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Urinary fistulas, although relatively uncommon, present a formidable challenge to the urogynecologist, general urologist, and general obstetrician-gynecologist. Current diagnostic modalities are reviewed and conservative and surgical therapies are outlined.
The urinary fistulas are not a frequent problem in our urological rutinary work, being the vesicovaginal ones the most common. However, it will be necessary to know them to be able to diagnose and treat them in the best way. In this article we classificate the different urinary fistulas (uro-gynecologicals, uro-vasculars, uro-cutaneous and entero-urinarys), explaining the possible etiologies and the correct management.
PURPOSE: Recto-urinary fistula formation is a rare occurrence, usually following surgery or another intervention for prostatic disease. Spontaneous closure is rarely successful and reconstructive procedures are usually performed. We report our experience in the last 30 years with modified York-Mason repair. To our knowledge our series of 24 patients is the largest reported using this approach. MATERIALS AND METHODS: We retrospectively reviewed the medical records of all patients who underwent acquired rectourethral or rectovesical fistula repair at our institution. A total of 24 patients underwent York-Mason recto-urinary fistula repair, 18 fistulas occurred secondary to prostatic surgery and 11 patients underwent 1-stage repair without preoperative urinary or fecal diversion. RESULTS: Overall 22 of the 24 fistulas were repaired successfully using the York-Mason approach. One patient required a repeat York-Mason procedure and another required a perineal incision to correct recurrence. All except 1 fistula were eventually surgically corrected. No fecal incontinence or anal stenosis developed. The fistula involved the bladder and urethra in 11 and 13 cases, respectively. Procedure time was less than 2 hours. Blood loss was 50 to 400 cc. No transfusions were required. CONCLUSIONS: York-Mason repair of recto-urinary fistula is an excellent approach to a rare and often confounding surgical complication. It provides nice exposure through unscarred planes and allows adequate closure. The success rate is excellent compared with that of other reported techniques. Postoperative recovery is rapid with minimal morbidity.
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Urinary fistulas developed in 13 of 134 patients after renal transplantation. Bladder fistulas originating from the anterior suture line in 6 patients were satisfactorily managed by urethral or paravesical drainage. Fistulas arising from the donor ureter were best treated by surgical repair using the recipient's own ureter. Caliceal fistulas in 3 patients were successfully treated with nephrostomy drainage. A favorable outcome was achieved in 11 of the 13 patients, with closure of the fistula and preservation of renal function.
OBJECTIVES: urinary fistula is a morbid complication after renal transplantation leading to graft losses and patient death. We review and update our data on urinary fistula after renal transplantation and the outcome after surgical and conservative management. MATERIALS AND METHODS: the charts of 1046 renal transplants were reviewed. Transplants were performed through an extended inguinotomy; vascular anastomoses to the iliac vessels and urinary reconstruction accomplished through the Gregoir technique. Fistulae were diagnosed by urinary leaks through the incision or by the occurrence of a collection in the iliac fossa. Patient was treated surgically or conservatively according to the characteristics of the fistula and patient clinical status. RESULTS: Thirty one fistulae were diagnosed (2.9%). Twenty nine leaks due to ureteral necrosis and 2 due to reimplantation fault. The incidence of leaks among cadaver and live donor transplants was 3.22% and 2.63%, respectively (p = 0.73). Among diabetic and non diabetic patients the incidence of urinary leaks was 6.4% and 2.6%, respectively (p = 0.049). Treatment consisted in anastomosis of the graft ureter or pelvis with the ureter of the recipient in 17 cases with success in 13 (76.5%). Prolonged bladder drainage was employed in 7 cases and the fistula healed in 4 (57%). Ureteral reimplantation was performed in 3 cases and did not work in any of them. Ureteral ligature plus nephrostomy was employed in two cases and worked in one (50%). Percutaneous nephrostomy and ureteral stenting with double J catheter were employed in one case each and worked in both. CONCLUSIONS: The anastomosis of the graft ureter with the ureter of the recipient is a good method for treating urinary fistulae after renal transplantation when local and systemic conditions are good. Ureteral ligature associated to nephrostomy should be applied in cases of unfavorable local conditions or clinically unstable patients.
OBJECTIVES: To specify the anatomical features of urinary fistulas and to evaluate the results of percutaneous and surgical treatment of post-transplantation urinary fistulas. PATIENTS AND METHODS: 11 urinary fistulas were observed after 160 renal transplantations, corresponding to an incidence of this complication of 6.8%. Urinary fistulas were treated percutaneously in three cases and surgically in eight cases. THE FOLLOWING COMPLICATIONS WERE OBSERVED DURING SURGICAL TREATMENT: extensive necrosis of the urethra in four cases, rupture of the sutures in two cases, a punctate pelvic fistula in one case. RESULTS: The incidence of fistula was 5.8% for Leadbetter reimplantation and 8.1% for Lich-Gregoir extravesical reimplantation. We obtained one success in three patients treated percutaneously and one death and seven successes out of eight patients treated surgically. We performed ureteropelvic anastomosis with the native ureter in the case of extensive necrosis of the ureter (4 cases), a new reimplantation in three cases and suture of the pelvic fistula in one case. CONCLUSION: More than one half of post-transplantation urinary fistulas observed in our department are secondary to ischaemic necrosis of the ureter. We emphasize the value of preservation of the ureteric blood supply during organ harvesting. Post-transplantation urinary fistulas must be treated surgically, as soon as possible, to avoid infectious complications.
Urinary fistulas developed in 18 of 200 renal transplants (9 per cent). Twelve fistulas healed after conservative treatment and 6 were repaired by an operation. Our repair technique included constructing a bladder flap for patching, incorporating the fistula into the bladder and suturing the bladder directly to the renal pelvis.
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Once previously attempted conservative maneuvers have failed, iatrogenic persistent urinary fistulas usually require difficult repeated operations. We describe 3 patients in whom cyanoacrylic glue was used to repair endoscopically persistent urinary fistulas occurring after major pelvic surgery. At a mean follow-up of 21 months, all patients were free of urinary leakage and had no evidence of recurrent urinary fistulas. This approach may represent a safe and effective way to repair postoperative urinary fistulas.
Most urinary fistulae of obstetric origin involve the bladder. The ureter is rarely injured. The authors report three cases of uretero-uterine fistulae, an entity accounting for 1.6% of all urinary fistulae resulting from obstetric trauma. Diagnosis and management are discussed with reference to 19 cases of uretero-uterine fistulae reported in the literature.
PURPOSE: We evaluated the adaptability and the efficacy of a cyanoacrylic glue for the conservative treatment of urinary fistulas of different etiologies using an endoscopic, percutaneous or endovaginal approach. MATERIALS AND METHODS: From May 1998 to July 2004, 13 patients with long lasting iatrogenic and/or inflammatory urinary fistulas were treated conservatively with endoscopic, percutaneous or endovaginal application of 1 to 3 cc of cyanoacrylic glue. RESULTS: The complication rate in this cohort of 13 patients was low. Occlusion therapy failed in 2 genitourinary fistulas which were wider (diameter greater than 1 cm) and short. In the remaining 11 cases urinary fistulas were successfully sealed and at a median followup of 35 months no relapses were observed. CONCLUSIONS: Cyanoacrylic glue is suitable for endoscopic, percutaneous and endovaginal use. This occlusion therapy represents a safe and minimally invasive approach that might be offered as a first line option for the treatment of urinary fistulas, especially narrow and long tract fistulas.
Recto-urinary fistula results as a complication following trauma to the perinium and pelvis. These fistulas are difficult to treat and have a high recurrence rate due to the difficult surgical approach in repairing them. Both the transabdominal or transperineal approaches used in repairing these fistulas are difficult and provide only limited exposure to the fistula being repaired. In the case report, we present a patient with complex recto-urinary fistula due to trauma to the pelvis 20 years previously. In this patient we used the transphincteric York Mason approach to directly approach the fistula, followed by construction of a tube flap connecting the bladder and the urethra. The technique is simple, easy and the outcome has been excellent after 4 years of follow-up.
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OBJECTIVE: To present the results of the staged management of complex entero-urinary fistulae. PATIENTS AND METHODS: Ten patients with complex entero-urinary fistulae were reviewed; all patients were referred to a national intestinal failure unit after failed treatment in other centres. Each patient was treated in three stages. The acute stage involved proximal defunctioning and distal drainage of both the gastrointestinal and urinary tracts to isolate the fistula, together with the eradication of sepsis. The recovery stage involved total parenteral nutrition, organ support, radiological planning of surgical reconstruction and intensive nursing. The reconstructive stage followed when the patient was stable, nutritionally replenished and intra-abdominal sepsis was controlled. Surgery was undertaken jointly by urological and gastrointestinal surgeons. RESULTS: The fistulae were treated successfully in all patients, with functional restoration in four, and/or diversion of the gastrointestinal and urological tracts in six. The mean (range) time to reconstruction was 5 (1-20) months. There were no postoperative deaths. CONCLUSION: A staged multidisciplinary approach with delayed reconstruction can achieve a successful outcome in the management of complex entero-urinary fistulae.