Changing trends in the etiology and management of vesicovaginal fistula

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1 International Journal of Urology (08) 5, 5--9 doi: 0./iju.49 Review Article Changing trends in the etiology and management of vesicovaginal fistula Muhammad A Malik, Muhammad Sohail, Muhammad TB Malik, Nauman Khalid and Adeen Akram Department of Urology, Madina Teaching Hospital, University Medical and Dental College, and Department of Gynecology, Allied Hospital, Punjab Medical College, Faisalabad, Punjab, Pakistan Abbreviations & Acronyms VVF = vesicovaginal fistula Correspondence: Muhammad A Malik M.D., F.C.P.S., Department of Urology, University Medical and Dental College, Sargodha Road, Faisalabad, Punjab 750, Pakistan. akrammlk@yahoo.com Received 9 March 07; accepted June 07. Online publication August 07 Abstract: Vesicovaginal fistula has remained a scourge and of public health importance, causing significant morbidity, and psychological and social problems to the patient. Continuous wetness, odor and discomfort cause serious social issues. The diagnosis has been traditionally based on clinical evaluation, dye testing, cystoscopic examination and contrast studies. A successful repair of such fistulas requires an accurate diagnosis and timely surgical intervention using techniques that are based on basic surgical principles with or without the use of interpositional flaps. The method of repair depends on the type and location of the fistula, and the surgeon s training and expertise. The main complications are recurrence and stress/urge incontinence. Prevention must include universal education, improvement in the social and nutritional status of women, discouraging early marriages, and the provision of improved accessible healthcare services. Key words: gynecological trauma, urogenital fistula vesicovaginal fistula, vesicovaginal fistula management, vesicovaginal fistula repair. Introduction VVF is an abnormal communication between the bladder and vagina, which results in continuous involuntary loss of urine through the vagina. It is among the most distressing and socially devastating conditions among women, and occurs most commonly as a result of obstetrical and gynecological injury. VVF comprises a major burden of obstetrical procedures-related morbidity in developing countries, as well as having a drastic social impact on quality of life. The first recorded reference to VVF was in 950 BC. VVF has been a social stigma for women for centuries. The occurrence of VVF goes back to more than 000 BC, when it was identified in 95 in an Egyptian mummy. Avicenna first described the relationship between VVF and obstructed labor or iatrogenic injury in 07. While Derry in 95, noted a large VVF that he concluded was the consequence of obstructed labor. Incidence and etiology The incidence of VVF is rare in the developed world; however, it has a drastically high prevalence in developing and underdeveloped countries. 4 VVF is stigmatized in many populations, making the true incidence and prevalence difficult to articulate. That notwithstanding, it is common in most sub-saharan countries, with an estimated million women in sub-saharan Africa and south Asia living with VVF, while new cases were recorded annually as at in sub-saharan Africa alone 5 and approximately 000 new cases in West Africa. 6,7 VVF fistula is one such long-term morbidity consequent upon poor obstetric care. VVF has remained a scourge and of public health importance, not just for the attendant medical and physical disabilities, but also for the inherent social, emotional and psychological strain, and stress on the victims. 8 It has been reported that at least million women in underdeveloped poor countries have unrepaired VVF. 9 Early marriage and child bearing, poor socioeconomic status, low literacy rate, malnourishment, and inadequately developed infrastructure for antenatal care and emergency obstetric services are important factors for this high prevalence in these nations The Japanese Urological Association 5

2 MA MALIK ET AL. In the industrialized world, the most common causes of VVF are gynecological or pelvic surgery, radiotherapy and malignancy. In underdeveloped countries, the most common cause is obstructed labor. 4,5 The impacted fetal head in obstructed, and prolonged labor causes massive field injury leading to VVF. On average, the Department of Urology, Madina Teaching Hospital, University Medical and Dental College, Faisalabad, Punjab, Pakistan, is carrying out 6 40 cases of VVF repair per year. Because of improved and accessible antenatal and natal care, and strict rules regarding early marriages, the number of cases of VVF as a result of obstructed labor has markedly reduced. Gynecological surgery is the cause of fistula in most of the cases. Hysterectomy is the most common surgical procedure resulting in VVF formation in developed countries, with an 80% incidence., Other gynecological procedures account for up to %. However, the incidence varies depending on the approach. The lowest is with transvaginal (0.:000), followed by transabdominal (:000) and laparoscopic procedures (.:000). 6 Contrary to the previous trend, a significant shift has been observed in Pakistan regarding the etiology of female urogenital fistula. A study carried out at Bahawal Victoria Hospital Bahawalpur found the rate of obstetric fistula to be 8.46% compared with post-hysterectomy fistula, which was 6%. 7 Another study at the same center showed the rate of post-hysterectomy fistulas to be 55%, as compared with that after obstructed labor, which was 40%. 8 A similar study reported obstructed labor in 68% of cases as the etiology of VVF, and gynecological surgery in % of cases. 9 Gynecological surgery is being reported to be the main cause of VVF in our department nowadays (>90%). Rare cases of VVF as a result of obstructed labor present to us, and most of these cases occur in remote areas. Classification VVF can be classified in various ways. Simple fistulas are small in size (<0.5 cm), and single in non-radiated patients with no malignancy involvement. Complex fistulas are large sized (.5 cm), failed previous fistula repair, or are associated with chronic disease or post-irradiated. A fistula sized cm is considered as intermediate. 0 Clinical presentation Total urinary incontinence with a history of recent gynecological or pelvic surgery, or obstructed labor is the classical presentation of VVF. However, a post-radiation fistula can present even after years of therapy. Diagnosis The location, size and number of fistulas are important before definite repair for a better outcome of the procedure. A high suspicion of index for VVF arises when a patient has a postoperative (gynecological) urine leak between the 7th and th day. This is probably as a result of necrosis followed by obstructed prolonged labor and tissue taken up in stitches in pelvic surgery. Diagnosis can be established by filling the bladder with methylene blue, inserting a tampon in the vagina and asking the patient to ambulate. Cystoscopy has prime importance in accurate mapping of a fistula, which helps in the future management plan. Physical examination of the site of the fistula and its surroundings is also vitally important. Surgery should be postponed if there are signs of acute inflammation, edema, necrosis, or other pathology of the bladder or vagina. In long-standing cases of VVF, or repeated recurrent cases, bladder capacity reduces, and this might change the management plans. Contrast studies including intravenous urogram or cystogram might not be helpful in showing genital abnormality; however, it is essential to rule out any associated ureterovaginal fistula. The advanced and more costly techniques include subtraction magnetic resonance fistulography, which proved to be highly informative in 0 cases. The Moir test consists of the patient first taking phenazopyridine in the clinic, three cotton swabs are placed into the vagina and 00 ml of methylene blue solution is inserted into the bladder through the urethra. 4 After removing the catheter, a tampon is inserted into the vagina. Two hours later, the tampon is inspected; if stained blue, it indicates VVF, and an orange stain indicates a ureterovaginal fistula. Most urologists rarely use this test, and they are more comfortable with cystoscopic evaluation and contrast studies for the diagnosis and management of genitourinary fistulas. Treatment Conservative management might be effective in small, nonmalignant and early-detected fistulas. Keeping a urethral catheter for 0.5 months along with anticholinergics might be helpful in spontaneous closure of these fistulae. If diagnosis is established late in small fistulas, electrocoagulation of the mucosal layer along with catheterization for 4 weeks could lead to closure of the fistula. 5 Fibrin sealant and collagen as an additional plug has been successfully used to treat VVF. This material can be placed in the fistulous tract after electrocoagulation and draining the catheter for several weeks. This gel-like material plugs the tract until tissue ingrows from the edges. 6 Unfortunately, in most cases, these conservative measures fail and surgery is required. The timing of surgery depends on the condition of the surrounding tissue. Early repair might be carried out on healthy tissue, while surgery should be delayed up to months to allow recovery from inflammation, edema, infection or necrosis. Based on experiments carried out on slaves in Montgomery, USA, James Marion Sims established the foundations of VVF repair in 85, which included proper exposure in the knee-chest position, the use of a weighted vaginal retractor, silver wire sutures, tension-free closure of the defect and proper postoperative drainage of the bladder. 7 VVF can be best managed following basic surgical principles, such as adequate exposure, identification of structures, wide mobilization, tension-free closure, good hemostasis and uninterrupted bladder drainage. 8, The Japanese Urological Association

3 Vesicovaginal fistula The choice of surgical repair of VVF depends on the surgeon s experience, the location and size of the fistula, and the patient s preference. 0 VVF is most commonly repaired transvaginally, as most gynecologists find this approach more convenient. The transabdominal route is mostly used by urologists., In general, simple fistulas are being managed by the vaginal approach, whereas complex fistulas are either repaired through the abdominal approach or vaginally using myocutaneous flaps. Most gynecologists prefer the vaginal approach, which has the merits of minimal blood loss, shorter hospital stay and relatively less postoperative morbidity, and at the same time a success rate comparable with the abdominal approach. 4 Formation of dead space, where inflammation and infection can develop along with vaginal shortening, might be associated with the vaginal approch. 5 Severely indurated vaginal epithelium, vaginal stenosis, improper exposure and repair requiring ureteric re-implantation are contraindications for the vaginal approch. 6,7 The abdominal approach has been recommended for high retracted fistulas with a narrow vagina, fistulas proximal to ureters, associated pelvic pathology, and multiple and recurrent fistulas. 8 The traditional O Connor s approach has been the most accepted method of VVF repair for supratrigonal VVF to date. The O Connor s approach provides excellent mobilization of tissues and omental interposition. In this approach, a long sagittal cystotomy (bivalving of the bladder) is carried out until the fistula is reached. The fistulous tract is excised, and two-layer closure is carried out with or without tissue interposition. A recent review by Dalela et al. from Lucknow, India, described a transperitoneal modification of the O Connor procedure that decreases the amount of bladder dissection and operative time. It is also postulated to decrease the postoperative voiding dysfunction and detrusor overactivity, which occurs with a larger cystotomy and vesical dissection. The modification involves a smaller, posterior cystotomy that is carried out toward the edge of the fistula. The fistula tract is excised, and the bladder defect is closed by advancing the flap that has been created. The closure is completed in a single, running, locking layer of monocryl suture. An omental flap is utilized in all cases where the omentum is able to reach this far. 8 Our preferred abdominal approach is transvesical, in which the bladder is opened by a vertical incision. After putting a small-caliber Foley catheter into the fistula and filling the balloon with saline, the fistula is pulled anteriorly. We routinely inject diluted adrenaline submucosally around the tract to minimize blood loss and to obtain a clear field while separating the vagina from the bladder. The vaginal wall and wall of the bladder are separated by a sharp dissection with scissors. The vagina and bladder are repaired separately without any tissue interposition. Both ureters are stented with feeding tubes for 4 5 days, and the bladder is drained with a -way large caliber Foley catheter ( 4-Fr); slow irrigation is usually carried out with saline fluid for 4 h to prevent any clot retention. By this approach, our success rate is >95% (Figs ). Step- Identification of fistula & canulation of ureteric orifices Fig. VVF on the posterior bladder wall., canulated ureteric orifices;, fistulous tract;, posterior wall of urinary bladder. Both ureters have been stented with 5-Fr feeding tubes., retracted muscles;, posterior wall of urinary bladder;, fistulous tract; 4, canulated ureteric orifices. In post-radiation VVF, repair should be carried out using a pedicle flap, as the post-irradiation fistula site has a poor blood supply. Laparoscopic repair using intracorporeal suturing and omental interpositioning is a feasible procedure in selected patients. Laparoscopic repair in expert hands provides a high success rate and low morbidity; however, it is not widely practiced because of the costs and considerable learning curves imposed by intracorporeal suturing. 9,40 Successful robotic VVF repair was reported for the first time in The advantages of the robotic technique include -D visualization, wristed instrumentation reducing the severe angulation required for laparoscopic VVF repair and technically simpler intracorporeal knotting. Transabdominal surgery can be carried out by laparoscopic or robot-assisted laparoscopic approaches. Success rates in large series are up to 86%. Difficulties, such as an increased learning curve and vesicovaginal plane dissection, have been overcome with innovations, such as the robotic platform and cutting to the light with vaginoscopy. While still in its infancy in VVF repair, single-site surgery has also been utilized with reasonable success. Although minimally invasive surgery offers numerous advantages, the most successful approach will still be the surgery with which the VVF surgeon is most familiar. 4 In patients seeking treatment after many years, the capacity of the bladder decreases as a result of continuous leakage of urine. The bladder has to be augmented by using a segment of the intestine. Occasionally, such patients even require urinary diversions to treat urinary leakage when augmentation cystoplasty is not possible. It is doubtful that a single procedure will emerge as an optimal surgery for all VVF patients, given the variability of the nature of the condition, the patient s characteristics and the expertise of the surgeon. Postoperative care Continuous bladder drainage through a Foley catheter is mandatory. In patients with VVF involving the bladder neck, 4 07 The Japanese Urological Association 7

4 MA MALIK ET AL. Step- Traction of fistulous tract with Foley catheter balloon and dissection around the fistula Step- Repair of vaginal & urinary bladder wall 4 Fig. Foley balloon shown inserted and inflated into VVF and traction applied by Foley balloon., canulated ureteric orifice;, margins of fistulous tract;, balloon of catheter raising the edges of the fistulous tract., balloon of catheter raising the edges of the fistulous tract;, posterior wall of urinary bladder;, canulated ureteric orifice; 4, margins of fistulous tract. the balloon of the catheter should not be filled to avoid pressure on the suture line; rather, it should be fixed by sutures. We usually use a -way -Fr catheter to irrigate for days, as catheter blockage is likely to cause failure of the procedure. The patient should remain catheterized for weeks. If there is any doubt about the success of the repair, a cystogram should be carried out before catheter removal, and the catheter should remain in place for another weeks if there is a minor leak. Anticholinergics should be given to patients who have bladder spasms, as these not only cause pain to patients, but might also compromise healing. Antiseptic tampon/gauze should be placed in the vagina for a day. Antibiotics coverage should be given until removal of the catheter. 4 Complications Frequency, urgency, urge incontinence, stress incontinence and failure are recognized complications of VVF repair. Stress incontinence most likely occurs in obstetric fistula in which injury involves the sphincter mechanism. Anticholinergic drugs might be helpful in reducing the symptoms. Failure of VVF repair and recurrence of fistula occurs in 0% of cases. Recurrent cases should be dealt with a gap of at least months from the previous attempt of repair. Interposition of flaps is considered to be protective for recurrent cases. 44 Conclusions VVF is among the most distressing conditions for women. It causes a great deal of social, emotional, and psychological stress and strain on the patients. The diagnosis is based on symptoms/signs, clinical tests and exact mapping by cystoscopy. The best chance of successful surgical repair is at the first attempt. Debate about the most appropriate Fig. VVF repair completed with vicryl /0 in two layers., canulated ureteric orifice;, repaired fistulous tract. Second layer repair shown along with feeding tubes inserted into ureters and fixed., repaired fistulous tract;, posterior wall of urinary bladder;, canulated ureteric orifices. route of repair continues; however, the role of interpositioning grafts is viewed positively, especially in recurrent and large fistulas. Laparoscopic and robot-assisted techniques continue to develop; however, these are expensive and require considerable learning curves. Measures for prevention must include universal education, improvement in the social and nutritional status of women, discouraging early marriage, and the provision of improved easily accessible healthcare services. Conflict of interest None declared. References Santosh K, Nitin SK, Ganesh G. Vesicovaginal fistula. An update. Indian J. Urol. 007; : Ghoniem GM, Khater UM. Vesicovaginal fistula. Pelvic floor dysfunction. Springer-Verlag, London, 006. Derry DE. Note on five pelves of women in the eleventh dynasty in Egypt. J. Obstet. Gynecol. Br. Emp. 95; 4: Eilber KS, Kavalier E, Rodriguez L, Rosenblum N, Raz S. Ten-year experience with transvaginal vesicovaginal fistula repair using tissue interposition. J. Urol., 00; 69: United Nations Population Fund. Obstetric fistula needs assessment report: findings from nine African countries. 00. [Cited 0 Jul 07.] Available from URL: ssment.pdf 6 Vangeenderhuysen C, Prual A, Ould el Joud D. Obstetric fistulae, Incidence estimates for sub-saharan Africa. Int. J. Gynaecol. Obstet. 00; 7: Biadgilign S, Lakew Y, Reda AA, Deribe K. A population based survey in Ethiopia using questionnaire as proxy to estimate obstetric fistula prevalence: results from demographic and health survey. Reprod. Health 0; 0: 4. 8 Umeora OUJ, Emma-Echiegu NB. Vesico-vaginal fistula in developing countries - time to turn off the tap. J. Preg. Child Health 05; : e0. 9 Wall LL. Obstetric vesicovaginal fistula as an international public-health problem. Lancet 006; 68: Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc. Sci. Med. 944; 8: Tancer ML. Observations on prevention and management of vesicovaginal fistula. J. Urol. 980; : The Japanese Urological Association

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