Genitourinary fistula

Genitourinary fistulas lead to multiple organ dysfunctions with prolonged and persistent disability and cause severe moral and physical suffering of patients.

[1], [2], [3]

Causes of the urogenital fistulas

According to etiological factors, three groups of urogenital fistulas are distinguished:

• traumatic, resulting from obstetric and gynecological surgeries, spontaneous childbirth, violent trauma;
• inflammatory, resulting from spontaneous perforation of the abscess of the small pelvis into the hollow organ;
• oncological, resulting from the disintegration of the tumor, or under the influence of radiation therapy.

In Europe, the causes of urogenital fistulas are often complications of gynecological operations. "African" genitourinary fistulas, resulting from various obstetric injuries, pose a serious social problem not only in developing countries, but throughout the world.

Obstetric urogenital fistulas, as a rule, are associated with unskilled birth control. Their formation is facilitated by protracted births, a narrow pelvis, and weakness of labor. In such cases, the bladder is permanently impaired between the pelvic bones and the fetal head, which leads to disruption of the urinary tract and genital tract trophism. Often, urogenital fistulas arise after cesarean section.

Against the background of a sharp decrease in the incidence of obstetric fistulas, the number of patients with fistulae after gynecological operations has recently increased. Lee et al. (1988) reported 303 women with genitourinary fistulas operated in the Mayo Clinic for fifteen years. Gynecological operations caused fistula formation in 82% of cases, obstetric interventions in 8%, radiotherapy in 6% and trauma in 4% of cases.

An increase in the frequency of detection of gynecological fistulas is associated with an increase in operative activity, an increase in indications for surgical treatment of cancer patients, late diagnosis of genitourinary tract injuries, and not always with adequate care. In the US, urogenital fistulas account for about 03% of the complications of all gynecological procedures (70-80% of all detected urogenital fistula). In 20-30% of cases, urogenital fistulas arise due to urological, colorectal and vascular procedures.

In gynecological practice, urogenital fistulas are formed mainly after a hysterectomy for  cervical cancer. In the United States and other developed countries, urogenital fistulas often appear after abdominal hysterectomy. According to Lee et al. (1988), in 65% of the 303 patients, urogenital fistulas were formed as a result of a hysterectomy for benign lesions. P. Harkki-Siren et al. (1998), having analyzed the national database of Finland, reported that. That vesicovaginal urogenital fistulas complicate a hysterectomy in 0,08%. According to S. Mulvey et al., The risk of vesicovaginal fistula formation is 0.16% after abdominal hysterectomy, 0.17% after vaginal hysterectomy and 1.2% after radical hysterectomy.

Ureterine-vaginal urogenital fistulas are almost always considered traumatic, and ureteral trauma usually occurs during surgery. According to V.I. Krasnopolsky and SN. Buyanova (2001), they make up 2-5.7% of all urino-genital fistula. Uretil-vaginal urogenital fistulas often arise as a result of abdominal hysterectomy with removal of the appendages. The pelvic ureteral section is usually damaged in the area of the voroncotazic ligament during ligation of the ovarian vessels. Another common place of damage to the ureters is the cardinal ligament, where the ureter passes under the uterine vessels. It can also be injured at the point of intersection of the tip of the vagina, at the base of the bladder.

Urethrovaginal urogenital fistulas are observed less often vesicovaginal (in the ratio 1: 8.5); they constitute 10-15% of the total number of urogenital fistula. Most often they arise as a result of surgical interventions for diverticula of the urethra, anterior vaginal prolapses (cystocele), sling operations with stress urinary incontinence.

Less often, their causes are injuries, severe independent birth,  cesarean section  and radiation therapy. Prognostically, urethrovaginal urogenital fistulas are heavier, since the pathological process often involves not only the urethra, but also a sphincter apparatus that provides voluntary urination.

The widespread introduction of laparoscopic operations in gynecology is associated with a high risk of damage to the ureters and the bladder as a result of coagulation or clipping of the vessels. Formation of vesicoureteral or ureteral vaginal fistulas with torpid current and delayed clinical manifestations (often after discharge from the hospital) can be explained by an increase in the volume of endoscopic interventions. According to P. Harkki-Siren et al. (1998). Laparoscopic hysterectomy in 0.22% of cases is complicated by vesicovaginal fistulas. According to Deprest et al. (1995), ureteral injury occurred in 19 (0.42%) of 4502 laparoscopic hysterectomy.

In the development of genital fistulas of inflammatory genesis, the main etiologic factor is considered purulent inflammation, and not secondary inflammatory changes in the fistulous course.

The most severe form of urogenital fistula is the so-called oncologic urogenital fistula, arising from cervical cancer as a result of tumor germination into the vesicovaginal septum. The average life expectancy of such patients is 5 months. Thanks to preventive examinations, this form of urogenital fistulas becomes more and more rare every year.

[4], [5]

Forms

Most often use the following anatomical classification of urogenital fistula:

• vesical-vaginal urino-genital fistulas;
• urethrovaginal urogenital fistulas;
• uterine vesical urogenital fistulas;
• vesical cervical urogenital fistulas;
• ureteral-vaginal urogenital fistulas;
• ureter-uterine urino-genital fistula;
• combined (vesicoureteral-vaginal, vesicoureteral-uterine, vesical-vaginal-rectal).

The most common vesicovaginal vestibular fistula, accounting for 54-79% of all urogenital fistula.

[6], [7]

Diagnostics of the urogenital fistulas

Diagnosis of urogenital fistulas, as a rule, does not cause great difficulties.

It is based on complaints of patients, history, examination of the patient,  ultrasound, endourological and radiographic methods (cystoscopy, excretory urography, vaginography, ascending cystography, CT.) There is no doubt that the correct diagnosis of urogenital fistulas is the key to future successful treatment.

[8], [9], [10],

Treatment of the urogenital fistulas

Conservative treatment of urogenital fistulas is ineffective. In some cases, the drainage of the bladder for a long time (from ten days to 6 weeks) leads to the closure of the fistula. More often - with point, timely diagnosed vesicovaginal fistulas.

Genitourinary fistulas are treated mainly by operational methods. The plastic surgery aims to normalize the function of the urinary organs and restore an arbitrary urination naturally. Only patients with a relapse of a malignant tumor are not subject to surgical correction. According to WG Davila et al. (2006), before attempting to close the fistula, it is necessary to exclude tumor recurrence by performing a biopsy of the affected tissue.

Unfortunately, it is seldom possible to prepare patients with vesicovaginal fistulae for fistuloplasty more quickly than for 8 weeks, which is associated with a severe inflammatory process in the vaginal cavity and in the fistula zone, and is not caused not only by trophic disturbances in the tissues of the vesicovaginal septum caused by errors operative technique, but also using obsolete suture materials - silk, lavsan, etc. Suture of the mother causes a perifocal reaction that strengthens the inflammatory process of the vaginal stump or in the fistula zone. According to CR Chappie (2003), fistulas should be operated 2 weeks after their development or after 3 months.

The complexity of the operation increases during this period, and the probability of success decreases. At present, optimal terms for fistuloplasty of puyrrhagal fistula are considered 3-4 months from the time of their formation. The development of antibacterial therapy, the improvement of suture material and surgical techniques prompt many surgeons to try early closure of fistulas, which helps to avoid prolonged discomfort in patients. AM Weber et al. (2004) support early surgical treatment only in uncomplicated cases (in the absence of acute inflammation).

The principles of surgical treatment of vesicovaginal fistulas developed more than a hundred years ago and described by Sims and Trendelenburg. It is based on excision of the cicatricial fissures of the fistula, extensive mobilization of the tissues of the vagina and bladder. Then separate seaming is carried out with mandatory shifting of the seam line relative to each other and prolonged drainage of the bladder to prevent the failure of the joints.

Conducting routine surgery is possible only after a long preoperative preparation (local anti-inflammatory treatment, if necessary -  antibiotic therapy ). It includes removal of necrotic tissues, fibrinous overlays of ligatures, secondary and ligature stones; washing the vagina with antiseptic solutions and the injection of tampons with various antiseptic and anti-inflammatory agents; use of proteolytic enzymes to accelerate the purification of tissues, the installation of solutions of antiseptics and stimulants of regenerative processes in the bladder; treatment of the skin of the perineum and hips with a disinfectant soap followed by lubrication with indifferent creams to eliminate dermatitis.

If necessary, use hormonal creams. When the fistula is located directly near the ureteral anus, before the surgery they perform their catheterization. It is necessary to conduct sanation, but, unfortunately, it is never complete, which is connected with the existence of a fistula supporting the infection of urine. The need for thorough preoperative preparation is due to the fact that plastic surgery in conditions of the ongoing inflammatory process is fraught with the development of postoperative complications and relapses.

Fistuloplasty is performed from various operative approaches. CR Chappie (2003) believes that the choice of access depends on the skills of the surgeon and his preferences, but the size and location of the fistula plays a big role. When surgery for vesicovaginal fistulas, transvaginal access is most physiological, but other accesses (transvesical, tansabdominal, laparoscopic) are also legitimate, to each of which there are indications and contraindications. So. Plastic vesicovaginal fistula with transvesical access is absolutely indicated when:

• fistulas located near the mouth of the ureters, the preliminary catheterization of which is impossible;
• involvement of the ureteral anus in the scar process or their displacement into the lumen of the fistula;
• combined ureteral-vesicovaginal fistulas;
• combination of vesicovaginal fistula with obstruction of pelvic ureteral divisions;
• radial stenosis of the vagina.

Recently, laparoscopic access with vesicovaginal fistulas is gaining more and more supporters.

To close the vesicovaginal fistula, many authors use the Lacko method. The essence of the operation is to suture the defect of the bladder after a broad mobilization of the latter and the vaginal tissues around the fistula and excising the fistula edges. Then, unlike fistuloplasty according to Sims, the front and back walls of the vagina are sewn together in the fistula zone. The operation allows you to save part of the vagina, which is important for maintaining the sexual function of patients. AM Weber et al. (2004) believe that this method is suitable for the elimination of simple vesicovaginal arising after hysterectomy, when the fistula is located near the dome of the vagina.

The success of any operation, especially plastic surgery, depends not only on careful preoperative preparation, but also on correct management of the postoperative period. The bladder is drained with a urethral catheter for a period of seven days to 3 weeks (depending on the complexity of the operation). Before the removal of the urethral catheter, some authors recommend performing a cystogram. Antibacterial drugs are prescribed taking into account the sensitivity of the microbial flora of urine.

To avoid spasms of the bladder in the postoperative period, a number of authors recommend prescribing anticholinergic drugs (oxybutynin, tolterodine). Also recommended the use of ointments containing estrogens, before the operation and within 2 weeks after it. All patients after plastic surgery for a disease such as urogenital fistulas are recommended to abstain from sexual activity for 2-3 months.

According to different authors, with transvaginal fistuloplasty, success can be achieved in 77-99% of cases, with transabdominal access in 68-100% of cases. CR Chappie (2003) believes that if the basic principles of operative treatment of simple vesicovaginal fistulas are observed, it is successful in 100%. There is an experience of operative treatment of 802 patients with vesicovaginal fistulas. After the first surgery for vesicovaginal fistula, 773 (96.4%) patients succeeded in achieving positive results, after another - in 29 (99.5%) women.

With ureteral-vaginal fistulas, the choice of the method of reconstructive surgery depends on the location of ureteral damage and its proximity to the bladder. Considering the fact that in most of the observations as a result of gynecological operations the ureter is damaged near the bladder, it is advisable to perform ureterocystoneostomy. According to the literature. The effectiveness of surgical treatment of ureteral-vaginal fistulas reaches 93%.

Operative correction of urethro-vaginal fistulas is a difficult task. This is due to the small size of the organ, in connection with which after excision of scar tissue changes a large defect is formed, when sewing, there is a tension of the tissues and possibly the development of the stricture of the urethra. Her defect is covered with her own tissues, a flap of the bladder. In addition, use the Martius flap, the vaginal mucosa, buccal flap. In those cases where the fistula is located in the proximal part of the urethra, the doctor's task is not only to close the defect, but also to restore the function of the sphincter.