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Urologic Fistula

Management of a malignant urinary fistula by ureteral embolization with coils.
Amsellem-Ouazana D, Cornud F, Conquy S, Beuzeboc P, Massault PP, Vieillefond A, Flam T, Zerbib M, Debre B
Urology. 2006 Aug;68(2):427.e1-3.

We report the case of a 42-year-old man with a synovial sarcoma of the prostate, metastatic at presentation, who after aggressive chemotherapy followed by extensive surgery developed a complex pelvic fistula involving the lower ureter, bladder, and enteral structures. The patient was a poor candidate for surgery because of his short life expectancy and poor health status. Conservative management with bilateral nephrostomy tubes did not allow sufficient fistulous output for symptomatic relief. Using the percutaneous access already in place, we performed bilateral ureteral embolization with coils. Complete ureteral occlusion was obtained with a minimally invasive procedure and allowed total symptomatic relief.

Tunneled Tunica Vaginalis Flap is an Effective Technique for Recurrent Urethrocutaneous Fistulas Following Tubularized Incised Plate Urethroplasty.
Routh JC, Wolpert JJ, Reinberg Y
J Urol. 2006 Oct;176(4):1578-81.

PURPOSE: In the last several years the use of the tubularized incised plate hypospadias repair has greatly increased. The most significant complication after this mode of urethroplasty is urethrocutaneous fistula development. Tunneled tunica vaginalis flap is a well described technique for repair of urethrocutaneous fistula. However, to our knowledge its use after tubularized incised plate repair has not yet been described. We present our results with this technique. MATERIALS AND METHODS: We retrospectively reviewed all patients undergoing repair of urethrocutaneous fistula after initial tubularized incised plate repair between January 2001 and December 2005. We analyzed the initial number and location of fistulas, number of previous urethrocutaneous fistula repairs, duration of surgery, and intraoperative and postoperative complications. RESULTS: A total of 16 boys (median age 2.2 years) underwent tunica vaginalis flap repair at our institution for urethrocutaneous fistula following initial failed tubularized incised plate repair. Of these patients 4 had not previously undergone urethrocutaneous fistula repair and 12 had undergone 1 to 4 failed repair attempts. All boys had a subcoronal fistula and 8 had additional fistulas along the penile shaft, 4 each with 3 and 4 fistulas, including 1 penoscrotal fistula. Mean surgical time was 45 minutes, and no intraoperative or postoperative complications occurred. After a mean followup of 18 months (range 4 to 36) no patient had recurrence of urethrocutaneous fistula. CONCLUSIONS: Tunneled tunica vaginalis flap repair is a highly successful technique for the treatment of urethrocutaneous fistula after initial failed tubularized incised plate repair. The technique is technically simple to perform, and we encountered no complications. Tunneled tunica vaginalis flap repair should be considered for treating urethrocutaneous fistula following initial failed tubularized incised plate hypospadias surgery, particularly in a repeat surgical setting.

A comparison of free skin graft, fascia lata, alloderm, bovine pericardium and primary repair in urethrocutaneous fistulas without diversion: an experimental study.
Ayyildiz A, Celebi B, Akgul KT, Nuhoglu B, Caydere M, Germiyanoglu C
Pediatr Surg Int. 2006 Sep 1;.

The purpose of this study is to compare primary repair procedure with those that use bio-concordant materials in the treatment of urethrocutaneous fistula. Twenty-five New Zealand rabbits were randomly placed into five groups (primary repair, free graft, allograft fascia lata, alloderm and bovine pericardium repair groups). A single dose of 20 mg/kg of ceftriaxon was applied intramuscularly as a prophylactic dose. Urethrocutaneous fistula was formed on midpenile level. Later, while primary repair was applied in one group, repair with free grafts and with other bio-concordant materials were performed in other groups. Urinary diversion was not used in any of the rabbits. The macroscopic observation was evaluated with urethrography obtained 21 days after the operation and then the rabbits were sacrificed. A total point was obtained by awarding a point to each good parameter in the histopathological evaluation and all the groups were compared. The urethrographic findings and macroscopic examinations were normal in all groups. In histopathological examinations, ranging from the best to worst results, bovine pericardium group (8 points) had a better total score than primary repair group (7 points), allograft fascia lata group (7 points) and alloderm group (7 points). The free graft group had the worst total point (6 points). Bio-concordant materials can be used in urethrocutaneous fistula repair as an alternative to primary repair or to the grafts obtained from body tissues.


Giant prostatic urethral calculus associated with urethrocutaneous fistula.
Kaplan M, Atakan IH, Kaya E, Aktoz T, Inci O
Int J Urol. 2006 May;13(5):643-4.

Urethral stones in men are rare clinical entity and most of them migrate from the urinary bladder. Urethral stones are rarely formed primarily in the urethra and are usually associated with urethral strictures or diverticula. We report a 41-year-old man with giant prostatic urethral stone (5.9x3.2x2.8 cm) associated with a urethrocutaneous fistula. The etiological factors, pathogenesis, clinical presentation, complications and management of giant urethral calculi are reviewed.


Robotic repair of vesicovaginal fistula: case series of five patients.
Sundaram BM, Kalidasan G, Hemal AK
Urology. 2006 May;67(5):970-3.

OBJECTIVES: To describe a technique of robotic repair of vesicovaginal fistula (VVF) and present our experience with 5 such patients. METHODS: A total of 5 patients were diagnosed with posthysterectomy (n = 4) or postmyomectomy (n = 1) VVF. All patients were first treated conservatively with continuous drainage using a Foley catheter without any success. After 12 weeks, these patients underwent robotic repair of the VVF. The steps of the technique of robotic repair are (a) vaginoscopy, (b) cystoscopy, (c) bilateral ureteral catheterization, (d) placement of ports for robotic repair, (e) peritoneoscopy, (f) lysis of adhesions, (g) incision of the bladder and cystotomy in reverse tennis racquet fashion encircling the fistula, (h) excision and freshening of the fistulous margins after complete separation of the bladder from the vagina, (i) closure of the vaginal opening horizontally and bladder opening vertically with interrupted Vicryl sutures, and, finally, (j) interposition of the omentum between these suture lines. RESULTS: Fistula repair was successful in all cases, with a mean operative time (from cystoscopy to the end of the procedure) of 233 minutes (range 150 to 330) and estimated blood loss of less than 70 mL. The length of hospital stay was a mean of 5 days (range 4 to 7). The Foley catheter was removed on the 10th postoperative day after voiding cystourethrography. At 6 months of follow-up, these patients continued to void normally without any recurrence of VVF. CONCLUSIONS: These data suggest that robot-assisted VVF repair is feasible and results in lower morbidity, a shorter hospital stay, and a quicker recovery. The minimally invasive approach of robot-assisted VVF repair may be a more attractive option for patients with VVF.

Successful management of vesicouterine fistula by luteinizing hormone-releasing hormone analog.
Yokoyama M, Arisawa C, Ando M
Int J Urol. 2006 Apr;13(4):457-9.

Vesicouterine fistula is a rare complication of cesarean section. Although surgical repair was mandatory for the management of the fistula previously, a recent review showed high efficacy of hormonal manipulation by the induction of amenorrhea. Herein, we report a new case of vesicouterine fistula secondary to cesarean section successfully treated by luteinizing hormone-releasing hormone analog for 6 months. Conservative hormonal treatment for vesicouterine fistula caused by cesarean section should be considered before surgical repair.

Prognostic factors of recurrence after vesicovaginal fistula repair.
Ayed M, El Atat R, Hassine LB, Sfaxi M, Chebil M, Zmerli S
Int J Urol. 2006 Apr;13(4):345-9.

PURPOSE: We evaluate the prognostic factors of recurrence in patients after the surgical repair of vesicovaginal fistula. MATERIALS AND METHODS: From 1985 to 2002, 73 women with vesicovaginal fistula underwent late (> 3 months) surgical repair. A multivariate analysis of the data was performed with the EPI-INFO software. All P-values were two-sided, with odds ratio and 95% confidence intervals. RESULTS: A total number of 73 patients underwent 97 procedures with a mean rate of 1.38 procedures/patient. The overall surgical success rate was 86.7%. Multivariate analysis demonstrated that recurrence was statistically significant for multiple fistulas (single vs two or more), fistula size (>10 mm), fistula type (Type I vs Type II), fistula etiology (obstetrical vs non-obstetrical) and the presence of urinary tract infection before the repair. Recurrence risk was fivefold higher for both the size and the type of the fistula, threefold higher for obstetrical etiology and 4.5-fold higher for multiple fistula. The interposition of flaps was a protective factor for recurrent cases. The surgical approach was not a significant prognostic factor of recurrence. CONCLUSION: Successful closure of a vesicovaginal fistula requires an accurate and a timely repair using procedures that exploit basic surgical principles. Multiple fistula, size and type of the fistula, and obstetrical etiology were the recurrence risk factors. We recommend in all patients with multiple risk factors for recurrence, the interposition of flaps.


Concurrent diagnosis of urothelial carcinoma and squamous cell carcinoma of the bladder in a patient with a vesicorectal fistula from invasive rectal cancer.
Kodama K, Mizuno T, Imahori T, Ida M, Matsubara F
Int J Urol. 2006 Mar;13(3):296-8.

Abstract A 47-year-old man underwent a low anterior resection of the rectosigmoid colon with en bloc cystoprostatectomy for vesicorectal fistula due to a locally advanced rectal cancer. Histopathological examination of the bladder revealed two additional primary malignancies: urothelial carcinoma and squamous cell carcinoma. To our knowledge, this is the first reported case of two histologically distinct urothelial malignancies that were diagnosed during a work up of vesicorectal fistula due to adenocarcinoma of the rectum.

Vesicovaginal fistula following a transobturator midurethral sling procedure.
Starkman JS, Meints L, Scarpero HM, Dmochowski RR
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr 21;.

Synthetic mid-urethral slings are currently the most common surgical procedure performed for the treatment of female stress urinary incontinence. The transobturator mid-urethral sling technique was originally described in 2001 and has since become widely accepted due to its high rate of success and low complication rate. Although complications remain infrequent, when they do occur, there is potential for significant patient morbidity. We report a case of a vesicovaginal fistula following a transobturator mid-urethral sling procedure and describe successful reconstruction with transvaginal sling excision, fistula closure, and placement of an autologous pubovaginal sling.

Urethrovaginal fistula-a rare complication after the placement of a suburethral sling (IVS).
Reisenauer C, Wallwiener D, Stenzl A, Solomayer FE, Sievert KD
Int Urogynecol J Pelvic Floor Dysfunct. 2006 May 4;.

A sixty-year-old woman with stress urinary incontinence had undergone a placement of an IVS (Tyco Health Care UK) in another hospital in February 2003. Seventeen months after the procedure, she complained about a suppurative discharge from the vagina and a recurrent severe stress urinary incontinence. The gynecological examination revealed an erosion of the sling into the vagina and a large urethrovaginal fistula bordered by granuloma. After removal of the sling, the urethrovaginal fistula was closed using a vaginal flap. A subsequent conservative treatment regime with duloxetine and pelvic floor training improved the stress urinary incontinence to the patient's satisfaction.


Urethral diverticulum, vesicovaginal, and rectovaginal fistula repairs using a xenograft.
Agarwala N, Cohn A
Obstet Gynecol. 2006 Apr;107(4 Suppl):46S.

Rectourethral fistulae: the perineal approach.
Morey AF
J Urol. 2006 Apr;175(4):1396.

Vesicovaginal fistula: obstetric causes.
Ramphal S, Moodley J
Curr Opin Obstet Gynecol. 2006 Apr;18(2):1 47-51.

PURPOSE OF REVIEW: Obstetric fistula has a devastating impact on the lives of women in poor countries. Currently, there is an international campaign by the World Health Organisation, United Nations Population Fund and other bodies to address this problem. This article reviews recent literature and highlights the paucity of evidence-based data. RECENT FINDINGS: Articles on the pathophysiology, co-morbidities and sequelae including physical injury to 'multiorgan systems' and social consequences associated with obstetric fistula, are discussed. In particular, the devastating social, economic and psychological effects on the health and well-being, reintegration and rehabilitation are addressed. There is a need for prevalence and incidence studies to measure the extent of this problem. The creation of well-equipped fistula centres with multidisciplinary teams to evaluate patients should be the aim. Expert surgeons and optimal databases with personnel to do research will benefit patients. SUMMARY: Prevention should involve alleviation of poverty and improvement in education, maternity services and health. Research on issues such as persistent stress incontinence following fistula closure, management of reduced bladder capacity, best technique for fistula repair, role of vaginoplasty, role of early repair in selective obstetric fistula, future reproductive function, dermatological management, and social and cultural issues must be done to improve women's health.

Rectovaginal fistula after Posterior Intravaginal Slingplasty and polypropylene mesh augmented rectocele repair.
Hilger WS, Cornella JL
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan;17(1):89-92. Epub 2005 Jul 29.

Posterior Intravaginal Slingplasty and mesh augmented rectocele repairs are procedures promoted for correction of vaginal relaxation. There is little data on the complications of these procedures alone or in combination. The first report of rectovaginal fistula after Posterior Intravaginal Slingplasty with graft augmented rectocele repair is presented. A 60-year-old female developed a rectovaginal fistula 3 months after undergoing a Posterior Intravaginal Slingplasty and mesh augmented rectocele repair for prolapse. Two attempts at correcting the fistula failed and there was a recurrence of her vault prolapse. She may now require diverting colostomy and repeat repair of her vault prolapse. The case report highlights the difficulties in treating a rectovaginal fistula that developed after Posterior Intravaginal Slingplasty and mesh augmented rectocele repair for vaginal vault prolapse. More data regarding complications associated with use of these procedures is needed prior to widespread use.