab Post Graduate Medical Institute Lahore

 Original Paper

Treatment modalities and outcome for Ureterovaginal fistula

inflicted in obstetrical and gynaecological practice

Abstract
Objectives; To find out optimal procedure of repair of uretervaginal fistula and
there outcome in gynaecology and obstetric practice.

Material and Methods; In this study 18 patients with diagnosis of ureterovaginal

fistula secondary to gynaecology or obstetric procedure were included. All the
patients were admitted and detailed history, physical examination and
investigation were done. Ivu, in all patients, and in certain inconclusive patients,
retrograde pyelography was performed, method opted for surgery was decided
on these investigation basis. We passed only JJ stent in 03 patients, 10
underwent ureteric implantation, and remaining 03 boari flap with psoas hitch.

Results; Ureteric implantation was done in 10 Patients, success was 100%,

Boari flap with psoas hitch in 05 patients, with 80% success, only JJ stent was
performed in 03 patients with 100% outcome.

Conclusion; Always try to treat the patients conservatively in ureteric injury, with
stenting if possible, patients with conservative management, along with ureteric
implantation group have good results, while in those with adjuvant maneuver
like Boari flap have fair success rate, in experienced hands.
 Treatment modalities and outcome for Ureterovaginal fistula
inflicted in obstetrical and gynaecological practice

Introduction;

The close anatomical relationship between the urinary tract and internal genital
organs predisposes the distal ureter to iatrogenic injury during pelvic and
gynaecological surgery. The incidence of ureteric injury during hysterectomy for
benign disease is 1:500 cases, which rises to 1% in cases of malignancy. The
risk of ureteric injury is higher during abdominal compared to vaginal
hysterectomies. Repeat caesarean sections and postpartum hysterectomies are
also associated with increased risk of injury to the lower urinary tract. Most of the
uterine injuries occur at the lower one third of the ureter5.

Aims & Objectives

To find out optimal procedure of repair of Ureterovaginal fistula in
gynaecology and obstetric practice.

Material and methods

Descriptive hospital based clinical study, conducted at the department

of Urology Mayo Hospital Lahore from November 2002 to October 2003.
and department of gynae obstetrics Lahore General hospital from May
2005 to Nov 2006. 18 patients with diagnosis of ureterovaginal fistulae
secondary to obstetrics or gynaecological procedures without any
previous attempt of repair were included in this study, Patients having
urinary fistulae with previous attempt of repair, fistula secondary to
radiotherapy, malignancy, fistula due to surgery other than obstetric and
surgery, gunshot, road traffic accident or stab injury were excluded from
study.

All the patients were admitted. A detailed history of the patients regarding
mode of gynecological or obstetrical procedure was obtained. History of surgery,
cause, type of injury was taken. Duration between the infliction of injury and
development of symptoms was recorded. This was followed by thorough clinical
examination including general physical examination, systemic and pelvic
examination. In the pelvic examination both per vaginal examination and
speculum examination were performed and the findings were recorded. In
addition to routine investigations, ultrasonography and intravenous urography
was done to evaluate the upper tract, status of bladder, ureter and any leakage.
In patients where intravenous urography was inadequate to demonstrates
ureteral anatomy then retrograde pyelography was performed.

Patients with ureterovaginal fistulae double J stent was tried to pass at the
initial stage. Where we were unable to pass the ureteric stent, the distance
between the ureteric orifice and the site of injury were noted. On the basis of
these findings the decision, regarding mode of procedure was made, where the
distance was 2-3 cm we go for ureteric reimplantation with double J stent, Boari
flap with Psoas hitch and double J stent was performed for distance more than 4-
5 cm. For suturing vicryl 4/0 was used for end to end ureteric anastomosis over
JJ stent. JJ stent was removed on 6th post operative week. Patients were
assessed for outcome.

Results

Table 1 Different surgical approaches adopted in repair of UVF (n=18)

 Surgical Procedure No. of patients %age
Ureteric Reimplantation 10 55.55%
Boari's flap 2 11.11%
JJ stent 3 16.66%
Ureteric reimplantation with psoas hitch 3 16.66%

Out of 18 patients of UVF ureteric catheter was passed in 3 patients

with a little resistence felt between 2-4 cm and this catheter was
replaced with JJ stent. Post operative x-ray kidney, ureter and bladder
(KUB) were performed to see the position of the JJ. In 10 patients
ureteric catheter was not passed beyond 2-3 cm and ascending
pyelogram shows, stricture 2-3 cm away from ureterovesical junction, so
ureteric reimplantation was done. In 5 patients ureteric catheter failed to
go beyond 4-6 cm and in these patients surgical repair with Boari's flap
was performed.

In UVF patients , whom underwent ureteric reimplantation all were

successful. Out of 5 patients in which Boari's flap was made, four patients
recovered and one was a failure. The JJ stent was passed in 3 patients and they
remained dry. Stent was removed in these patients after 6 weeks, ascending
pyelogram shows no residual stricture. The JJ stents were used in all patients in
which repair of UVF was done. These patients were discharged from the hospital
with JJ stents and they were called after six weeks for removel of JJ stent. The
average hospital stay of the patients after different procedures for the UVF was
4.66 days.
Table 2, Success Rate in UVF Repair (n=18)

Procedure No. of Success Percantage

pt. rate
Ureteric Reimplantation 10 10 100%

Boari's Flap 2 1 50%

JJ Stent 3 3 100%
Ureteric reimplantation with psoas 3 3 100%
hitch
Total 18 17 87.50%

Discussion

Ureter is the most commonly injured organ after urinary bladder,

during gynecological and obstetrical surgery1. Mostly injury occurs at the
lower third of ureter5. There are three places, where ureter is very close
to the vagina, (1) the distal ureter just lateral to vagina where the uterine
artry crosses ventral over the ureter to enter the uterus, (2) over the
pelvic brim where the ovarian vessels crosses the ureters in the
infunfibulo pelvic ligament, (3) at the angle of vaginal fornix. True
incidence of ureteral injury is unknown, however results from various
studies suggest a ranges from of 0.02 to 2.5%.1,2,3 The most common
4,7
cause of ureteric injury was abdominal hysterectomy . The risk of
ureteric injury is higher after Laproscopic hysterectomy compared with
traditional hysterectomy13. We performed intravenous urography (IVU)
to see the site of injury followed by cystoscopy to exclude the possible
vesical injury and retrograde ureterography to see the site and nature of
injury. This is standard procedure recommended in many studies14.

The uretrovaginal fistulae may be treated with internal stents, end to

end anastamosis of ureter if the distance is short, ureteric reimplantation
with JJ stenting, ureteric reimplantation with psoas hitch or Boeri flap 6.
If damage is extensive and involving the distal ureter and gap is more, it
is difficult to mobilize the ureter sufficiently to anastamose it without
tension then Psoas hitch, Boari flap or combined procedure are the
treatment of choice. We performed ureteric reimplantation in 10
patients with good results, managed with just JJ stent, in 3 patients with
good success, in 3 patients we performed ureteric implantation
(submucosal tunnel) with psoas hitch, with 100% success rate while 02
patients underwent boeri flap with JJ stent, with success rate of 50%.
The success in these patients depends on many factors, included,
following surgical principles, infection free and most importantly
experience of the surgeon.

The overall success rate in present study is 87.50% for uretrovaginal

fistulae where as international data shows that in developed countries
the success rate for ureterovaginal fistulae ranges from 93.9 to 95%
after first attempt9,11. No technique is considered superior to the other.
The optimal approach is that works best in the surgeons' hand. The
route of approach is also best tailored to the individual patient.

The use of interposition graft is likely to contribute towards better

outcome as international studies in which these grafts were used
showed better out come.
 In all the patients JJ stents were used for splinting the ureteric
repair. It prevent the post operative urinary leakage, and reduces the
postoperative morbidity10, however controversies exist in the use of JJ
stent, in uncomplicated cases. In survey of American urological
association of 1453 cases, about 75% used splints for ureteric repairs
the consensus view is that, there use do a lot of good than to harm the
patient 12. we use only jj stent to manage these patients conservatively,
with good result.

Conclusion;

Intra operative identification of ureteric injuries is a rare feature, The iatrogenic

ureteric injury is inevitable, due to close proximity of the ureter to the internal
genital organ. Outcome depends on the site, size, location of the injury, and
expertise of the surgeon. So prompt diagnosis, appropriate surgical repair, better
endourological techniques, along with experience of the surgeon, is the
associated with better outcome.

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