Functional: Urinary Fistulae: Difference between revisions

===== UrologySchool.Com Summary: =====

===== History and Physical Exam =====

* '''History'''

** '''<span style="color:#ff0000">Most common complaint is constant urinary drainage per vagina</span>'''

*** The amount of urinary leakage can vary considerably from patient to patient and may be proportional to the size of the fistula tract.

** '''Pain is uncommon'''

* '''Physical exam'''

** '''A pelvic examination with a speculum should always be performed'''.

*** '''VVFs after hysterectomy are most commonly located along the anterior vaginal wall at the level of the vaginal cuff'''

** '''<span style="color:#ff0000">Visual and manual assessment of inflammation surrounding the fistula is necessary,</span>''' because it may affect timing of the repair.  

***Significant inflammation, infection, or induration around the fistula may mitigate against immediate repair.

===== Laboratory =====

* '''<span style="color:#ff0000">Urinalysis +/- culture, when indicated</span>'''

*Cytology, when indicated

===== Imaging =====

* '''<span style="color:#ff0000">Lower tract imaging (with cystogram and/or voiding cystourethrogram (VCUG))</span>'''

** '''A cystogram that fails to demonstrate a suspected VVF but lacks voiding images or postvoid images should be considered non-diagnostic.'''

* '''<span style="color:#ff0000">Upper tract imaging (with CT urography)</span>'''

**'''Up to 12% of postsurgical VVFs have an associated ureteral injury or ureterovaginal fistula'''

===== Other =====

* '''<span style="color:#ff0000">Cystoscopy</span>'''

** '''<span style="color:#ff0000">Should be performed in patients for whom a suspicion of VVF is present</span>'''

===== History and Physical Exam =====

* '''<span style="color:#ff0000">Most common presenting symptom is the onset of constant urinary incontinence 1-4 weeks after surgery.</span>'''

* '''<span style="color:#ff0000">In direct contrast to VVF, in the setting of continuous urine leakage from a ureterovaginal fistula, patients will continue to report normal voiding habits because bladder filling is maintained from the contralateral, presumably undamaged, upper urinary tract</span>'''

===== Imaging =====

* '''<span style="color:#ff0000">Suspicion of a ureterovaginal fistula should prompt upper tract imaging</span>'''

** Ureterovaginal fistulae may be seen on CT urography or MRI.

** '''CT urogram most commonly will demonstrate some degree of ureteral obstruction and associated caliectasis or ureteral dilation. These findings in the presence of constant vaginal drainage strongly suggest a ureterovaginal fistula.'''

*** Alternatively, if the fistula is mature and large, the upper urinary tract may appear completely unremarkable; however, urine will be seen opacifying the vagina before the postvoid image.

** If '''retrograde pyelography''' demonstrates the fistula, as well as ureteral continuity, then an attempt at stenting is warranted.

** '''Cystography is performed primarily to exclude a coexistent VVF.'''

*** A cystogram will not demonstrate the ureterovaginal fistula unless there is preexisting vesicoureteral reflux.

* '''Most common cause: Cesarean section'''

* '''Unlike other types of urogynecologic fistulae, vesicouterine fistulae may or may not manifest with constant urinary incontinence because of the sphincter-like activity of the cervix:'''

** '''Exception is in the setting of an incompetent cervix (e.g. post-partum period) wherein urinary leakage is constant'''

* '''Diagnosis: made by a combination of cystoscopy and radiographic studies'''

* '''Management:'''

** '''Prolonged indwelling bladder catheterization or fulguration of the fistula tract''' followed by bladder drainage may be successful in select cases, especially in patients with small, immature fistulae.

** '''Hormonal induction of menopause''' will induce involution of the puerperal uterus, and this principle has been used with some success in treating this condition.

** Surgical therapy for vesicouterine fistulae is often contingent on the specific reproductive wishes of the patient. If there is no further desire for childbearing, then transabdominal hysterectomy and bladder closure should be considered. For the patient who desires preservation of fertility, uterine-sparing surgery can be considered

** In industrialized countries, urethrovaginal fistulae in adults mostly have an iatrogenic cause.

*** Hysterectomy is not associated with formation of urethrovaginal fistula.

** In the developing world, urethrovaginal fistula may occur as a result of obstructed labor with or without associated VVF.

* '''Diagnosis and Evaluation'''

** '''Symptoms of urethrovaginal fistulae are largely dependent on the size and location of the fistula along the urethral lumen'''

*** '''Proximal fistulae can be associated with stress incontinence, or, if they are located at the bladder neck, continuous incontinence may result, similar to that associated with VVF'''

*** '''Distal fistulae beyond the sphincteric mechanism may be completely asymptomatic or may be associated with a splayed urinary stream.'''

** '''Can often be made on physical examination and cystourethroscopy; however, VCUG is most useful'''

** '''An associated VVF will be found in up to 20% of cases, and therefore a thorough evaluation of the entire lower urinary tract is warranted'''

* Management:

** Foreign material should be excised as widely as possible from the margins of the fistula

** Various types of soft-tissue flaps are often an important component of a successful urethrovaginal fistula repair including, most commonly, a Martius labial fat flap, but also gracilis and rectus abdominis muscle

** SUI may persist after repair of urethrovaginal fistulae. Whether repair of SUI should be done concomitantly with the fistula surgery or should be deferred until after repair of the fistula is controversial

==== Etiology ====

===== History and physical exam =====

* '''<span style="color:#ff0000">Pneumaturia is the most common presenting symptom'''

*'''<span style="color:#ff0000">Classic presentation of vesicoenteric fistula''' (described as Gouverneur syndrome) '''<span style="color:#ff0000">consists of (4):'''

*#'''<span style="color:#ff0000">Suprapubic pain'''

*#'''<span style="color:#ff0000">Urinary frequency'''

*#'''<span style="color:#ff0000">Dysuria'''

*#'''<span style="color:#ff0000">Tenesmus'''  

*Symptoms of vesicoenteric fistulae may originate from the urinary or GI tract; however, in general, '''<span style="color:#ff0000">storage LUTS are more common at presentation.'''  

* '''<span style="color:#ff0000">Recurrent UTIs or cystitis refractory to antibiotic therapy may suggest a colovesical fistula'''

***# '''<span style="color:#ff0000">The presence of colonic diverticula</span>'''

* '''Cystography and transrectal contrast studies (e.g., barium enema)'''

**'''Although commonly used are less likely to demonstrate the fistula'''

===== Other =====

* '''<span style="color:#ff0000">Endoscopy</span>'''

** '''<span style="color:#ff0000">The finding of bullous edema during cystoscopy is nonspecific; however, in the appropriate clinical setting, this can be very suggestive of a colovesical fistula.</span>'''

*** '''80-100% of cases of colovesical fistulae have an abnormality noted on cystoscopy'''

* Bourne test

** Performed after a nondiagnostic barium enema.

** The first voided urine after the barium enema is immediately centrifuged and then examined radiographically. Radiodense particles in the urine are considered a positive test result and evidence for a vesicoenteric fistula

* Activated charcoal

** Oral administration of activated charcoal, which, in the setting of a fistula, will appear in the urine as black particles

* '''Most common cause: inflammatory bowel disease (e.g. Crohn’s disease)'''

* '''Usually right-sided involving the terminal ileum'''

** Rarely, diverticulitis or ulcerative colitis will lead to left-sided ureteroenteric fistula.

* Other causes include urolithiasis, tuberculosis, external and iatrogenic trauma, radiation, and transitional cell carcinoma.

* '''Unlike vesicoenteric fistulae, ureteroenteric fistulae are more likely to manifest with bowel rather than urinary symptoms. Pain may also be reported in the hip, flank, or anterior thigh.'''

* '''The diagnosis can be made by retrograde pyelography, although CT and MRI are more useful.'''

* Treatment involves ureterolysis and possible bowel resection.

* '''Most common cause has historically been chronic inflammatory disease, such as xanthogranulomatous pyelonephritis or other infectious diseases involving the kidney or bowel.''' '''However, iatrogenic surgical trauma, especially that related to percutaneous renal surgery and percutaneous nephrolithotomy (PCNL), has been associated with an increasing number of such fistulae'''

* '''The majority of patients have nonspecific symptoms,''' including malaise, nonspecific GI symptoms, urinary frequency, flank mass, or tenderness.

* Management

** A large nephrostomy tube, enteric suction or bowel rest, antibiotics, and removal of any foreign body (e.g., a stone) may be attempted. Internal stenting of the urinary tract may be pursued for maximal drainage.

** Fistulae associated with a poorly functioning kidney are best treated by primary closure of the bowel and nephrectomy.

** '''Acquired rectourethral fistula may occur in the male under a variety of clinical circumstances, including those related to prostatectomy''' for benign or malignant disease, cryotherapy, pelvic radiotherapy, anorectal surgery, external penetrating trauma, urethral instrumentation, locally advanced prostatic or rectal malignancy, infection (e.g., TB), ruptured prostatic abscess, or inflammatory disease (e.g., Crohn disease)

*** '''The incidence of rectourethral fistula after radical retropubic prostatectomy is low but owing to the frequency with which the operation is performed, it is the most common cause of rectourethral fistula.'''

**** '''Rectal injury during radical prostatectomy occurs in < 1-2% of patients'''

* '''Diagnosis and evaluation'''

** Symptoms may include fecaluria, hematuria, UTI, nausea, vomiting, and fever

** '''A VCUG or retrograde urethrogram usually provides a definitive diagnosis of rectourethral fistula.'''

** '''In patients with a history of pelvic malignancy, biopsy of the fistula is suggested to evaluate for a local recurrence of the tumour. Cystoscopy and sigmoidoscopy visualize the fistula tract in the vast majority of cases and provide a mechanism for biopsy.'''

** '''It is important to make an assessment of continence and sphincteric function in patients with rectourethral fistula after radical prostatectomy'''. Given the location of most rectourethral fistulas at or near the vesicourethral anastomosis and the membranous urethra, there is a risk for persistent severe stress incontinence postoperatively after rectourethral fistula repair

* '''Management'''

** Most rectourethral fistula will require surgical repair, although some will close with conservative management.

*** '''Rectourethral fistula that follows open or laparoscopic prostatectomy may heal spontaneously with catheter drainage, bowel rest, and intravenous hyperalimentation'''.

*** '''In some cases, fecal diversion is necessary.'''

*** '''Staged repairs might be considered in (5):'''

***# Large fistulae

***# Associated with radiation therapy

***# Uncontrolled local or systemic infection

***# Immunocompromised states

***# Inadequate bowel preparation at the time of definitive repair

** Transrectal approaches with and without division of the anal sphincter have been described for the operative repair of rectourethral fistula.

*** '''The York-Mason procedure''' is a transrectal, transsphincteric approach that has been found to be effective and to have low morbidity

** '''Most common causes are procedures in which percutaneous renal access is required, such as PCNL.''' Alternatively, a long-term indwelling nephrostomy tube may lead to pyelovascular fistula formation.

* '''Diagnosis and evaluation'''

** '''Patients may have life-threatening hemorrhage and hypovolemic shock, or intermittent gross hematuria'''

** ≈75% of patients with renovascular fistulae have an abdominal bruit

* '''Management'''

** '''Depends on the cause of the fistula and the associated clinical manifestations'''

*** '''Patients with severe hemorrhage on removal of the nephrostomy tube can be temporized in some instances by replacing the tube, or, in large mature tracts, by placing a Foley catheter to tamponade the bleeding.'''

*** '''In patients with ongoing bleeding, transcatheter angiographic embolization of the lacerated vessel is recommended.'''

*** '''≈70% of fistulae occurring after needle biopsy of the kidney close spontaneously within 18 months, thus, expectant management is an appropriate first step'''

*** '''Fistulae due to renal cell carcinoma warrant nephrectomy'''

* '''Most reported ureterovascular fistulae are ureteroiliac artery fistulae''', although ureteroiliac vein fistulae have been reported as well.

* Ureterovascular fistulae may manifest with microscopic hematuria, intermittent gross hematuria, or life-threatening exsanguinating hemorrhage.

* Management

** In a stable patient with a suspected ureterovascular fistula, radiographic evaluation can be used for diagnostic purposes and treatment planning (reconstructive options or angiographic embolization).

** In the unstable patient, surgical intervention must be considered early, especially because radiographic evaluation may be nondiagnostic.