An update on surgery for vesicovaginal and urethrovaginal

fistulae
Dirk De Ridder
Department of Urology, University Hospitals KU Purpose of review
Leuven, Leuven, Belgium
This review offers a comprehensive summary of the recent publications on the treatment
Correspondence to Dirk De Ridder, MD, PhD, FEBU, of vesicovaginal fistula. Most reports are related to obstetric fistula in the developing
Department of Urology, University Hospitals KU
Leuven, Herestraat 49, 3000 Leuven, Belgium world but in the developed world fistula treatment remains a challenge.
Tel: +32 16 346930; Recent findings
e-mail: [Link]@[Link]
The quality of the research in this field is improving. Efforts are being made to improve the
Current Opinion in Urology 2011, 21:297–300 classification of fistula as a prognostic tool. Surgical innovations are few in this field.
Laparoscopic approaches are reported but only on a very limited amount of patients.
Summary
The surgical management of fistula remains a two-track item: the gigantic experience
on obstetric fistula of fistula surgeons in Africa and Asia and the limited experience of
some Western centres with mostly a small series of iatrogenic fistula. Advances are
made in both worlds. The previously isolated fistula surgeons are now better organized
and they stimulate scientific research in countries with very limited resources. The
centres in the developed world explore new surgical approaches such as laparoscopy
and minimally invasive treatments.

Keywords
obstetric fistula, urethrovaginal fistula, vesicovaginal fistula

Curr Opin Urol 21:297–300

ß 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
0963-0643

review of this topic, other publications such as the review

Introduction by the International Consultation on Urological Diseases
Vesicovaginal fistula is uncommon in the developed are recommended [2].
world but is still a major problem in the developing world
[1].
Prevalence
In the developing world fistula is usually iatrogenic as a Duong et al. [3] studied the risk factors for developing
consequence of gynaecological surgery or radiotherapy. a vesicovaginal fistula after hysterectomy for benign
conditions. They found that American Association for
The research in this field is characterized by a lack of Surgery of Trauma (AAST) grade V cystotomies
good quality studies. Most data come from cohort studies during surgery are predictive for the development of
and usually present only short-term outcome of these a fistula as well as tobacco use, large volume uterus
patients. Organizing research in rural African or Asian and important blood loss. Grade V cystotomies are
environments with poor transport possibilities remains an defined as intraperitoneal or extraperitoneal bladder
important challenge for the fistula surgeons. wall lacerations extending into the bladder neck or
ureteral orifice (trigone). Also fistula secondary to mesh
These fistula surgeons have now created a new multi- implants for pelvic organ prolapse has been reported
disciplinary society International Society of Obstetric [4,5].
Fistula Surgeons (ISOFS, [Link]) that will help
in improving the quality of the research and that will Radiotherapy and chemotherapy for gynaecological
improve the exchange of knowledge and science cancer can also be complicated by vesicovaginal fistula.
between specialists. In a series of 24 women with cervical cancer, treated by
external radiotherapy, brachytherapy and chemotherapy,
one patient developed a fistula [6]. In another study
Text of review on 23 patients with stage IVA cervical cancer treated
This review is limited to the most relevant papers that with radiotherapy with or without chemotherapy and
were published from 2009 till now. For a more extensive hyperthermia, five developed one or more fistulae
0963-0643 ß 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/MOU.0b013e3283476ec8

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 298 Female urology

(22%) [7]. No significant association was found between

Key points
prognostic variables and fistula formation.
 The surgical treatment of vesicovaginal fistula still
A new study on the prevalence of obstetric fistula in largely depends on the experience of the surgeon.
Malawi showed a lifetime prevalence of 1.6/1000 [8].  There are no good data comparing different surgical
Most women live 3 years with a fistula before they can approaches.
be operated on. The mean age was 29 years, what was  Postfistula repair incontinence can be partially pre-
vented by adequate surgical treatment.
significantly higher than usually accepted. This probably
reflects the regional differences in the usual age at which
women get married. Moreover only 31.1% developed the four main categories, with three subcategories, depend-
fistula during their first delivery, whereas other publi- ing on the fistula size. The amount of scarring is also
cations usually report a fistula to occur in primipara. The noted [11]. This classification has been used retrospec-
prevalence correlates also with the occupation of the tively to analyse failures after fistula repair. There are also
women and the tribal origin, but not with the level of data on intraobserver and interobserver variability. The
education or religion. intraobserver variability was studied in 119 women. The
three parameters (fistula type, size and scarring) all had
the Spearman’s coefficients between 0.82 and 0.87. The
Assessment interobserver variability was studied in 50 women, who
The problem of the classification of fistula still persists. were examined by two clinicians. Also in this study the
There is no generally accepted classification [9]. Cur- Spearman’s coefficients were high (0.84–0.86) with a
rently two classifications are widely used: the Waaldijk Kappa of 0.74 (all P < 0.01) [12]. More research will be
Classification and the Goh Classification. needed to compare both classifications and to come to a
generally accepted classification system.
The Waaldijk [10] classification system has been used for
25 years, and large cohorts of patients have been studied.
The classification system seems to correlate with out- Prognostic factors
come. Despite the large dataset there are no studies The predictive value of any classification system by itself
available on intraobserver and interobserver variability. is limited. Most authors agree that the functional and
anatomical result will be less optimal with increasing size
The fistula is measured in centimetres. The external of the fistula, increasing amounts of scarring and the
urethral meatus is used as a reference point. The Waaldijk urethral involvement [13]. The experience and skill of
system uses three distinct categories: the fistula surgeon and the quality of the postoperative
care are both important for the outcome of the patient but
(1) Type I fistula, not involving the urethra or bladder this is difficult to measure.
neck.
(2) Type II fistula, involving the urethra. Type II is Goh et al. [11] used their classification to analyse retro-
subdivided into spectively the occurrence of stress incontinence after a
(a) IIA: preservation of the distal urethra (distal 1 cm, successful fistula repair. Women with fistula closest to the
measured from the external urethral meatus). urethral meatus had the highest risk for stress inconti-
(b) IIB: the is loss of the distal urethra (the distance nence. Also women with significant vaginal scarring and
between the external urethral meatus and the circumferential fistulae had a higher risk for incontinence
distal fistula edge is <1 cm). and for failure of the closure. These factors however did
(c) Both type II fistula classes are further subclassi- not correlate with the fistula closure rate but only with the
fied in postclosure stress incontinence.
(i) not circumferential.
(ii) denoting the circumferential nature of the Lewis et al. [14] reviewed 505 cases in Sierra Leone. They
defect. used univariate and multivariate analysis to correlate
(3) Type III fistula, which describes less common fistula classification and outcome. Univariate significant vari-
such as vesicointestinal or vesicocutaneous fistula. ables were the age at which the fistula occurred, the
(4) The size of the fistula, anal function, and anal sphinc- index pregnancy, the location and surface area of the
ter anatomy are classified as well. Scarring of the fistula, the urethral status and the amount of fibrosis. In
vagina is not taken into account. multivariate analysis, only the amount of fibrosis turned
out to be significant in predicting outcome.
The classification of Goh takes the external urethral
meatus as a reference point from which the most distal Nardos et al. [15] performed a retrospective analysis of
edge of the fistula is measured in centimetres. There are 1045 patients of the Addis Ababa Hamlin fistula hospital.

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 Vesicovaginal and urethrovaginal fistulae De Ridder 299

They found that a small bladder capacity, urethral position was used in 15 women in Alexandria with 100%
destruction, circumferential involvement and severe success [25]. Also an immediate laparoscopic closure of
vaginal scarring to be negative predictive factors. fistula that was formed during hysterectomy proved to be
successful [26]. A transvesicoscopic technique was used
On the contrary, Raassen et al. [16] were unable to find by Nerli and Reddy [27] in four women, whereas Rizvi
predictive factors after multivariate analysis in a prospec- et al. [28] published their experience with a laparoscopic
tive study on 581 East-African women. Only those women Mini-O’Connor technique in eight women.
who were operated on within 3 months of the occurrence of
the fistula had a better outcome (anatomical and social). For fistula that cannot be repaired or that have failed
previous attempts, a urinary diversion might be indicated.
Waaldijk [17] prospectively followed 845 women after a By lack of resources in the developing world to supply
fistula type II Aa repair and concluded that scarring and adequate urostomy material, ureterosigmoidostomy is
previous operations did not significantly influence the still being used as a first solution. Alemu [29] published
continence rate. The author also evaluated 1716 consecu- their experience in 13 patients who were treated with a
tive women, showing that the postoperative incontinence Mainz II pouch between 2004 and 2008. All but one of
rate correlates with the urethral involvement. the patients were continent and the upper urinary tract
was preserved in most of them. Long-term follow-up will
of course be needed to assess the risk of malignant
Surgery deterioration of the anastomotic site.
The surgical approach to fistula is dependent of the
fistula size, localisation etc. but also on the expertise of
the surgeon and the facilities in which the patient will be Conclusion
operated [18]. The treatment of vesicovaginal fistula still has to be
looked at in two different views: the one from the fistula
In the developing world a vaginal approach is to be surgeon in the developing world with very limited
preferred. In the developed world a variety of approaches resources and the other from the more advanced surgeons
has been described: vaginal, abdominal, laparoscopic, in the developed world who have better access to tech-
robot assisted. nology and resources.

For an extensive review on the vaginal approaches, we Advances are being made in both worlds but important
refer to the ICI book chapter dealing with obstetric fistula questions remain. A cross-sectional study among 40 fis-
[2]. Currently there is a high variability in vaginal fistula tula surgeons allowed Arrowsmith et al. [19] to formu-
care [19]. late the most important research questions. The optimal
length of catheterization after fistula repair, the efficacy of
Antibiotic prophylaxis has been studied in a randomized surgical and nonsurgical repair for postrepair urinary
way by Muleta et al. [20]. The author proved that a incontinence, the predictive factors for incurable fistula
single shot of gentamycin at induction of the anesthesia and so on. are all topics that need further study.
was as effective as an extended use of amoxicilline,
chloramphenicol or cotrimoxazole. This study can have
a major impact on the cost of fistula surgery in developing
countries.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
 of special interest
Minimally invasive techniques have been described  of outstanding interest
recently for small fistulae. The use of a pointed electrode Additional references related to this topic can also be found in the Current
to fulgurate a small fistula tract has been revisited by World Literature section in this issue (p. 346).

Hong et al. [21] and Shah [22]. Other authors have 1 De Ridder D. Vesicovaginal fistula: a major healthcare problem. Curr Opin
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[23]. Fibrin glue can also be used to reinforce the vaginal 2 De Ridder D, Badlani GH, Browing A, et al. Fistula in the developing world. In:
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