Female non-obstetric urogenital fistula repair: long-term patient-reported outcomes and a scoping literature review.

OBJECTIVE: To investigate long-term and patient-reported outcomes, including sexual function, in women undergoing urogenital fistula (UGF) repair, addressing the lack of such data in Western countries, where fistulas often result from iatrogenic causes. PATIENTS AND METHODS: We conducted a retrospective analysis at a tertiary referral centre (2010-2023), classifying fistulas based on World Health Organisation criteria and evaluating surgical approaches, aetiology, and characteristics. Both objective (fistula closure, reintervention rates) and subjective outcomes (validated questionnaires) were assessed. A scoping review of patient-reported outcome measures in UGF repair was also performed. RESULTS: The study included 50 patients: 17 (34%) underwent transvaginal and 33 (66%) transabdominal surgery. History of hysterectomy was present in 36 patients (72%). The median (interquartile range [IQR]) operating time was 130 (88-148) min. Fistula closure was achieved in 94% of cases at a median (IQR) follow-up of 50 (16-91) months and reached 100% after three redo fistula repairs. Seven patients (14%) underwent reinterventions for stress urinary incontinence after transvaginal repair (autologous fascial slings). Patient-reported outcomes showed median (IQR) scores on the International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms Modules (ICIQ-FLUTS) of 5 (3-7) for filling symptoms, 1 (0-2) for voiding symptoms and 4.5 (1-9) for incontinence symptoms. The median (IQR) score on the ICIQ Female Sexual Matters Associated with Lower Urinary Tract Symptoms Module (ICIQ-FLUTSsex) was 3 (1-5). The median (IQR) ICIQ Satisfaction (ICIQ-S) outcome score and overall satisfaction with surgery item score was 22 (18.5-23.5) and 10 (8.5-10), respectively. Higher scores indicate higher symptom burden and treatment satisfaction, respectively. Our scoping review included 1784 women, revealing mixed aetiology and methodological and aetiological heterogeneity, thus complicating cross-study comparisons. CONCLUSIONS: Urogenital fistula repair at a specialised centre leads to excellent outcomes and high satisfaction. Patients with urethrovaginal fistulas are at increased risk of stress urinary incontinence, possibly due to the original trauma site of the fistula.

Surgical Approach to Urethral Diverticulum and Urethrovaginal Fistula With Mesh Erosion.

INTRODUCTION AND HYPOTHESIS: This video illustrates a rare surgical case involving a urethral diverticulum, urethrovaginal fistula, and mesh erosion. METHODS: We present a 58-year-old patient attending a tertiary care center with a suspected urethrovaginal fistula. Her concerns included stress urinary incontinence (SUI), recurrent urinary tract infection, and vaginal pain. The surgical history was notable for the placement of two different mesh slings during the same procedure to treat SUI. Preoperative evaluation and findings are illustrated in detail. The video uses a high-definition surgical camera to emphasize the initial intraoperative evaluation with localization of the fistula and diverticulum. We then demonstrate the approach to the dissection with the goal of ensuring complete resection of the diverticulum, fistula, and mesh, while preserving healthy tissue for subsequent closure. The utilization of unique and specialized tools for each portion of the procedure is also illustrated. A layered vaginal closure, including a Martius flap, is created to prevent recurrence. RESULTS: The surgery was accomplished without complications. CONCLUSIONS: To our knowledge, concomitant findings of a urethral diverticulum, urethrovaginal fistula, and mesh erosion are unique in the literature. We postulate that this triad could have resulted from the mesh burden in this particular patient.

Transvaginal primary layered repair of postsurgical urethrovaginal fistula.

INTRODUCTION AND HYPOTHESIS: Urethrovaginal fistula (UVF) is a rare disorder, which implies the presence of an abnormal communication between the urethra and the vagina. METHODS: Surgical repair options include transurethral, transabdominal and transvaginal procedures, either with or without tissue interposition. The vaginal route is considered a safe and effective option to correct UVF. This video is aimed to present a case of direct transvaginal layered repair of urethrovaginal fistula, without the use of tissue interposition. The featured patient is a 66-year-old woman who developed a symptomatic UVF after a complicated laparoscopic hysterectomy for endometrial cancer 3 years before. Cystoscopy demonstrated the presence of a 7 mm urethral orifice a few millimeters caudal from the bladder neck. After proper informed consent, the patient was admitted to transvaginal primary layered repair, according to the technique demonstrated in the video. The featured procedure was completed in 60 min and blood loss was < 100 ml. No surgical complications were observed. RESULTS: The procedure was successful in restoring the anatomy and relieving the symptoms. CONCLUSION: Transvaginal layered repair without tissue interposition represents a safe and effective procedure for the surgical management of postsurgical urethrovaginal fistula.

Surgical management of recurrent urethrovaginal fistula with a skin island flap.

INTRODUCTION AND HYPOTHESIS: A urethrovaginal fistula is a possible rare complication of tension-free vaginal tape procedures. Surgical management of these fistulas is sometimes complicated, and failure can occur. The operation is difficult when the defect between the urethra and the vagina is larger or scarred, so surgical intervention and the preferred technique are controversial. METHODS: The patient was referred to our department, where the first operation was performed to address the urethrovaginal fistula by the transvaginal and transabdominal approach with interposed omentum. This initial repair failed, resulting in a large urethrovaginal fistula with minimal redundant anterior vaginal wall to provide a tension-free closure. This video presentation describes the second operation-transvaginal repair of a large recurrent urethrovaginal fistula using the skin island flap technique. RESULTS: The video of the procedure shows how to address a recurrent urethrovaginal fistula by employing a skin flap. An examination during the patient's follow-up visit 3 months later revealed excellent healing and persistent stress urinary incontinence (SUI). Six months after the fistula repair, the patient underwent a bulking agent procedure. CONCLUSIONS: The skin island flap procedure allowed the larger defect to heal, though it did not address the SUI, which was later treated by application of a bulking agent.

Long-term functional outcomes following non-radiated urethrovaginal fistula repair.

OBJECTIVE: To review long-term functional outcomes after urethrovaginal fistula (UVF) repair. MATERIALS AND METHODS: Following IRB approval, women who underwent transvaginal non-irradiated UVF repair with minimum 6-month follow-up were reviewed. Surgical outcomes were assessed by validated questionnaires: UDI-6, IIQ-7, FSFI and visual analogue scale for QoL. Two groups were compared: (1) synthetic sling-related versus (2) non-sling-related UVF. Descriptive statistics were applied with p < 0.05 for significance. RESULTS: From 1996 to 2013, 18 patients underwent UVF repair, with a mean age of 46 years (range 20-66), BMI 29 (range 21-42) and mean follow-up at 52 months (range 9-142). Overall repair success rate was 95%. Prior failed UVF repair was recorded in 11 women (61%). Statistical differences noted for Q4: 1.9 versus 0.8 (p = 0.03) and Q5: 1.3 versus 0 (p = 0.02) and VAS between the two groups, favoring the non-sling group; 1.5 (0.6) versus 5 (4) (p = 0.05). No differences in IIQ-7 were noted between the two groups (p = 0.09). Of the 18 patients, 5 remained sexually active and of those, 2 responded to FSFI (40%) with low scores. Reoperation rate was 33% (6 women) with 3 requiring periurethral-bulking agent for recurrent SUI, 2 transurethral laser for residual urethral sling mesh strands and 1 urethral dilation. CONCLUSION: This large contemporary series of non-radiated UVF indicates a satisfactory outcome in UVF closure repair at a mean 4- to 5-year long-term follow-up, with the synthetic sling-related group performing worse.

Transvaginal repair of a urethrovaginal fistula using the Latzko technique with a bulbocavernosus (Martius) flap.

INTRODUCTION AND HYPOTHESIS: Urethrovaginal fistula is a rare disorder that may occur following sling procedures for stress urinary incontinence, excision of a urethral diverticulum, anterior vaginal wall repair, radiation therapy, and prolonged indwelling urethral catheter. The most common clinical manifestation is continuous urinary leakage through the vagina, aggravated by an increase in the intra-abdominal pressure. Appropriate management, including timing of the surgical intervention and the preferred technique, remains controversial. METHODS: This video presentation describes the transvaginal repair of a urethrovaginal fistula using the Latzko technique and a bulbocavernosus (Martius) flap. RESULTS: The patient's postoperative course was uneventful. At her follow-up visit 2 months later, she was free of urinary leakage, and a pelvic examination revealed excellent healing, with complete closure of the fistula. CONCLUSIONS: Transvaginal repair using the Latzko technique with a vascular bulbocavernosus (Martius) flap is an effective and safe mode of treatment.

Congenital urethrovaginal fistula with transverse vaginal septum.

Congenital urethrovaginal fistula is an extremely rare genitourinary anomaly. Literature search identified only five reported cases, all of which were associated with urogenital abnormalities. Transverse vaginal septum is another rare condition, resulting from abnormalities in the vertical fusion between the vaginal components of the Mullerian ducts and the urogenital sinus; and associated fistulous connection of the vagina with the urethra is even rarer. Herein we describe the case of a 35-year-old woman who presented with dyspareunia, and a 1-year history of infertility, who was found to have a urethrovaginal fistula with low transverse vaginal septum. The patient was successfully treated with excision of the septum and closure of the urethrovaginal fistula.

IMAGING DIAGNOSIS-URETHROVAGINAL FISTULA CAUSED BY A MIGRATING GRASS AWN IN THE VAGINA.

A young intact female dog was presented with urinary incontinence. Abdominal ultrasound revealed the presence of hyperechoic linear structures within the cranial vagina suggestive of foreign material. A computed tomography (CT) retrograde vaginourethrogram demonstrated the presence of a fistulous tract between the urethra and vagina. A presumptive diagnosis of urethrovaginal fistula due to migration of foreign material was made. The grass awn was removed with vaginoscopic-guided retrieval. Fourteen days later, surgical repair of the fistula and an ovariohysterectomy were done. This case report emphasizes the usefulness of CT for diagnosis and precise anatomical localization of genitourinary tract fistulas.

Concomitant repair of stress urinary incontinence with proximal urethrovaginal fistula: Our experience.

INTRODUCTION: Proximal urethrovaginal fistula (UVF) located close to the bladder neck may cause extensive sphincter damage and is usually associated with continuous incontinence, which may mask the associated stress urinary incontinence (SUI). Simultaneous correction of SUI avoids a second surgery for SUI, which needs dissection in ischemic fields and carries a high risk of failure. The aim of this study is to describe our technique of concomitant repair of SUI with proximal UVF and our results. METHODS: Between July 2010 and August 2014, 14 patients underwent UVF repair in Jackknife position by the interposition of a Martius flap and simultaneous correction of SUI by modified McGuire pubovaginal autologous fascial sling. The procedure was carried out a minimum of 3 months of presentation and after detailed preoperative evaluation. RESULTS: After a mean follow-up of 28 months, all 14 patients were continent. None of the patients developed recurrence of the UVF. Two patients presented with retention immediately after catheter removal and clean intermittent catheterization training was given to both of them. Two patients became pregnant during the follow-up period and were advised cesarean section near term. CONCLUSIONS: Repair of proximal UVF and correction of SUI can be performed in the same session to avoid the operation in an ischemic field.

Spontaneous closure of urethrovaginal fistula associated with pelvic fracture.

Female urethral injury following pelvic fracture is a rare entity. Due to the absence of large series, management guidelines are still not standardized. Patients can have associated urethrovaginal or vesicovaginal fistula, management of which poses a major challenge to the reconstructive urologist. Spontaneous closure of fistula produced by gynecological or obstetrical injuries have been described in the literature. Spontaneous closure of fistula caused due to pelvic fracture has not been described in the literature.

A case of sacrococcygeal teratoma associated with antenatally acquired urethrovaginal fistula and hydrocolpos.

BACKGROUND: Sacrococcygeal teratomas (SCTs) are known to cause urological complications, but urethrovaginal (UV) fistula as a complication of SCT is rare. We herein report a case of SCT with UV fistula and hydrocolpos. CASE PRESENTATION: A 1-day-old female neonate presented to our department with prominent swelling in the sacrococcygeal region. She was born at 37 gestational weeks via spontaneous vaginal delivery from a 39-year-old woman. The weight of the baby was 2965 g, and her Apgar scores were 4/10 (at 1 and 5 min). An MRI examination confirmed an 11 × 11 cm Altman classification typeII SCT associated with hydrocolpos, a dilated urinary bladder, and bilateral hydronephrosis. When she was 5 days, the SCT was excised totally and a coccygectomy was performed. After the operation, as her urinary output appeared unstable, a cystoscopic examination was performed on the third postoperative day. This revealed that the UV fistula was located approximately 1 cm from the urethral opening. In addition, the proximal urethra was unobstructed and connected to the bladder. The cystoscope allowed for the passage of a urinary catheter through the urethra. After 1 month of catheter placement, she was discharged from the hospital at 57 days of age. Follow-up was uneventful, with neither urinary infection nor retention. CONCLUSIONS: SCTs are associated with not only trouble with rectal function and lower extremity movement but also urinary complications. The pathogenesis of this UV fistula is thought to be the rapid growth of the SCT that developed in the fetal period, resulting in obstruction of the urethra by the tumor and the pubic bone, which in turn caused urinary retention and the formation of a fistula as an escape route for the pressure. Because SCTs can cause a variety of complications depending on the course of the disease, careful examination and follow-up are necessary.

Vaginal calculus in adult woman: A case report.

Vaginal calculus in adult woman is an extremely rare condition. The diagnosis and management can be challenging due to rare cases. We present a case of vaginal calculus in adult woman secondary to urethrovaginal fistula due to previous pelvic trauma. The patient barely has no complaint until one day she is experiencing infertility. Stone extraction, vaginoplasty and urethroplasty with Martius flap were performed with satisfactory results.

Giant vaginal stone as a complication of long-term urethrovaginal fistula: A case report.

CASE PRESENTATION: A case of a 57 years old woman came with the chief complaint of urinary incontinence since 20 years ago. After labor, she complained of urinary incontinence and left untreated. Physical examination and urethrocystoscopy revealed vaginal stone sized 90 × 70 mm and urethrovaginal fistula. We performed hysterectomy and vaginal stone removal, continued with fistula closure and vaginal repair. Up to 2 months follow up, no sign of urinary leakage and incontinence was found. CONCLUSION: Vaginal stone is a rare Case that might be present in a case of long term urethrovaginal fistula with neglected contraceptive device.

Urethrovaginal fistula 11 years after a bone anchor sling using woven polyester and treatment with a Martius flap.

INTRODUCTION: We encountered a urethrovaginal fistula diagnosed 11 years after a bone anchor sling. CASE PRESENTATION: A 58-year-old woman underwent a bone anchor sling to treat stress urinary incontinence. At age 69, mid-urethral sling was planned because of a recurrent stress urinary incontinence diagnosis, but a urethrovaginal fistula was found immediately before the procedure. After removing woven polyester, the previous sling material, simple fistula closure was carried out but failed. Usage of a vaginal speculum and powerful medical lamps during a stress test revealed leakage from both the urethrovaginal fistula and the external urethral meatus. She underwent another fistula closure using a Martius flap. Subsequently, a 1-h pad test improved from 195 to 5.1 g/h. The remaining mild stress urinary incontinence did not necessitate further treatment. CONCLUSION: Anti-incontinence procedures using synthetic materials can cause urethrovaginal fistula. Attention must be paid to the possibility of urethrovaginal fistula when patients complain of worsened incontinence postoperatively.

Female Pelvic Fistulae.

Female pelvic fistulae are a pathologic connection between the urinary or gastrointestinal tract and the genital tract. Although this condition has been present for millennia, successful surgical treatments have only been described for the past few hundred years. In developed nations, the most common cause of genitourinary fistulae is benign gynecologic surgery, but worldwide it is obstetric trauma. Fistulae management is rooted in surgical intervention with the highest probability of success associated with the first repair.

Urologic trauma from vaginal dilation for congenital vaginal stenosis: A newly-described and challenging complication.

Vaginal dilation is first line therapy for vaginal agenesis. No major urologic complications have even been described. We present the management and successful outcome of immediate repair for urethral trauma in a patient with history of congenital anomalies managed with vaginal dilation. Proper exposure is difficult, but urologic repair can be achieved with or without concomitant vaginal repair.

Urethrovaginal Fistula: A Rare Complication Secondary To Impacted Foreign Body In Vagina.

We report a case of urethrovaginal fistula following impacted foreign body in vagina. Fistula was suspected on the basis of history and examination and was later on confirmed by voiding cystourethrogram. Cystourethroscopy was done and the fistula was repaired transvaginally in layers. We are reporting this case because of its rarity.

Acquired Urethrovaginal Fistula and Urethral Atresia in a Patient with a Sacrococcygeal Teratoma.

Acquired urethrovaginal fistulae and urethral atresia are rare findings in pediatric patients, but have been described in adult patients related to trauma or iatrogenic injury. Little exists in the published literature to guide management of such conditions in children, but lessons learned from congenital causes can help. Herein we discuss the preoperative evaluation and management of a child with an acquired urethrovaginal fistula and urethral atresia likely related to in utero compression from an intrapelvic sacrococcygeal teratoma and provide several images detailing the complex anatomy.

Closure of a Recurrent Urethrovaginal Fistula in a Girl with Cloacal Anomaly Using Deflux Injection.

In a girl born with cloaca, both hemivaginae and rectum were located above the bladder neck, and both ureters were connected to the hemivaginae. After diverting colostomy and cystovaginoscopy on the second day of life, the repair of cloaca was performed at 10 months of age by posterior sagittal anorecto vaginoplasty (PSARVP), including laparotomy and bilateral ureteric reimplantation. Eight months after the surgery, she developed a vesicovaginal fistula, which was repaired and closed by open surgery through the bladder. Three months after this procedure, a tiny urethrovaginal fistula was noticed, which was closed at the age of 2 years using hook diathermy to refresh the edges and was then closed by Deflux injection. The proper closure of the urethrovaginal fistula was confirmed by radiology and cystoscopy 3 months after the surgery. This report shows that injection of Deflux into a tiny urethrovaginal fistula following refreshing the edges may be a valid treatment option in selected cases.

Management of Urethral Lesions and Urethrovaginal Fistula Formation Following Placement of a Tension-Free Suburethral Sling: Evaluation From a University Continence and Pelvic Floor Centre.

Introduction The complication of tape erosion in the urethra following placement of a retropubic (TVT) or transobturator (TOT) tension-free suburethral vaginal sling or an accidental iatrogenic transurethral tape position can result in the formation of a urethrovaginal or vesicovaginal fistula. The objective of the investigation is the evaluation of the management of such rare complications. Patients and Methods Retrospective analysis of 14 patients who were treated for a urethral lesion or urethrovaginal fistula formation status post TVT/TOT placement between June 2011 and February 2018 in the Tübingen University Department of Gynaecology. Results As surgical therapy, 57.1% (n = 8) cases underwent vaginal fistula closure using a Martius flap of the labium majus and in 21.4% (n = 3) using a vaginal rotation skin flap. In 21.4% (n = 3), exclusively vaginal suture reconstruction of the urethra following excision of the tape running transurethrally or tape erosion was performed. 50% (n = 7) of the patients had lasting continence postoperatively without any further need for therapy. In 28.6% (n = 4), there was ongoing stress urinary incontinence, in 21.4% (n = 3) mixed urinary incontinence. Six of the 7 patients with persistent incontinence underwent new placement of a tension-free suburethral retropubic sling (TVT) an average of 8.8 months (5 - 13 months) postoperatively which was uncomplicated in all patients and achieved satisfactory continence. The 3 patients with mixed urinary incontinence and persistent urgency components additionally received anticholinergic medication. During the time period investigated, there were no long-term complications, in particular no recurrent fistulas. Conclusion The rare but relevant complications of a urethral erosion, transurethral tape position or urethrovaginal fistula formation status post TVT/TOT placement can be successfully managed via vaginal surgery. Persistent postoperative urinary incontinence with the need for a two-phase repeat TVT placement following sufficient wound healing must be preoperatively clarified.