Treatment of genital fistulas

Surgical tactics and approaches

Treatment of any urogenital fistulas is based on a surgical approach. The choice of surgical approach depends on the localization of the defect and concomitant complications. Transabdominal approach is used in the most complex situations. It is indicated if the fistula is located high (near the ureteral orifice), there are extensive urine collections, ureteral stricture, or concomitant purulent pathology in the lesser pelvis. This approach is also indispensable when extensive plastic surgery of the pelvic organs and anterior abdominal wall is required.

The classical treatment strategy for vesicovaginal defects involves strict expectant management. The surgery is performed 3–6 months after the injury. This time is critically necessary for the maximum subsidence of the inflammatory reaction caused by the previous intervention.

Prevention of fistula formation includes timely treatment of background diseases of the urogenital system, competent management of labor (prediction of complications and timely Cesarean section), as well as early detection and adequate treatment of postpartum purulent-septic processes.

Ureteral-genital fistulas

This group includes ureterovaginal and extremely rare ureterouterine fistulas. They account for up to 30% of all urogenital fistulas and always have an iatrogenic (traumatic) origin. Most commonly, the ureter is injured during radical gynecological surgeries, and less frequently in obstetric practice. Intraoperatively, only 20% of such injuries are recognized. If the injury is not noticed in time, severe complications develop: urinary peritonitis, phlegmon, purulent pyelonephritis, or ureteral stricture.

The key symptom is involuntary urine leakage, which occurs simultaneously with preserved independent urination. The time of symptom onset depends on the nature of the injury:

• Parietal wound: a urine collection rapidly forms, body temperature rises, and urine leakage begins in 2–3 days.
• Ureteral ligation: urine outflow is impaired, which leads to dystrophy and necrosis of the wall. First, intense pain occurs in the kidney region, then fever, and only on the 10th–12th day does leakage appear.

Cystoscopy and chromocystoscopy are primarily used for diagnosis. Retrograde catheterization of the orifice and intravenous (excretory) urography are also used to assess the state of the kidneys, the healthy part of the ureter, and the extent of collections. Additionally, renal ultrasound and functional tests (Zimnitsky, Nechiporenko tests) are prescribed.

Treatment is performed exclusively via the transabdominal approach. Either ureteroneocystostomy (creation of a new anastomosis with the bladder) or ureteral transplantation into the bowel is performed. Surgery can be performed no earlier than 5–7 weeks from the onset of leakage, provided there is a complete absence of inflammation.

Urethrovaginal fistulas

They occur due to trauma to the urethra during pathological labor or vaginal gynecological surgeries (most frequently during anterior colporrhaphy, removal of Gartner's duct cysts, or anterior vaginal wall cysts).

The clinical picture directly depends on the level of the injury:

• Proximal or middle segment: total incontinence is observed. Urine is not retained at all, leaking constantly in both vertical and horizontal positions.
• Distal segment: the ability to voluntarily urinate is preserved, however, the urine stream exits into the vagina through the fistula tract.

Diagnosis of large defects is limited to visual inspection and palpation. For clarification, probing (a bulbous probe is inserted into the external urethral meatus and emerges into the vagina) and a dye test are used. A warm solution with methylene blue is injected into the bladder—if a fistula is present, it stains the vagina. For pinpoint defects, urethrocystoscopy and vaginography are indicated.

Surgical closure or complete reconstruction of the urethra is performed 3–6 months after the injury so that the tissues restore their reparative properties. The surgery is performed strictly after sanitation of the genital and urinary tracts, and short-term fixation of a Foley catheter is used to prepare the intervention zone.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Prevention of vesicogenital fistula formation in obstetrics.
• Methodology for performing the dye test (with methylene blue).
• Instrumental diagnostics: cystoscopy and excretory urography.
• Complications of unrecognized intraoperative ureteral injury.
• Functional renal studies when planning reconstructive surgery.

Other topics in the "Gynecology" section

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