Genitourinary fistula

Urogenital fistulas lead to multiple organ dysfunctions, long-term and persistent loss of ability to work, and cause severe mental and physical suffering in patients.

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Causes urogenital fistulas

Based on etiological factors, three groups of urogenital fistulas are distinguished:

• traumatic, resulting from obstetric and gynecological operations, spontaneous birth, violent trauma;
• inflammatory, arising as a result of spontaneous perforation of a pelvic abscess into a hollow organ;
• oncological, arising as a result of tumor breakdown or under the influence of radiation therapy.

In Europe, urogenital fistulas are most often caused by complications of gynecological surgeries. "African" urogenital fistulas, which occur as a result of various obstetric injuries, are a serious social problem not only in developing countries, but throughout the world.

Obstetric urogenital fistulas are usually associated with unskilled labor management. They are caused by protracted labor, a narrow pelvis, and weak labor activity. In such cases, the bladder is pinched for a long time between the pelvic bones and the fetus's head, which leads to a disruption of the trophism of the urinary and genital tracts. Urogenital fistulas often occur after a cesarean section.

In the context of a sharp decline in the incidence of obstetric fistulas, the number of patients with fistulas after gynecologic surgery has recently increased. Lee et al. (1988) reported on 303 women with urogenital fistulas who were operated on at the Mayo Clinic over a fifteen-year period. Gynecologic surgery was the cause of fistula formation in 82% of cases, obstetric interventions in 8%, radiation therapy in 6%, and trauma in 4%.

The increase in the frequency of detection of gynecological fistulas is associated with the growth of surgical activity, expansion of indications for surgical treatment of cancer patients, late diagnosis of damage to the genitourinary tract and not always adequate care. In the United States, genitourinary fistulas account for about 0.3% of complications of all gynecological procedures (70-80% of all detected genitourinary fistulas). In 20-30% of cases, genitourinary fistulas occur as a result of urological, colorectal and vascular procedures.

In gynecological practice, urogenital fistulas are formed mainly after hysterectomy for cervical cancer. In the USA and other developed countries, urogenital fistulas are more common after abdominal hysterectomy. According to Lee et al. (1988), 65% of 303 patients had urogenital fistulas as a result of hysterectomy for benign tumors. P. Harkki-Siren et al. (1998), having analyzed the national database of Finland, reported that vesicovaginal urogenital fistulas complicate hysterectomy in 0.08%. According to S. Mulvey et al., the risk of developing vesicovaginal fistulas is 0.16% after abdominal hysterectomy, 0.17% after vaginal hysterectomy, and 1.2% after radical hysterectomy.

Uretero-vaginal urogenital fistulas are almost always considered traumatic, and the ureter injury usually occurs during surgery. According to V.I. Krasnopolsky and S.N. Buyanova (2001), they account for 2-5.7% of all urogenital fistulas. Uretero-vaginal urogenital fistulas most often occur as a result of abdominal hysterectomy with removal of the appendages. The pelvic section of the ureters is usually damaged in the area of the infundibulopelvic ligament during ligation of the ovarian vessels. Another common site of ureteral injury is the cardinal ligaments, where the ureter passes under the uterine vessels. It can also be injured at the intersection of the apex of the vagina, at the base of the bladder.

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

Less often, they are caused by trauma, difficult spontaneous childbirth, cesarean section and radiation therapy. In prognostic terms, urethrovaginal urogenital fistulas are more severe, since the pathological process often involves not only the urethra, but also the sphincter apparatus, which ensures voluntary urination.

Widespread introduction of laparoscopic operations in gynecology is associated with a high risk of damage to the ureters and bladder as a result of coagulation or clipping of vessels. Formation of vesicovaginal or ureterovaginal fistulas with a torpid course and delayed clinical manifestations (often after discharge from the hospital) can be explained by the expansion of the volume of endoscopic interventions. According to P. Harkki-Siren et al. (1998), laparoscopic hysterectomies are complicated by vesicovaginal fistulas in 0.22% of cases. According to Deprest et al. (1995), damage to the ureters occurred in 19 (0.42%) of 4502 laparoscopic hysterectomies.

In the development of genital fistulas of inflammatory genesis, the main etiological factor is considered to be purulent inflammation, and not secondary inflammatory changes in the fistula tract.

The most severe form of urogenital fistulas are the so-called oncological urogenital fistulas, which occur with cervical cancer as a result of tumor growth into the vesicovaginal septum. The average life expectancy of such patients is 5 months. Thanks to preventive examinations, this form of urogenital fistulas is becoming rarer every year.

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Forms

The following anatomical classification of urogenital fistulas is most commonly used:

• vesicovaginal urogenital fistulas;
• urethrovaginal urogenital fistulas;
• vesicouterine urogenital fistulas;
• vesicocervical urogenital fistulas;
• ureterovaginal urogenital fistulas;
• ureteral-uterine urogenital fistulas;
• combined (vesicoureterovaginal, vesicoureteral-uterine, vesico-vaginal-rectal).

The most common are vesicovaginal urogenital fistulas, accounting for 54-79% of all urogenital fistulas.

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Diagnostics urogenital fistulas

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

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

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Treatment urogenital fistulas

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

Urogenital fistulas are treated mainly by surgical methods. Plastic surgery aims to normalize the function of the urinary organs and restore voluntary urination in a natural way. Only patients with a recurrence of a malignant tumor are not subject to surgical correction. According to WG Davila et al. (2006), before attempting to close a fistula, it is necessary to exclude a recurrence of the tumor by performing a biopsy of the affected tissue.

Unfortunately, it is rarely possible to prepare patients suffering from vesicovaginal fistulas for fistuloplasty in less than 8 weeks, which is associated with a severe inflammatory process in the vaginal stump and in the fistula area, which are caused not only by trophic disorders in the tissues of the vesicovaginal septum caused by errors in surgical technique, but also by the use of outdated suture materials - silk, lavsan, etc. The mother's suture causes a perifocal reaction that increases the inflammatory process in the vaginal stump or in the fistula area. According to CR Chappie (2003), fistulas should be operated on 2 weeks after their development or after 3 months.

The complexity of the operation increases during this period, and the probability of success decreases. Currently, the optimal time for fistuloplasty of puervo-vaginal fistulas is considered to be 3-4 months from the moment of their formation. The development of antibacterial therapy, improvement of suture material and surgical technique encourages many surgeons to try to close fistulas earlier, which allows avoiding long-term discomfort for 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 were developed over a hundred years ago and described by Sims and Trendelenburg. It is based on excision of the cicatricial edges of the fistula, wide mobilization of the tissues of the vagina and bladder. Then they are separately sutured with mandatory displacement of the suture line relative to each other and long-term drainage of the bladder to prevent suture failure.

Planned surgical intervention is possible only after long preoperative preparation (local anti-inflammatory treatment, if necessary - antibacterial therapy ). It includes the removal of necrotic tissue, fibrinous ligatures, secondary and ligature stones; washing the vagina with antiseptic solutions and insertion of tampons with various antiseptic and anti-inflammatory agents; use of proteolytic enzymes to accelerate tissue cleansing, installation of antiseptic solutions and stimulators of regenerative processes in the bladder; treatment of the skin of the perineum and thighs with disinfectant soap followed by lubrication with indifferent creams to eliminate dermatitis.

If necessary, hormonal creams are used. When the fistula is located directly near the mouths of the ureters, their catheterization is performed before the surgical intervention. It is necessary to carry out sanitation, but, unfortunately, it is never complete, which is due to the existence of a fistula that maintains urine infection. The need for careful preoperative preparation is due to the fact that plastic surgery in conditions of an ongoing inflammatory process is fraught with the development of postoperative complications and relapses.

Fistuloplasty is performed using various surgical approaches. CR Chappie (2003) believes that the choice of approach depends on the surgeon's skills and preferences, but the size and location of the fistula play a major role. In operations on vesicovaginal fistulas, transvaginal approach is the most physiological, but other approaches (transvesical, transabdominal, laparoscopic) are also legitimate, each with its own indications and contraindications. Thus, plastic surgery of vesicovaginal fistulas using transvesical approach is absolutely indicated for:

• fistulas located near the mouths of the ureters, preliminary catheterization of which is impossible;
• involvement of the ureteral orifices in the cicatricial process or their displacement into the lumen of the fistula;
• combined ureterovesicovaginal fistulas;
• combination of vesicovaginal fistula with obstruction of the pelvic ureters;
• radial stenosis of the vagina.

Recently, laparoscopic access for vesicovaginal fistulas has been gaining more and more supporters.

To close vesicovaginal fistulas, many authors use the Latsko method. The essence of the operation is to suture the bladder defect after wide mobilization of the latter and vaginal tissues around the fistula opening and excision of the fistula edges. Then, unlike Sims' fistuloplasty, the anterior and posterior walls of the vagina are sutured in the fistula area. The operation allows preserving 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 eliminating simple vesicovaginal fistulas that arise after hysterectomy, when the fistula is located near the vaginal dome.

The success of any operation, especially plastic surgery, depends not only on careful preoperative preparation, but also on proper 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 removing the urethral catheter, some authors recommend performing a cystogram. Antibacterial drugs are prescribed taking into account the sensitivity of the microbial flora of the urine.

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

According to various authors, transvaginal fistuloplasty is successful in 77-99% of cases, and transabdominal access - in 68-100% of cases. CR Chappie (2003) believes that if the basic principles of surgical treatment of simple vesicovaginal fistulas are followed, it is successful in 100%. There is experience in surgical treatment of 802 patients with vesicovaginal fistulas. After the first operation for vesicovaginal fistulas, positive results were achieved in 773 (96.4%) patients, after the second - in another 29 (99.5%) women.

In ureterovaginal fistulas, the choice of reconstructive surgery depends on the location of the ureteral injury and its proximity to the bladder. Considering that in most cases, 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 ureterovaginal fistulas reaches 93%.

Surgical correction of urethro-vaginal fistulas is a difficult task. This is due to the small size of the organ, due to which, after excision of cicatricial tissues, a large defect is formed, the suturing of which causes tissue tension and possible development of urethral stricture. Its defect is closed with the patient's own tissues, a flap from the bladder. In addition, a Martius flap, vaginal mucosa, and a buccal flap are used. In 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.