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Fistulae in the industrialized world
-the most are iatrogenic
-congenital anomalies
-malignancy
-inflammation
-infection
-radiation therapy
-external tissue trauma, ischemia
-parturition
 The risks during pelvic surgery increase relative to
-the complexity of the resection,
-the extent of primary disease and
-when there has been prior radiotherapy (especialy for recurrent disease)
 When fistula occurs following radiotherapy for primary treatment
-this may be an indication of tumour recurrence.
The hallmark sign of fistula
-leakage of urine
Intraoperative diagnosis of urinary fistula
-only in 1/2 of cases
VVF (vesicovaginal fistula)
-the most common acquired fistula of the urinary tract
Etiology of VVF in the industrialized world
-iatrogeic injury followed by
-malignancy
-pelvic radiation
-obstetrical trauma (forceps, uterine rupture)
Developing world the etiology of VVF
-prolonged obstructed labor due to cephalopelvic disproportion
-pressure necrosis to the anterior vaginal wall, bladder, bladder neck and proximal urethra
Obstetric fistulae tend to be
-larger
-located distally in the vagina
-may involve large portions of the bladder neck and proximal urethra
DD of vaginal fistula
-stress (urethral incontinence)
-urge (bladder incontinence)
-overflow incontinence
The most common compliant in patients with VVF is
-constant urinary drainage per vagin
Pain and VVF
-uncommon
-unless there is considerable skin irrigation
Patients who developed VVF after hysterectomy more commonly had
-postoperative ileus
-hematuria
-bladder irritability
-elevated WBC
VVF resulting from radiation therapy
-may not present for months to years following comletion of radiation
Most commonly VVF following hysterectomy are located
- along the anterior vaginal wall
-at the level of the vaginal cuff
The presence of  a VVF may be confirmed
-by instilling a vital blue dye into the bladder per urethra
Double dye tampon
-oral phenazopyridine (Sedural)
-methylene blue instillation
Tampon is discolored yellow orange on the  top suggestive
-uretero-vaginal fistula
Tampon is discolored blue in the midportion of the tampon
-VVF
Tampon is discolored blue in the bottom suggests
-urethrovaginal fistula
Cystoscopy and VVF
-importantly in the setting of a prior history of pelvic malignancy
-biopsy of the fistula is often done to evaluate for the possibility of a recurrent maligancy
VCUG and VVF
-should be performed
-cystogram may objectively determine the presence and location of the fistula
Cystogram that fails to demonstrate a suspected VVF , but lacks voiding images
-should be considered nondiagnostic
Cross sectional imaging and VVF
-important in assessing for recurrent malignant disease
-delayed CT
Other studies
-creatinine of vaginal fluid
-urine culture
-cytology
Contrast-enhanced CT with late excretory phase reliably diagnoses urinary fistulae and provides information about
- ureteric integrity and the presence of associated urinoma
 . Magnetic resonance imaging, particular with T2 weighting
- also provides optimal diagnostic information regarding fistulae and may be preferred for urinary - intestinal fistulae
The goal of treatment of VVF
-the rapid cessation of urinary leakage with return of normal and complete urinary and genital function
Before epithelialisation is complete an abnormal communication between viscera will tend to close
-spontaneously, provided that the natural outflow is unobstructed or if urine is diverted
Combining available data gives an overall spontaneous closure rate of
- 13% ± 23%
Spontaneous closure is more common for fistulae in size
-less than 3 mm
Time for closure of fistula and treatment by indselling catheter
-2-3 weeks
Uncomlicated fistula
-small
-postsurgical
Complex fistula
-radiated
-large
Complex fistula should be evaluated for
-delayed repair (infection)
Small uncomlicated cyst (3-5mm)
-catheter
-fulguration
-fibrin sealant
Persistent VVF after conservative theray
- immediate surgical repair
Surgical repair of VVF
-abdominal
-vaginal
-transvesical
-tissue interposition
Delayed repair for
-postlabor fistula
-radiation induced fistula
Delayed repair allows
-maximal demarcation of ischemic tissue and resolution of associated edema and inflammation
Fistula located low on trigone or near the bladder neck and approach
-difficult to exposure transabdominally
Fistula located high at the vaginal cuff and approach
-may be difficult to exposure by vaginal approach
Fistual located near ureteral orifice and abdominal approach
-may necessiate reimplantation
Fistula located near orifice nd transvaginal approach
-may not be necessary even if fustula tract located near ureteral orifice
Timing of abdominal operation and vaginal
-abdominal often delayed 3-6 months
-vaginal can be done immediately
Sexual function and vaginal and abdominal approaches
-abdominal-no change in vaginal depth
-vaginal-rsk of vaginal shortening (Latzko technique)
Adjunctive flaps for abdominal approach
-omentum
-peritoneal flaps
-rectus abdominus flap
Adjunctive flaps for vaginal approach
-labial fat pad (Martius fat pad)
-peritoneal flap
-gluteal skin or gracilis
-myocutaneous flap
Relative indications for  abdominal approach
-large fistulae
-location in a deep narrow vagina
-radiation fistulae
-failed transvaginal approach
-small capacity bladder requiring augmentation
-need for ureteral reimplantation
-inability to place a patient in the lithotomy position
Preoperative estrogen supplementation in the postmenopausal women with vaginal atrophy and VVF
- may be beneficial
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