Management of Urethrovaginal Fistulas

Transcription

1 european urology 50 (2006) available at journal homepage: Surgery in Motion Management of Urethrovaginal Fistulas Dmitri Y. Pushkar *, Vladimir V. Dyakov, John W. Kosko, Gevorg R. Kasyan Department of Urology, Moscow State Medico-Stomatological University, Moscow, Russia Article info Article history: Accepted August 1, 2006 Published online ahead of print on August 15, 2006 Keywords: Incontinence Surgical treatment Urethrovaginal fistula Abstract Objectives: Despite the apparent similarity, urethrovaginal fistulas (UVFs) are not identical to vesicovaginal defects. Obstetric trauma and vaginal surgery are the causes of a majority of urethrovaginal fistulas. Methods: Careful preoperative evaluation is essential for identifying small UVFs or associated vesicovaginal fistulas and includes physical examination, cystourethroscopy, intravenous pyelography, ultrasonography, and urinalysis, but sometimes the final surgical plan can only be decided on after the patient is examined under anaesthesia with a metal sound in the urethra. Significant tissue deficit is the main characteristic of UVF repair and the minimal space present often does not allow placing any additional tissue between the urethral and vaginal walls. Results: Seventy-one women (mean age, 43 yr) with UVFs have been treated in our clinic. Our results have shown successful closure of the fistula in 90.14% of patients after primary surgery and 98.59% after a second operation. Postoperative stress urinary incontinence developed in 37 patients (52.11%). We used both synthetic and autologous slings for their management. Twenty-two patients (59.46%) were cured, 12 (32.43%) were improved, and 3 remained incontinent (8.11%). The long-term results of 21 patients with mean follow-up time of 99.6 mo show no fistula recurrence. Postoperative bladder outlet obstruction (5.63%) was successfully managed by urethral dilation or urethrotomy. Conclusions: This article gives a detailed description of UVF surgical treatment. An attached DVD demonstrates one case that includes UVF primary repair, recurrent fistula repair, and surgery for continence restoration. # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Department of Urology of MSMSU, , Tverskaya, , Moscow, Russia. Tel ; Fax: address: pushkar@co.ru (D.Y. Pushkar) /$ see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 european urology 50 (2006) Introduction 1.1. Etiology Urethrovaginal fistulas (UVFs) remain one of the rare problems in female urology. Often UVFs are considered within the context of vesicovaginal fistulas, but this approach may mislead the surgeon into thinking that these fistulas are identical, when, in fact, there are important differences in etiology, treatment, and sequelae secondary to repair, all of which need to be considered. The main differences are that obstetric trauma remains the primary cause of many UVFs and the localisation of the fistula in the urethra leads to significantly fewer tissues available for use during repair. This latter factor may lead to poor functional results even after successful closure of the fistula, sometimes resulting in stress urinary incontinence (SUI) or obstruction due to urethral stenosis. Childbirth and obstetric traumas were the causes of a majority of urethral defects in past centuries [1]. At present, this condition also commonly results from prior surgeries such as anterior colporrhaphy, urethral diverticulectomy, paraurethral cyst removal, anti-incontinence surgery, and so on [2,3]. Other causes of UVFs include urethral trauma, pelvic surgery, lower urinary tract instrumentation [4] (prolonged catheterisation), and radiation. Prolonged obstructive labour, however, remains a major cause of urethral injury in developing nations [1] Clinical presentation UVFs may present with a tiny pinpoint lesion manifested by vaginal voiding or may present as complete loss of the urethra with total urinary incontinence (Fig. 1). The clinical presentations of UVFs depend on the location and the size of the fistula. The patient may be continent and often minimally symptomatic if the fistula is located in the distal third of the urethra. These patients usually complain of urinary drainage per vagina during or after voiding. Intermittent positional wetness is often present when the UVF is localised in the middle or proximal urethra. Other symptoms that present in these patients are perineal skin irritation, recurrent urinary tract infections, and vaginal fungal infections. The time from initial lesion to the onset of clinical symptoms depends on the etiology of the UVF. Approximately 90% of genitourinary fistulas associated with pelvic surgery are symptomatic within 7 30 d postoperatively. An anterior vaginal wall laceration associated with Fig. 1 Urethrovaginal fistula before (A) and after (B) surgical management. obstetric fistulas typically (75%) presents within the first 24 h after delivery. In contrast, radiationinduced UVFs are associated with slowly progressive devascularisation necrosis and may present 30 d to many years later [5]. 2. Methods 2.1. Patients In our clinic from 1972 to the present we have treated 71 patients with UVFs. The mean age of the patients was

3 1002 european urology 50 (2006) Table 1 Etiology of urethrovaginal fistulas Etiology (n = 71) Patients (n) Patients (%) Obstetric procedures % Periurethral cyst surgery % Anterior colporrhaphy % Autologous sling % Periurethral bulking agents % Synthetic slings % Foreign body of the urethra % Cryoablation of urethral polyp % yr (range: yr). The majority of UVFs (70.42%) were caused by previous vaginal surgeries such as periurethral cyst removal, colporrhaphy, fascial and synthetic slings, cryoablation of urethral polyp (Table 1); only 26.76% of our patient suffered obstetric fistulas. Two patients (2.82%) developed UVF because of urethral foreign bodies. Transvaginal fistula repair was carried out in all cases. Martius flaps were used in nine patients Preoperative evaluation and timing of surgery The diagnosis of UVF is not usually difficult and often these fistulas can be identified with vaginal speculum examination alone. The presence of concomitant pelvic organ prolapse should also be evaluated in both the supine and the standing positions. Atrophic vaginitis should be treated with topical estrogens prior to surgical repair. The possibility of stress or urgency incontinence should also be considered, and directed testing should be done to exclude these diagnoses. Large fistulas can be palpated manually. The identification of smaller fistulas can be facilitated by distention of the bladder with methylene blue-dyed saline. It is necessary remember that UVFs may be associated with vesicovaginal fistula. Cystourethroscopy helps to identify the location and size of the fistula tract and affords evaluation of the bladder, which is important to exclude involvement of the bladder neck and trigone. Even in the presence of a normal trigone, we recommend renal ultrasonography and intravenous pyelography screening examinations to exclude occult upper tract abnormality. A standard urinalysis is an essential part of preoperative evaluation (Table 2). We do not recommend cystometry as a routine preoperative evaluation but it may become helpful in the presence of urinary urgency [6]. It should be emphasised that the optimum timing of surgery remains a point of discussion among the leading experts. We usually use a delayed repair that is >2 mo after the initial trauma (or fistula recurrence when the initial repair has failed). The best results can be obtained when the urethral defect is detected immediately during the traumatising procedure. Table 2 Preoperative evaluation Physical examination Urethrocystoscopy Intravenous pyelography Ultrasonography Urinalysis Currently, physical examination during the patient s presentation in our clinic guides our choice of the timing of the fistula repair. Local tissue quality and absence of inflammation are the main factors that should be used during decision-making Surgical technique: tips and tricks The patient is placed in the dorsal lithotomy position and examined with a vaginal speculum; the Trendelenburg position can improve visualisation of the UVF. Careful vaginal examination at this time is essential to eliminate the risk of missing any additional small fistulas that were not found during routine vaginal examination without anaesthesia. During vaginal examination, careful assessment of the quality of the surrounding tissues is essential to help plan the surgical approach to ensure that sufficiently healthy tissues are used in the repair. In the case of a large fistula or if there has been significant compromise of, or injury to, adjacent areas, additional tissue flaps may be necessary to achieve a proper repair. Placing a metallic urethral sound or bougie during the initial evaluation aids identification of small fistulas. Usually UVFs do not involve the ureteric orifices. A 16F or 18F Foley catheter is placed into the bladder. A circumferential incision is made around the fistula to separate and mobilise the urethral and vaginal walls (Fig. 2A). Care must be taken to preserve the urethral wall during this mobilisation. Extensive excision of perifistular tissues in these patients should be avoided because this may lead to a lack of urethral wall or postoperative urethral stenosis or both. After the urethral wall is mobilised, sutures are placed transversely, if possible, to minimise urethral narrowing. For midurethral fistulas further SUI should be considered as a potential future complication. To minimise scar formation postoperatively and facilitate subsequent sling placement if necessary, a full-thickness flap may be created from the proximal urethra or even the bladder and brought in to avoid any tissue tension. During suture placement, the urethral mucosa should be avoided. Recently, we have used noninterrupted sutures with fine monofilament absorbable material. Once the first line of sutures is completed, evaluation of the urethra with a metallic urethral sound in place allows the surgeon to see small defects in the suture line, which must also be closed. A second suture line with the same suture material must then be placed using periurerhral and perivaginal tissues to provide watertight closure. It should be emphasised that one suture layer is not enough to secure the urethral wall properly and two layers are required to avoid fistula recurrence. The second layer could be either continuous or interrupted sutures but must cover the first layer as completely as possible. Before final vaginal mucosa closure, careful examination of the suture line with a fine urethral sound should be attempted to detect unsutured places (Fig. 2B and C). Interpositional tissue should be considered whenever the closure lines or vaginal tissues are of questionable quality. When tissues are insufficient, a Martius flap should be considered to secure the closure, which necessitates careful mobilisation of vaginal mucosa. In contrast with vesicovaginal fistulas, where mobilisation is extended to the perivesical tissue, patients with UVFs often present with minimal space between urerthral wall and the vagina. This

4 european urology 50 (2006) Fig. 2 The steps of urethrovesical fistula surgery: mobilisation of vaginal and urethral walls with simultaneous formation of the vaginal flap (A); suturing of the urethral wall in transverse fashion (B); and vaginal wall closure (C). minimal space often does not allow placing any additional tissue between the urethral and vaginal walls. Therefore, further mobilisation must be undertaken to facilitate flap placement. The final step of the procedure is vaginal wall closure. Any absorbable 3-0 synthetic suture is suitable. A Foley catheter stays in place for 6 9 d. All patients receive broad-spectrum antibiotics for 1 wk. Patients may be discharged from the hospital on the second day postoperatively and sexual intercourse must be avoided for 4 wk. Because every fistula is unique and requires an individualised approach, it is difficult to describe a standard fistula repair, but some useful tips and general principles can be kept in mind. Careful preoperative examination with a metallic urethral sound helps the surgeon identify and characterise the pathology to create an effective surgical plan; intraoperative use of urethral sounds helps to identify small defects in the suture line during the procedure and enables the

5 1004 european urology 50 (2006) surgeon to close these defects to achieve a watertight closure. Only fine monofilament synthetic absorbable material should be used to provide fistula closure. Avoidance of deep suturing of the urethral wall and suture lines, which are oriented longitudinally to the axis of the urethra, helps to minimise urethral stenosis postoperatively. Bring additional tissues with great care after sufficient vaginal wall mobilisation. Obtain informed consent from the patients about fistula recurrence, SUI, or obstructive voiding complications. 3. Results Successful closure of the fistula was achieved in 64 of the 71 patients (90.14%) after primary surgical treatment. Seven patients underwent a secondary UVF repair that was successful in six; thus the total success rate rose to 98.59%. The single patient (1.41%) in whom treatment was unsuccessful had paraurethral bulking agent injection as the cause of her fistula. The short-term results were obtained within 3 mo after the surgery. In the postoperative period, 52.11% of the patients (37 of 71) developed SUI. These patients were treated with fascial slings (4 patients), autologous skin slings (13 patients), retropubic (17 patients), or obturator tension-free synthetic slings (3 patients) procedures. Twenty-two (59.46%) were objectively cured, 12 of the women (32.43%) expressed they were satisfied, and 3 patients remained incontinent (8.11%). Another complication of the UVF repair was obstructive voiding due to urethral stenosis. It has been detected in four (5.63%) patients. Urethra dilation (2 patients) and urethrotomy (2 patients) have been used for management of obstruction (Table 3). The long-term results of 21 patients with mean time of 99.6 mo (range: mo) show no fistula recurrence. Table 3 Complication rate following urethrovaginal fistula surgical management Surgical complications (n = 71) Patients (n) Patients (%) Stress urinary incontinence % Fistula recurrence after first operation % Fistula recurrence after secondary repair % Urethral stenosis % 4. Discussion Only a limited number of papers on UVF repair are available. The vaginal approach is used in almost all cases [7]. Several authors advise using Martius or rectus abdominal flaps [8,9]. We consider that the usage of flaps has a limited role in most UVF cases. Development of tissue engineering leads to application of the achievements of science in current practice [10]. In our opinion the allograft or autograft cell insertion may be possible in the future for small and narrow fistulas, whereas bigger ones might be managed surgically. The role of buccal mucosa autografts is limited to urethral reconstruction and the possibility of using that in UVF management is not evident yet [11]. Just a few series in the literature report the result of UVF repair. Blaivas [12] reviewed the results in 24 women with bladder-neck and urethral defects with a 79% success rate after primary surgery. Goodwin and Scardino [13] claimed a 70% success rate following one operation in 24 patients and 92% following second operation. Lee [14] similarly reported a 92% correction rate of UVF in 50 patients after one surgery and 100% success after secondary surgery. Keetel [7] presented 24 patients with UVF and reported an overall success rate 87.5%. In our series the success rate of fistula repair was 90.14% after one operation and 98.59% after recurrent fistula repair. These results are in accordance with the results of other investigators mentioned above. Our data show that 52.11% of patients with UVF develop SUI symptoms after successful fistula closure. Some of these patients can be identified preoperatively. Patients with large fistulas or fistulas in the bladder-neck area are at higher risk for the subsequent development of SUI. Patients should be evaluated 2 3 mo after the fistula closure with specific emphasis on secondary lower urinary tract symptoms. Although urethral stenosis may occur and usually requires urethral dilation, overactive bladder symptoms are rare. Despite limited experience, our current preferred standard anti-incontinence procedure is an obturator tension-free vaginal tape. Care must be taken during the synthetic tape placement to avoid urethral trauma. It should be noticed that before the tension-free tape era we used autologous skin or fascial slings to restore continence in these patients and this required extensive periurethral mobilisation, including the bladder neck, which in some patients resulted in additional urethral trauma. All patients with SUI symptoms after UVF have type 3 SUI due to a lack of urethral elasticity and mobility.

6 european urology 50 (2006) We feel that synthetic sling placement, which can be done with minimal periurethral mobilisation, opens new horizons for proper continence restoration in this group of patients. The possibility of urethral erosion after synthetic sling placement in patients with prior UVF repair is certainly worth considering; however, our experience has not shown any such complications. An obturator approach using an inside-out technique is preferable because it involves less tissue mobilisation than other sling procedures. 5. Conclusions In recent centuries obstetric trauma has remained the main cause of UVF. Currently, because of advances in obstetric care, urologists in the developed world encounter UVFs only rarely and many of the fistulas seen are secondary to vaginal surgery (e.g., incontinence sling procedures). Surgical treatment of UVFs is not identical to vesicovaginal defect surgery and has some important differences that should be considered. Complications include bladder outlet obstructions that are managed by urethral dilation or urethrotomy. Another major complication is urinary incontinence. Tension-free vaginal tape is a treatment option. This article has an attached DVD film that shows a unique case of one patient with a UVF who had a recurrent fistula after primary surgery and developed incontinence after secondary fistula repair. All stages of the treatment are presented in one film. We believe that the presentation of this case will help the urologist better understand the main aspects of surgical treatment of UVFs. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi: / j.eururo and via com. Subscribers will find the supplementary data attached (DVD). References [1] Zacharin R. Obstetric fistula. Vienna: Springer-Verlag; [2] Hilton P. Fistulae. In: Shaw R, Souter W, Stanton S, editors. Gynecology. ed 2. London: Livingstone; p [3] Lee R, Symmonds R, Williams T. Current status of genitourinary fistula. Obstet Gynecol 1988;71: [4] Zimmern PE, Handley HR, Leach GE, et al. Transvaginal closure of the bladder neck and placement of suprapubic catheter for destroid urethra after long-term indwelling catheter. J Urol 1985;134:554. [5] Cardoso L, Staskin D. Textbook of female urology and urogynecology. London: ISIS Medical Media; p [6] Hilton P. Urodynamic findings in patients with urogenital fistulae. Br J Urol 1998;81: [7] Keettel WC, Sehring FG, deprosse CA, Scott JR. Surgical management of urethrovaginal and vesicovaginal fistulas. Am J Obstet Gynecol 1978;131: [8] Imdad Ali N, Kaul SA, Pathak HR, Rangnekar NP. Role of the martius procedure in the management of urinaryvaginal fistulas. J Am Coll Surg 2000;191: [9] Bruce RG, El-Galley RE, Galloway NT. Use of rectus abdominis muscle flap for the treatment of complex and refractory urethrovaginal fistulas. J Urol 2000;163: [10] Atala A. Tissue engineering, stem cells, and cloning for the regeneration of urologic organs. Clin Plast Surg 2003; 30: [11] Berglund RK, Vasavada S, Angermeier K, Rackley R. Buccal mucosa graft urethroplasty for recurrent stricture of female urethra. Urology 2006;67: [12] Blaivas JG. Treatment of female incontinence secondary to urethral damage or loss. Urol Clin North Am 1991; 18: [13] Goodwin WE, Scardino PT. Vesicovaginal and urethrovaginal fistulas: a summary of 25 years of experience. Trans Am Assoc GU Surg 1979;71: [14] Lee RA. Current status of genitourinary fistula. Obstet Gynecol 1988;72:313 9.