Editing Functional: Urinary Fistulae (section)

==== Management ====
* '''<span style="color:#ff0000">Options (3):</span>'''
*# '''<span style="color:#ff0000">Indwelling catheter</span>'''
*# '''<span style="color:#ff0000">Fulguration</span>'''
*# '''<span style="color:#ff0000">Fibrin sealant</span>'''
*#'''<span style="color:#ff0000">Surgery</span>'''

===== Indwelling catheter =====
* '''<span style="color:#ff0000">A trial of indwelling catheterization and anticholinergic medication for at least 2-3 weeks may be warranted in selected patients with newly diagnosed VVF,</span>''' because spontaneous healing may result (spontaneous closure rate ≈13%)
** Drainage of the bladder should start immediately to prevent epithelialization of the fistula tract.
** '''<span style="color:#ff0000">Characteristics associated with favorable outcomes</span>'''
*** '''<span style="color:#ff0000">Size <2-3 mm</span>'''
*** Simple injuries to the bladder that do not involve devascularization or thermal injury spread that result in interrupted blood supply to the area
* '''<span style="color:#ff0000">Fistulous tracts that remain open ≥3 weeks after adequate catheter drainage are unlikely to resolve without further intervention</span>'''

===== Fulguration =====
* '''Patients with small epithelialized fistulae, usually <3-5 mm in diameter,''' '''may benefit from a minimally invasive treatment involving disruption of the epithelial layer of the fistula tract.'''
* A small cautery electrode is passed into the fistula tract endoscopically as far as possible. The electrode is slowly withdrawn from the tract with the electrode set on coagulation.
* Catheterization may be combined with minimally invasive electrocoagulation of the fistula tract.
* Fulguration risks failure and the possibility of enlarging the size of the fistula in patients with:
*# Thin vesicovaginal septum
*# Large VVF
*# Non-oblique fistula tract
*# Significant inflammation around the fistula tract.

===== Fibrin sealant =====

*'''Has been used as an adjunctive measure to treat VVF'''

===== Surgery =====
* '''<span style="color:#ff0000">Pre-operative Counselling</span>'''
**'''<span style="color:#ff0000">Sexual activity should be documented</span>'''
*** '''Some vaginal procedures, including the Latzko procedure, may result in vaginal shortening and postoperative dyspareunia'''
** '''Pre-operative estrogen supplementation may be beneficial in the postmenopausal patient with vaginal atrophy; topical estrogen preparations may improve vascularity and local tissue quality'''
* '''Technique'''
** '''<span style="color:#ff0000">Approaches (2):</span>'''
**#'''<span style="color:#ff0000">Transvaginal</span>'''
**#'''<span style="color:#ff0000">Transabdominal (transvesical)</span>'''
**#* '''Success rates are similar between the two approaches'''
**#** The most important factor is the experience of the operating surgeon
**#* '''Advantages of transvaginal approach (3):'''
**#** Shorter operative times
**#** Shorter hospital stay
**#** Less blood loss
**#* '''Disadvantages of transvaginal approach (3):'''
**#** Relative lack of familiarity of the vaginal cuff anatomy to many urologists
**#** Potential for vaginal shortening, especially with the Latzko approach
**#** Difficulty in exposing high or retracted fistulae located near the vaginal cuff, especially in deep, narrow vaginas, or in those without any apical prolapse (though these are not contraindications)
**#* '''Advantages of abdominal approach (2):'''
**#** Other intra-abdominal pathology requiring repair
**#** Complicated fistulae including those associated with multiple prior failed attempts at repair, or those that are large (>5cm)
**#* No difference in risk of ureteral injury in transabdominal vs. transvaginal approach
**'''Excision of the fistula tract itself is not always necessary and may even compromise the repair in some patients'''
** Transvaginal approach to VVF repair uses a 3-4 layer closure
**'''<span style="color:#ff0000">Tissue interposition</span>'''
***'''The interposition of a healthy, well-vascularized tissue flap during VVF repair may be beneficial under certain circumstances, such as (6):'''
***#Recurred after a prior attempt at repair
***#Related to previous radiotherapy
***#Ischemic or obstetric fistulae
***#Large fistulae
***#Associated with a difficult or tenuous closure because of poor tissue quality
*** '''<span style="color:#ff0000">Most commonly used flaps for VVF repaired:</span>'''
**** '''<span style="color:#ff0000">Transvaginal repair: Martius flap or peritoneum</span>'''
**** '''<span style="color:#ff0000">Transabdominal: omentum or peritoneum</span>'''
*** '''Other options for a flap include:'''
**** '''Gracilis muscle'''
**** '''Labial myocutaneous flaps'''
**** '''Seromuscular intestinal flaps'''
**** '''Rectum abdominis flaps'''
***** '''<span style="color:#ff0000">Martius flap</span>'''
****** Labial fat pad consisting of adipose tissue and connective tissue
****** '''<span style="color:#ff0000">Blood supply derives from (3):</span>'''
******# '''<span style="color:#ff0000">Superiorly from the external pudendal artery</span>'''
******# '''<span style="color:#ff0000">Laterally from the obturator artery</span>'''
******# '''<span style="color:#ff0000">Inferiorly from the posterior labial vessels (branch of the internal pudendal artery)</span>'''
****** '''Preferred for low or distal fistulae''' '''involving the trigone, bladder neck, and urethra'''
***** '''Peritoneal flap'''
****** '''Preferred for high-lying post-hysterectomy VVF'''
******* For post-hysterectomy fistulae, the distance from the labial harvesting site of the Martius flap to the fistula at the apex of the vagina may be considerable. Mobilizing and then tunneling the Martius flap to reach this location may compromise its blood supply and viability.
****** May also be used as an adjunctive measure during transabdominal repair of VVF, although the approach and technique are vastly different
***** '''Omental flap'''
****** Blood supply derives from right and left gastroepiploic arteries
******* '''Blood supply enters''' the omentum perpendicular to its origin off the greater curvature of the stomach, '''enabling vertical incisions''' and mobilization into the deep pelvis.
******* '''In many individuals the flap will reach into the deep pelvis without mobilization and without tension'''; however, wide mobilization may be necessary to permit the omentum to reach the deep pelvis in some cases; however, 
******Can be a useful adjunctive measure in the setting of infection or inflammation because of its rich blood supply and lymphatic properties
**Postoperative drainage 
***Can be maintained by single or dual catheters.
**** Most commonly, both urethral and suprapubic drainage catheters are left postoperatively; the disadvantage to single-catheter drainage is principally that the catheter will malfunction, clog, or kink, resulting in bladder filling, eventual overdistention, and disruption of the suture line.
** Timing of repair
***Timing of repair is somewhat controversial
*** Radiation-induced fistula should be repaired after the fistula has matured
* '''Complications'''
** '''Late post-operative (3):'''
**# '''Vaginal shortening'''
**# '''Vaginal stenosis'''
**# '''Recurrence of the fistula'''
* '''Follow-up'''
**'''A postoperative cystogram should include voiding or postvoiding images to ensure that the VVF has been adequately repaired'''
*** There is no standard filling volume for cystography.
*** Generally, 2 to 3 weeks from surgery is an adequate time period for postoperative imaging.
* The success rate reported for a simple VVF repair is >90%.
** Complicated VVFs, including those resulting from obstetric causes, larger fistulae, and those associated with radiation, generally have a lower success rate.
*** Radiation-induced fistulae can be repaired vaginally, and adjuvant flaps are used to bolster the repair
** In patients with obstetric fistulae associated with loss of the bladder neck and proximal urethra, relatively high rates of persistent severe sphincteric incontinence are noted despite successful repair of the VVF
*** Stress urinary incontinence may coexist with VVF; however, it is usually not related to the repair.
* '''In some patients, repair of VVF is not possible or multiple surgical attempts have failed. Urinary diversion can be considered.'''
* '''Fistulae in patients who are not candidates for surgical intervention may be managed by percutaneous ureteral occlusion and permanent nephrostomy.'''