be helpful in fistula identification and localiza-

Ureterovaginal Fistula

tion. Speculum examination can occasionally

identify the fistula tract on the anterior vaginal

Etiology and Presentation

wall. A thorough pelvic exam is essential to rule

Fistulas from the ureter to the uro-genital tract

out additional pathology, including additional

are uncommon, most frequently involving the

fistula sites more proximal in the vagina. An

proximal vagina and rarely the uterus or fallo-

associated VVF is found in 20% of patients.48

Vaginal tissues should be inspected for viability,

pian tubes.63 Risk factors include endometriosis,

obesity, pelvic inflammatory disease, radiation

infection, and atrophy, and treated with antibio-

therapy, and

pelvic malignancy.64 Iatrogenic

tics or

estrogen cream as needed. Cystoure-

injuries during pelvic surgery, specifically gyne-

throscopy is an essential,yet challenging,process

cologic surgery, are the most common etiologies

due to the short length of the female urethra.

of ureterovaginal fistulae, with the incidence

Distal compression at the meatus, and a short

estimated at 0.5–2.5%.64,65 Most commonly, UVF

beak “female” cystoscope or flexible fiberoptic

result from surgeries for benign disease, during

cystoscope can assist in visualization. The blad-

hysterectomy, caesarean section,

or cystocele

der neck and bladder should be examined for an

repair66 rather than oncologic procedures. Risk

additional fistula. If a component of stress or

of injury appears greatest

from

laparoscopic

urgency

incontinence

is suspected,

or if the

hysterectomy, followed by abdominal, then vagi-

patient

has suspected

concomitant

detrusor

nal hysterectomy.67 The ureter is injured in the

dysfunction, videourodynamics can be used to

distal one third or pelvic portion, due to its close

more appropriately characterize the pathology.

proximity to the uterosacral ligaments, uterine

Surgical repair of a urethrovaginal fistula can

artery, and cervix. Direct injury or devascular-

be difficult and requires careful consideration

ization with subsequent necrosis can cause uri-

and planning. There may be extensive soft tissue

nary extravasation, urinoma formation, and

defects and a dearth of viable tissue for a multi-

eventual drainage into the vagina at the level of

layered repair.9 Surgical approach, including the

use of adjacent tissue flaps, is dependent on fis-

the vaginal cuff.

Patients usually present with clear or serous

tula size, location, and tissue viability. Small fis-

continuous vaginal discharge 1–4 weeks follow-

tulas may be managed with a multilayered

ing surgical intervention.66 Occasionally, this is

closure, including interposition grafts such as a

associated with a prodrome of flank or abdomi-

Martius flap.46,49 Large fistulas may require ure-

thral reconstruction and more extensive sur-

nal pain, nausea, and low-grade

fevers as a

result of urinoma formation and/or ureteral

gery.47,50,51 With many urethrovaginal fistulae,

soft tissue flaps can provide an additional layer

obstruction.48 In contrast to VVF, patients will

continue to urinate at normal intervals, as the

of viable tissue, decreasing the historical high

contralateral kidney maintains cyclic bladder

rate of failure with vaginal wall advancement

filling.

flaps.9,49,52-57 Labial fat pad flaps (Martius),graci-

lus and rectus muscle, fibrin glue, myocutane-

ous flaps, and labial skin grafts have been

described to decrease

failure rates.9,46,49,55,57-61

Diagnosis and Management

Distal fistulas can be managed conservatively

with observation or extended meatotomy if

Diagnosis of a ureterovaginal fistula can usually

there is no associated incontinence or voiding

be accomplished with a complete history and

symptoms.62 Timing of the operative interven-

physical examination, followed by radiologic

tion is controversial,similar toVVF.Preoperative

evaluation with studies, including intravenous

stress incontinence may persist following repair

urogram (IVU)/CT urogram (CTU), cystoscopy,

of a proximal or mid-urethral urethrovaginal

retrograde

pyelography,

and

cystography

fistula, and concomitant repair of SUI at the

(Fig. 35.4). It is imperative to discriminate UVF

time of initial repair is controversial.43,46

from VVF and evaluate for concomitant VVF

Concomitant SUI repairs have been reported

during the course of evaluation. A double dye

using Martius flaps interposed between the fis-

test may allow differentiation of UVF and VVF

tula and the autologous pubovaginal sling.43

in cases of

continuous leakage.21 Once the