Etiology and Prevalence

The etiology of VVF differs in various parts of the world. In the industrialized world, the most common cause (>75%) of VVF is injury to the bladder at the time of gynecologic, urologic, or other pelvic surgery (Symmonds, 1984; Lee et al, 1988; Tancer, 1992). Surgical injury to the lower urinary tract most commonly occurs in the setting of hysterectomy (Fig. 77–2), whereas most of the remainder are related to general surgery procedures in the pelvis, anterior colporrhaphy or cystocele repair, anti-incontinence surgery, or other urologic procedures (Armenakas et al, 2004). Of 207 VVF repaired at the University of Caliornia–Los Angeles (UCLA) over a 10-year period ending in 2001, Eilber and colleagues (2003) reported the cause as abdominal hysterectomy in 83%, vaginal hysterectomy in 8%, radiation in 4%, and miscellaneous in 5%. In 1964, Massee and colleagues from the Mayo Clinic reviewed the cause of urogenital fistulae in 262 patients and cited uterine operations as a proximate cause in 73.7%, vaginal wall operations in 6.5%, urinary tract operations in 6.9%, and obstetric operations in 6.5%, with the remainder being due to miscellaneous causes. A later series of greater than 300 fistulae from the same institution cited gynecologic surgery as the cause of VVF in 82%, obstetric procedures in 8%, radiation in 6%, and trauma or fulguration in 4% (Lee et al, 1988). Other causes of VVF in the industrialized world include malignancy, pelvic radiation, and obstetrical trauma (including forceps lacerations and uterine rupture) (Everett and Mattingly, 1956; Gerber and Schoenberg, 1993). The use of vaginal mesh for prolapse repair may also result in VVF (Margulies et al, 2008; Ridgeway et al, 2008). Although fortunately uncommon during labor, approximately 22% of uterine ruptures are associated with a bladder injury (Raghavaiah and Devi, 1975). Prior to 1900, the most common cause of VVF in the United States was obstructed labor (Stothers et al, 1996). However, obstructed labor and obstetric trauma, in general, now account for very few VVF in the United States and other industrialized nations, probably due to the widespread availability of excellent prenatal and perinatal obstetric care.

The rate of iatrogenic bladder injury during abdominal hysterectomy is estimated to be between 0.5% and 1.0% (Keettel et al, 1978). Mathevet and colleagues (2001) reported the incidence of bladder injury during vaginal hysterectomy to be 1.7% in 3076 cases, with all injuries being recognized and repaired intraoperatively. Despite the immediate intraoperative repair reported in this series, there were four VVF noted, giving a crude VVF rate during vaginal hysterectomy of 0.13%. The reported incidence of intraoperative bladder injury varies considerably in the literature, depending on whether routine cystoscopy was performed. In series where cystoscopy was not performed, the overall rate of bladder injury was reported to be approximately 2.6 per 1000 cases, whereas in series where cystoscopy was routinely performed, the overall rate of bladder injury was approximately 10.4 per 1000 cases (Gilmour et al, 1999). The incidence of fistula after hysterectomy is estimated to be approximately 0.1% to 0.2% (Harris, 1995). There are approximately 140 to 150 VVF repairs annually in England and Wales (Hilton, 1997).

Posthysterectomy VVF are thought to result most commonly from an incidental unrecognized iatrogenic cystotomy near the vaginal cuff (Kursh et al, 1988). If unrecognized intraoperatively, a pelvic urinoma may develop and ultimately drain out through the vaginal cuff. Ongoing urinary drainage along this tract results in a fistula. Other potential mechanisms for posthysterectomy VVF include tissue necrosis from cautery, a suture placed through both the bladder and vaginal wall during closure of the vaginal cuff, or an attempt to control pelvic bleeding by suture ligature. Tissue ischemia and then necrosis promotes fibrosis and induration, finally resulting in an epithelial or mucosal lining of the tract and the development of a fistula tract. Possibly, factors other than an isolated suture placed through the bladder and vagina are necessary for posthysterectomy VVF formation because, at least, in an animal model, deliberate suture fixation of the bladder to the vagina does not invariably result in VVF in the absence of infection, urinary extravasation, or other complicating factors (Meeks et al, 1997).

In the developing world where routine perinatal obstetrical care may be limited, VVF most commonly occur as a result of prolonged obstructed labor due to cephalopelvic disproportion, with resulting pressure necrosis to the anterior vaginal wall, bladder, bladder neck, and proximal urethra from the baby (Arrowsmith et al, 1996) (Fig. 77–3). The constellation of problems resulting from obstructed labor is not limited to VVF and has been termed the “obstructed labor injury complex” and includes varying degrees of each of the following: urethral loss, stress incontinence, hydroureteronephrosis, renal failure, rectovaginal fistula, rectal atresia, anal sphincter incompetence, cervical destruction, amenorrhea, pelvic inflammatory disease, secondary infertility, vaginal stenosis, osteitis pubis, and foot drop (Arrowsmith et al, 1996). The obstructed labor injury complex occurs largely in developing countries in certain cultures due to several factors, including (1) marriage and conception at a very young age, which results in childbearing in a relatively small and immature pelvis, (2) poor nutrition resulting in stunted skeletal (e.g., pelvic) growth in the mother, and (3) relative absence of qualified prenatal and obstetrical care (Margolis and Mercer, 1994). Patients may suffer with obstructed labor for days in a rural environment, eventually traveling to a distant health care facility only to have a stillborn fetus and a VVF. In direct contradistinction to the epidemiology of VVF in the industrialized world, 96.5% of 932 VVF seen at a single hospital in Nigeria over a 7-year period were temporally associated with labor and delivery (Wall et al, 2004). The incidence of obstetric fistula in developing countries has been estimated at approximately 0.3% to 0.4% of deliveries (Margolis et al, 1994), or between 1 and 4 per 1000 vaginal deliveries (Margolis et al, 1994; Danso et al, 1996). In sub-Saharan Africa the incidence rate has been estimated at 10.3 per 100,000 deliveries (Vangeenderhuysen et al, 2001). An estimate of up to 500,000 new cases of obstetric fistula occur throughout the world annually (Hilton, 2003), although the total morbidity from obstructed maternal labor has been estimated to be in excess of 5 million individuals annually (Kelly, 1991). Risk factors include young or old maternal age, and primigravids (Danso et al, 1996).

Obstetric fistulae tend to be larger, located distally in the vagina, and may involve large portions of the bladder neck and proximal urethra. Even in experienced hands, these are often very difficult to repair due to the extensive soft tissue loss, as well as the ischemia and fibrosis of adjacent tissues (Arrowsmith, 1994; Elkins, 1994). Obstetric fistulae are devastating injuries in the developing world, with significant socioeconomic ramifications (Donnay and Weil, 2004; Wall et al, 2004). The affected individuals, commonly young teens, are often ostracized and shunned from family and friends and become permanent outcasts in society. Only rarely are these individuals able to get adequate care and repair due to the lack of organized health care in many countries in the developing world. Major efforts are underway to improve education, the socioeconomic status of women, and access to health care in these regions (Tahzib, 1983; Tahzib, 1989; Kelly, 1991; Wall, 1996; Donnay and Weil, 2004; Kelly, 2004). With improvements in the delivery of prenatal care in some areas of the developing world, it appears that the incidence of VVF due to obstetric causes may be decreasing as a subset of all VVF, with a proportional increase in the rate of iatrogenic gynecologic fistulae approaching that in industrialized nations (Ayhan et al, 1995; Obi et al, 2008). Another important cause of VVF in some parts of the world is traditional folk treatments such as “gishiri cutting,” which may account for up to 13% of VVF in some series (Tahzib, 1983). This ritual practice involves using a knife to incise the anterior vagina as a treatment for a variety of conditions, including infertility, dyspareunia, dysuria, and back pain.

Other causes of VVF include urologic or gynecologic instrumentation, including percutaneous procedures (Ramsay et al, 1992; Pruthi et al, 2000), retroperitoneal, vascular or pelvic surgery, infectious and inflammatory diseases (Borjas and Rodriguez Diaz 1949; Bland and Gelfand, 1970; Ba-Thike et al, 1992; Monteiro et al, 1995), foreign bodies (including neglected pessaries) (Binstock et al, 1990; Goldstein et al, 1990; Grody et al, 1999), congenital VVF (Rousseau et al, 1996), sexual trauma (Roy et al, 2002), vaginal laser procedures (Colombel et al, 1995), and external violence (see Table 77–3). The three most common locally advanced malignancies that result in VVF include cervical, vaginal, and endometrial carcinoma, which in aggregate account for approximately 3% to 5% of VVF in the industrialized world.

Table 77–3 Etiology of Vesicovaginal Fistula

Traumatic Postsurgical Abdominal hysterectomy Vaginal hysterectomy Anti-incontinence surgery Anterior vaginal wall prolapse surgery (e.g., colporrhaphy) Vaginal biopsy Bladder biopsy/endoscopic resection/laser Other pelvic surgery (e.g., vascular, rectal) External trauma (e.g., penetrating, pelvic fracture, sexual) Radiation therapy Advanced pelvic malignancy Infectious/inflammatory Foreign body Obstetric Obstructed labor Forceps laceration Uterine rupture Caesarean section injury to bladder Congenital

VVF due to radiation therapy deserve special mention. These VVF may occur several decades after completion of the radiation (Zoubek et al, 1989). The incidence of urinary fistula following radiation therapy varies with the type, dose, and location of the radiation. Both external beam and interstitial (Aristizabal et al, 1983) radiation therapy may result in VVF. An incidence of 1.6% of any type of urinary fistula was noted in one series of greater than 2200 patients treated with a variety of different radiation modalities for cervical carcinoma (Alert et al, 1980). Perez reported a 0.6% to 2.0% incidence of VVF formation in 1456 patients undergoing combined external beam radiotherapy and brachytherapy for stages I to III cervical cancer (Perez et al, 1999). In a series of 2096 patients undergoing therapy for cervical cancer, there was an overall genital fistula rate of 1.8%, including rectovaginal fistulae. All patients diagnosed with fistula had received radiation therapy, and the median interval from completion of radiation to presentation of VVF was 8.7 months (Emmert and Kohler, 1996). Higher radiation doses seem to correlate with a greater risk for overall morbidity, as well as fistula formation (Perez et al, 1984; Perez et al, 1999). The endarteritis as a result of the radiation therapy may involve the surrounding tissues, limiting reconstructive options. An important consideration in any fistula following radiation therapy for malignancy is the possibility that the fistula represents a recurrence of the malignancy. Therefore biopsy of fistula tract should be strongly considered prior to considering definitive repair in these patients.

Intraoperative Risk Factors for Iatrogenic VVF

Clearly, intraoperative injury to the urinary bladder is a primary risk factor for subsequent development of a postoperative VVF. Other risk factors for postoperative VVF formation include prior uterine surgery (cesarean section), endometriosis, infection, diabetes, arteriosclerosis, pelvic inflammatory disease, and prior radiation therapy (Blandy et al, 1991; Likic et al, 2008). In a large series of VVF, Tancer and colleagues (1992) described several factors that increased the risk for VVF following hysterectomy, including prior uterine operation (especially cesarean section), endometriosis, recent cold-knife cervical conization, and prior radiation therapy. Nevertheless, almost 30% of the patients in this series had no identifiable risk factor. The operative approach to hysterectomy is an important factor, because bladder injuries are at least three times more common during abdominal hysterectomy compared with vaginal hysterectomy. Intraoperative recognition and repair of bladder injury is paramount in prevention of VVF; however, despite intraoperative repair, VVF may still result in a substantial number of patients. In 1969, Hutch emphasized five factors in the prevention of VVF during gynecologic surgery: (1) immediate detection of bladder injury using vital dyes if necessary; (2) watertight closure of the bladder; (3) satisfactory extravesical drain placement; (4) avoidance of a vaginal incision, if possible, following recognition of the bladder injury; and (5) prolonged, uninterrupted postoperative bladder drainage (Hutch and Noll, 1970).

Clinical Features

Treatment

Etiology and Presentation

The most common etiology for ureterovaginal fistulae is surgical injury to the distal ureter, with gynecologic procedures being by far the most common cause (Symmonds, 1976; Dowling et al, 1986; Badenoch et al, 1987b; Lee et al, 1988; Blandy et al, 1991). The vast majority of ureterovaginal fistulae occur during procedures for benign rather than malignant indications (Mandal et al, 1990), including hysterectomy most commonly, but also caesarean section, cystocele repair, and other pelvic surgery such as infertility procedures (von Eye et al, 2008; Mongiu et al, 2009) (Table 77–7). Regarding the approach for hysterectomy, the risk of ureteral injury appears to be greatest during laparoscopic hysterectomy, followed by abdominal and then vaginal hysterectomy (Harkki-Siren et al, 1998). The incidence of iatrogenic ureteral injury during major gynecologic surgery is estimated to be about 0.5% to 2.5% (Symmonds, 1976; Payne, 1996; Gilmour et al, 1999).

Table 77–7 Etiology of Ureterovaginal Fistula

Gynecologic Surgery

Abdominal hysterectomy Vaginal hysterectomy Radical hysterectomy Caesarian section Anterior colporrhaphy (cystocele repair)

Other Pelvic Surgical Procedures

Vascular surgery Urologic surgery including retropubic bladder neck suspensions Colon surgery

Other

Locally advanced malignancy Radiation therapy Pelvic trauma Chronic inflammatory diseases: actinomycosis, etc.

The mechanism of injury resulting in iatrogenic postoperative ureterovaginal fistulae includes ureteral laceration or transection, blunt avulsion, crush injury, partial or complete suture ligation, and, finally, ischemia due to operative devitalization of the ureteral vascular supply and/or cautery injury. Overall, the ureter is most commonly injured during gynecologic surgery in the distal one third or pelvic portion, which is, accordingly, the only location at which a ureteral injury may result in a ureterovaginal fistula. Not uncommonly this occurs inadvertently during an attempt by the surgeon to control active bleeding using clamps or suture ligation of large tissue segments in the deep pelvis.

The pelvic ureter is intimately related to the female genital tract throughout its course. In the deep pelvis, the ureter passes at the lateral edge of the uterosacral ligament and ventral to the uterine artery, and then passes just lateral to the cervix and fornix of the vagina. In close apposition to these structures, the ureter must be carefully avoided during any gynecologic procedure in the deep pelvis. Any injury to the ureter that exposes the ureteral lumen (i.e., laceration), or results in delayed necrosis of a portion of the ureter (i.e., suture ligation) and subsequent urinary extravasation, may lead to a fistula. A ureterovaginal fistula may result from a sequence of events, including urinary extravasation from the ureteral injury, urinoma formation, subsequent extension along nonanatomic planes created during surgery, and eventual drainage through the vaginal incision or an ischemic area of the vaginal cuff. Infection, prior radiation therapy, or other factors that may impede healing probably promote the development of ureterovaginal fistulae under these circumstances.

The most common presenting symptom is the onset of constant urinary incontinence 1 to 4 weeks following surgery (Mandal et al, 1990). This may have been preceded by several days of flank or abdominal pain, nausea, and low-grade fever, presumably as a result of urinoma and/or obstruction of the kidney (Lee et al, 1988). Flank pain will often be masked in the postoperative period due to the use of postoperative narcotic analgesics. Importantly, and in direct contrast to VVF, in the setting of continuous urine leakage from a ureterovaginal fistula, patients will continue to report normal voiding habits as bladder filling is maintained from the contralateral, presumably undamaged, upper urinary tract.

Diagnosis and Management

Diagnosis and confirmation of a ureterovaginal fistula can usually be accomplished with a combination of a relevant history, physical examination, and appropriate radiologic studies, including cross-sectional imaging (such as a CT urogram), intravenous urography (IVU), and retrograde pyelography (Mandal et al, 1990) (Fig. 77–19). A double dye test may be of some value in differentiating between a ureterovaginal and vesicovaginal fistula as a cause of ongoing urinary leakage (Raghavaiah, 1974). Suspicion of a ureterovaginal fistula should prompt upper tract imaging (Badenoch et al, 1987a). The IVU or CT urogram most commonly will demonstrate some degree of ureteral obstruction and associated caliectasis or ureteral dilation (Selzman et al, 1995). 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 prior to the postvoid image (Fig. 77–20). Antegrade pyelography following nephrostomy tube decompression of a partially obstructed ureter may be associated with similar findings (Fig. 77–21). A high oblique or lateral film may be necessary to differentiate the contrast in the bladder from that in the vagina. A retrograde pyelogram may show the ureter and fistula well, or may demonstrate an abrupt termination of the ureter 2 to 4 cm from the ureteral orifice. Retrograde pyelography may be the single best test to diagnose a ureteral injury (Payne, 1996). 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. Ureterovaginal fistulae may be seen on CT urography (Fig. 77–22); however, an additional role for such cross-sectional imaging is to evaluate for an associated pelvic abscess or undrained urinoma.

The goal of therapy is the expeditious resolution of urinary leakage, avoidance of urosepsis, and preservation of renal function. Once the diagnosis is made, prompt drainage of the affected upper urinary tract is essential (Gerber and Schoenberg, 1993), because partial ureteral obstruction is often present. An attempt at ureteral stenting or percutaneous nephrostomy tube decompression is warranted as soon as possible (Dowling et al, 1986; Kostakopoulos et al, 1998a) if direct open surgical repair is not immediately considered. Occasionally, conservative, nonoperative management, alone, will result in fistula closure in patients with ureteral continuity and a normal-appearing ureter beyond the fistula (Alonso et al, 1986), although this is unusual. Endoscopic management, including ureteral stenting, may be sufficient to promote closure of the fistula in some cases. Dowling and colleagues (1986) reported that 11 of 23 patients with ureteral injuries recognized postoperatively were successfully managed with nephrostomy tube drainage and/or ureteral stenting. Selzman and coworkers (1995) reported successful management of 7 of 20 ureterovaginal fistulae with internal ureteral stenting alone. None of the 7 patients in whom a ureteral stent was successfully placed required open surgery. In general, if ureteral continuity can be demonstrated on imaging, retrograde placement of a stent is often possible. In some cases, an antegrade stent placement will be successful where a retrograde attempt had failed.

If ureteral stenting is unsuccessful due to complete ureteral occlusion, or prolonged leakage persists despite stenting, then formal surgical repair is indicated (Fig. 77–23). Timing of the repair of ureterovaginal fistulae is controversial. Some authors advocate early repair (Talbert et al, 1965; Flynn et al, 1979; Badenoch et al, 1987b; Blandy et al, 1991; Selzman et al, 1995), while others recommend a delay of 4 to 8 weeks (Hulse et al, 1968; Lee and Symmonds, 1971). More recent literature suggests that early repair is preferred and is not associated with an increase in morbidity or higher failure rates (Payne, 1996).

As noted previously, ureterovaginal fistulae most commonly result from injury to the distal one third of the ureter below the level of the iliac vessels. The usual site of the injury in the very distal ureter and the surrounding fibrosis and inflammation usually precludes primary repair of the fistula. Therefore open surgical repair most commonly involves ureteroneocystostomy. The ureter is located and dissected as distally as possible in the pelvis. Care is taken to preserve the periureteral adventitial layer to prevent ureteral ischemia. The ureter is divided distally, and a ureteroneocystostomy is performed with or without a psoas hitch. Occasionally, a Boari flap may be necessary due to extensive ureteral injury. Robotic and laparoscopic repairs have been reported using the same principles as open repair (Modi et al, 2005; Laungani et al, 2008; Modi et al, 2008; Patil et al, 2008), with the potential benefits of shorter hospitalization and quicker convalescence. Rarely, transureteroureterostomy, ileal substitution of the ureter, or renal autotransplantation are required. In patients with a normal contralateral kidney in whom there is extensive renal damage due to obstruction or infection, nephrectomy may be the most expeditious method of management.

Successful repair of ureterovaginal fistulae is expected in greater than 90% of cases. Blandy and colleagues reported on early repair of iatrogenic injury to the ureter in 43 cases including 30 ureterovaginal fistulae. All patients were cured using a combination of techniques including the Boari flap (Blandy et al, 1991). Others have reported similar results (Lee and Symmonds, 1971; Flynn et al, 1979; Mandal et al, 1990).

Ureteral fistulae to other gynecologic organs have been reported. Ureterouterine fistulae may occur as a result of caesarean section, uterine malignancy and elective abortion (Keegan and Forkowitz, 1982; Lazarevski and Badiev, 1996; Wang and Hung, 1997; Sheen et al, 1998). Ureterofallopian tube fistulae have also been reported as a consequence of laparoscopic fulguration of endometriosis (Steckel et al, 1993).

Etiology and Presentation

Vesicouterine fistulae are among the least common urogynecologic fistulae. Less than 100 cases were reported in the world literature between 1908 and 1986, with no series having greater than four patients (Tancer, 1986). However, the incidence of this condition is increasing in parallel with the rising numbers of low-segment caesarean sections being done worldwide (Porcaro et al, 2002). Caesarean section is by far the most common cause of this unusual fistula (Tancer, 1986; Miklos et al, 1995; Vu et al, 1995). Tancer related that of the 74 cases of vesicouterine fistulae reported from 1947 to 1986, 57 followed low-segment caesarean section, 7 followed vaginal operative delivery, while the remaining cases were related to a variety of disparate scenarios, including induced abortion, hysterectomy, and dilation and curettage (D&C) (Tancer, 1986). Jozwik and colleagues (1997) reported that 21 of 24 vesicouterine fistulae treated over a 12-year period occurred following caesarean section, the majority of which were repeat caesarean sections. Those undergoing vaginal birth after a prior caesarean section (VBAC) are also at risk for vesicouterine fistula (Gil and Sultana, 2001). Vesicouterine fistulae may occur spontaneously as a result of a ruptured uterus during obstructed labor. In these cases, the posterior bladder wall may tear along the uterine rupture line creating the potential for a fistula. Bladder wall invasion by chorionic villi penetrating beyond the uterine serosa, placenta percreta, may also create a vesicouterine fistula (Krysiewicz et al, 1988). A foreign body such as an intrauterine device (IUD) (Schwartzwald et al, 1986), uterine artery embolization (Sultana et al, 2002), brachytherapy (Memon et al, 1998), and traumatic bladder catheterization (Futter and Baker, 1995) have all been reported to cause vesicouterine fistula. In most cases, simultaneous injury to the bladder and uterus is the inciting event. An unrecognized and unrepaired (occult) bladder injury, or incorporation of a portion of the bladder during closure of the uterus following any number of operations, may result in a vesicouterine fistula. Anatomically, the most common location of the fistula is along the posterior bladder wall in the midline, or from the genital side, just cephalad to the internal cervical os.

Unlike other types of urogynecologic fistulae, vesicouterine fistulae may or may not present with constant urinary incontinence due to the sphincter-like activity of the cervix; the exception is in the setting of an incompetent cervix where urinary leakage is constant. In this clinical setting, which typically occurs following vaginal delivery, urine flows from the bladder through the fistula into the uterine cavity and then into the vagina through an incompetent cervical os. Tancer (1986) described 12 such patients, with urinary incontinence as the presenting symptom, out of 15 patients with vesicouterine fistulae following vaginal operative delivery. However, in the setting of a relevant clinical history, vesicouterine fistulae will also present with menouria and cyclical hematuria in the setting of urinary continence. Youssef syndrome describes the presenting symptom complex of vesicouterine fistula: menouria, cyclic hematuria with associated apparent amenorrhea, infertility, and urinary continence (Youssef, 1957; Tancer, 1986) in a patient who has undergone prior low-segment caesarean section. Endometriosis of the bladder, in which cyclical hematuria may be present, must be differentiated from this condition.

Diagnosis and Management

Diagnosis of vesicouterine fistula can be made by a combination of cystoscopy and radiographic studies, although a high degree of suspicion is necessary to pursue the diagnosis if initial radiographic studies prove negative (Smayra et al, 2005). Cystoscopy may demonstrate a midline lesion along the posterior bladder wall (Fig. 77–24). Urine cytology may reveal endothelial cells. Instillation of contrast material into the bladder (cystogram) will outline the uterine cavity (Fig. 77–25), whereas a hysterosalpingogram will demonstrate filling of the bladder. MRI, CT (Fig. 77–26), and ultrasonography have been used in the diagnosis and evaluation of vesicouterine fistulae as well (Mercader et al, 1995; Huang and Yao, 1996; Murphy et al, 1999). An IVU or contrast-enhanced CT scan can be used to exclude concomitant ureteral injury.

Several different approaches have been advocated for the treatment of vesicouterine fistulae. Spontaneous resolution may occur, and Graziotti and colleagues (1978) noted that only five such cases, including theirs, had previously been reported in the literature. Therefore these authors recommend against a “precocious” surgical repair of these lesions as time may allow some fistulae to resolve without surgery. Prolonged indwelling bladder catheterization or fulguration of the fistula tract followed by bladder drainage may be successful in select cases, especially those with small, immature fistulae (Graziotti et al, 1978; Molina et al, 1989; Ravi et al, 2003; Novi et al, 2004). Hormonal induction of menopause will induce involution of the puerperal uterus, and this principle has been used with some success in treating this condition as well (Hemal et al, 1994; Jozwik and Jozwik, 1999; Ravi et al, 2003). Jozwik and colleagues (1999) reported successful treatment in 8 of 9 patients using hormonal manipulation.

Surgical therapy for vesicouterine fistulae is often contingent on the specific reproductive wishes of the patient (Smayra et al, 2005), as well as other surgical factors, but is considered definitive therapy (DiMarco et al, 2006; Rao et al, 2006). If there is no further desire for childbearing, then transabdominal hysterectomy and bladder closure should be considered. Ureteral stents can be placed to facilitate identification of the ureters intraoperatively. Following performance of the hysterectomy, the fistula tract on the posterior bladder wall is excised and the bladder is closed primarily. An omental flap can be placed into the deep pelvis to buttress the bladder closure and separate the bladder closure from the vaginal closure to reduce the possibility of a postoperative vesicovaginal fistula. For the patient who desires preservation of fertility, uterine-sparing surgery can be considered. In a manner similar to an O’Conor transabdominal VVF repair, the bladder is opened and bivalved down to the fistula tract. Careful dissection allows separation of the bladder from the uterus beyond the fistula tract. The fistula tract is excised from both structures, the uterus and bladder are closed individually, and an interpositional flap, usually omentum, is secured between the two organs. Fertility is possible following repair of vesicouterine fistula. Lotocki and colleagues (1996) reported five pregnancies with four full-term deliveries in a cohort of 16 patients who had undergone uterine-sparing surgery for vesicouterine fistulae. Minimally invasive laparoscopic and robotic surgical approaches to the repair of vesicouterine fistulae have been reported (Miklos, 1999; Tarhan et al, 2007; Ramalingam et al, 2008).

Etiology and Presentation

In the industrialized world, urethrovaginal fistulae most commonly occur as a result of vaginal surgery, including anti-incontinence surgery, anterior vaginal wall prolapse surgery, and urethral diverticulectomy (Henriksson et al, 1982b; Webster et al, 1984; Blaivas, 1989; Glavind and Larsen, 2001). Importantly, with the rising popularity of midurethral synthetic slings for the treatment of stress urinary incontinence, there is the potential for increasing numbers of urethrovaginal fistulae due to iatrogenic urethral injury at the time of sling placement (Reisenauer et al, 2007; Morton and Hilton, 2009) (Fig. 77–27). In the developing world, similar to the etiology of VVF, obstructed labor is the most common cause of urethrovaginal fistulae (Elkins, 1994) (Fig. 77–28). In the setting of obstructed labor, this condition occurs due to extensive ischemic necrosis and often extends beyond the bladder neck, resulting in a combined urethrovesicovaginal fistula. These are extraordinarily challenging cases to repair due to the size of the fistula, ischemia of the surrounding tissues, and implications for continence in those individuals with destruction of the bladder neck and proximal urethra. Fortunately, due to modern obstetrical care in the industrialized world, these are rarely seen. Other causes of urethrovaginal fistulae include radiation therapy for pelvic malignancy, trauma (including pelvic fracture), and vaginal neoplasms. Another important cause in the long-term–care setting is urethral catheter erosion (Trop and Bennett, 1992; Andrews and Shah, 1998). In patients with poor sensation, especially the cognitively or otherwise neurologically impaired patient, pressure necrosis from a chronically indwelling catheter may result in a traumatic hypospadius and urethrovaginal fistula. If not recognized, over time the catheter may erode to the level of the bladder neck and beyond, effectively creating a bivalved urethra and a urethrovesicovaginal fistula (Fig. 77–29).

Symptoms of urethrovaginal fistulae are largely dependent on the size and location of the fistula along the urethral lumen. A small fistula may produce only minimal leakage, whereas a large urethrovaginal fistula can present with continuous urine drainage. 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 vesicovaginal fistulae. Distal fistulae beyond the sphincteric mechanism may be completely asymptomatic or may be associated with a splayed urinary stream. Occasionally, distal fistulae are associated with vaginal voiding and pseudoincontinence, so called because the patient only complains of urinary incontinence when rising from a seated position after voiding. This occurs as a result of urine accumulation in the vagina during voiding, with emptying occurring upon standing—so-called vaginal voiding (Fig. 77–30).

Diagnosis and Management

The diagnosis of urethrovaginal fistula can often be made on physical examination and cystourethroscopy; however, voiding cystourethrography is most useful (Fig. 77–31), especially in complex cases. Small fistulae may be very difficult to locate on physical examination, even with a speculum, due to the surrounding vaginal rugation (Fig. 77–32). It is important to note that an associated vesicovaginal fistula will be found in up to 20% of cases, and therefore a thorough evaluation of the entire lower urinary tract is warranted (Lee et al, 1988).

Endoscopic examination of the urethra should be performed. However, due to its short length, the female urethra may be difficult to fully examine with a standard rigid cystoscope, because the irrigation fluid is discharged 1 to 2 cm proximal to the lens. A flexible cystoscope or a specially designed female cystoscope with a short beak is very helpful in visualizing the entire urethral lumen, because the irrigation fluid is discharged next to the lens, distending the adjacent urethral lumen (Fig. 77–33). Once the diagnosis is made on cystoscopy, the bladder is examined for additional fistulae. Videourodynamics may accurately characterize any associated incontinence, including that associated with detrusor dysfunction. This study also assesses the anatomic relationship of the fistula to the bladder neck and urethra, as well as examines associated VVF.

The surgical repair of urethrovaginal fistulae is challenging and can often be more difficult than repair of VVF. This is due to several factors, including extensive soft tissue defects as well as the lack of local viable tissue for a multilayer repair (Keettel et al, 1978). Repair of urethrovaginal fistulae usually involves the use of rotational vaginal wall flaps, but anterior- (Elkins et al, 1992) and posterior-based (Khanna, 1992) bladder flap tubes have been used as well.

A number of factors should be considered prior to repair. If the fistula is due to a foreign body, such as a synthetic sling (Reisenauer et al, 2007), the foreign material should be excised as widely as possible from the margins of the fistula, debridement performed on the associated devitalized or inflamed tissue and then the fistula closed with healthy tissues and flaps, if necessary. Small fistulae may be managed by a multilayered closure, usually with an interpositional graft such as a Martius flap (Webster et al, 1984; Leach, 1991). Larger fistulae, including those resulting from obstructed labor, may require extensive surgery, including urethral reconstruction (Tehan et al, 1980; Elkins et al, 1992; Wang and Hadley, 1993). Distal fistulae without associated voiding symptoms or incontinence may be observed or, alternatively, can be managed with an extended meatotomy (Lamensdorf et al, 1977). The quality of the vaginal tissues should be optimized prior to operative repair, which may include the use of antibiotics to treat associated infection, or topical estrogen treatment in those patients with significant atrophic vaginitis. Similar to VVF, timing of repair is controversial. Some authors have suggested that a waiting time of 2 to 6 months is advisable in most patients, with a waiting period of up to 1 year in those with radiation fistulae (Webster et al, 1984; Zimmern et al, 1986). Other authors have advocated immediate repair as soon as the vaginal tissues are free of infection and inflammation (Blaivas, 1989; Blaivas et al, 1995).

Etiology and Presentation

Vesicoenteric fistulae commonly occur in the setting of bowel disease, such as diverticulitis, colorectal carcinoma, and Crohn disease. Less common causes include radiation, infection, and trauma—external penetrating trauma, as well as that due to iatrogenic surgical trauma. Diverticulitis is the most common cause of colovesical fistulae in most series, accounting for approximately 70% of cases (Mileski et al, 1987; Pollard et al, 1987; Walker et al, 2002; Najjar et al, 2004) (Table 77–8). The second most common cause of vesicoenteric fistulae is cancer, followed by Crohn disease. The peak incidence of vesicoenteric fisula is between 55 and 65 years of age, although fistulae due to Crohn disease present much earlier (Badlani et al, 1980). Approximately 2% of patients with diverticulitis may experience a colovesical fistula as a complication of their disease (Hafner et al, 1962). In a multi-institutional retrospective review of 400 patients with Crohn disease over a 10-year period, 8 patients (2%) were found to have enterovesical fistulae (Gruner et al, 2002). The underlying GI tract disease strongly influences the type of fistula; ileovesical fistulae are more common in Crohn disease than in cancer, and colovesical fistulae are usually due to diverticulitis.

Table 77–8 Causes of Vesicoenteric Fistulae*

Diverticulitis	65%-75%
Malignancy	10%-15%
Crohn disease	5%-6%
Other (trauma, appendiceal abscess, foreign body)	<5%

* See Morse and Dretler, 1974; Amendola et al, 1984; Pollard et al, 1987; Schofield, 1988; Walker et al, 2002.

Symptoms of vesicoenteric fistulae may originate from the urinary or gastrointestinal tract; however, in general, lower urinary tract symptoms are more common at presentation (Morse and Dretler, 1974; Ray et al, 1976). In the early stages, symptoms are nonspecific and relate to lower urinary tract dysfunction. Lower urinary tract symptoms include pneumaturia, frequency, urgency, suprapubic pain, recurrent urinary tract infections (UTIs), and hematuria (Table 77–9). Pneumaturia is considered the most common presenting symptom noted in 50% to 70% of cases (Morse and Dretler, 1974; Pontari et al, 1992; Jarrett and Vaughan, 1995; Solem et al, 2002). GI symptoms may include fecaluria and tenesmus. The classic presentation of vesicoenteric fistula is described as Gouverneur syndrome and consists of suprapubic pain, urinary frequency, dysuria, and tenesmus (Sans et al, 1986). Recurrent UTIs or cystitis refractory to antibiotic therapy may suggest a colovesical fistula (Rao et al, 1987). Although it is rare for enterovesical fistulae to present with sepsis (Woods et al, 1988), patients presenting with such signs are found to have urinary obstruction in approximately 70% of cases (Mileski et al, 1987).

Table 77–9 Presenting Symptoms of Vesicoenteric Fistula*

Pneumaturia	52%-77%
Fecaluria	36%-51%
Urinary tract infection symptoms (frequency, urgency, dysuria)	44%-45%
Fever and chills	41%
Abdominal pain	25%
Nonspecific gastrointestinal symptoms	25%
Hematuria	5%-22%
Orchitis	10%
Urine per rectum	5%

* Morse and Dretler, 1974; Pontari et al, 1992; Najjar et al, 2004.

Diagnosis

Many studies exist for the diagnosis of enterovesical fistulae; however, there are significant problems with both false negatives and false positives among the diagnostic modalities, and thus the diagnosis is often made on clinical grounds. Cystoscopy has the highest yield in identifying a potential lesion, with some type of abnormality noted on endoscopic exam in greater than 90% of cases (Morse and Dretler, 1974) (Fig. 77–35). However, the findings on cystoscopy are often nonspecific and include localized erythema, papillary, or bullous change; a definitive diagnosis using cystoscopy can be made in only 35% to 46% of cases (Woods et al, 1988; Pontari et al, 1992). Cystoscopy and biopsy of abnormal-appearing tissue, or an established fistula tract in the setting of a history of malignancy is indicated to evaluate for the possibility of a malignant fistula.

Cross-sectional imaging, especially CT scanning has become the imaging modality of choice (Goldman et al, 1984; Goldman et al, 1985; Jarrett and Vaughan, 1995; Gruner et al, 2002). CT or MRI (Haggett et al, 1995) may localize the fistula tract, as well as the involved segment of bowel. The triad of findings on CT that are suspicious for colovesical fistulae consist of (1) bladder wall thickening adjacent to a loop of thickened colon, (2) air in the bladder (in the absence of previous lower urinary manipulation), and (3) the presence of colonic diverticula (Labs et al, 1988). Labs and colleagues (1988) correctly diagnosed colovesical fistulae on CT in 11 of 12 patients with surgically confirmed lesions. CT is now generally considered to be the most sensitive and specific modality for the diagnosis of colovesical fistulae in suspect patients (Najjar et al, 2004), with diagnostic accuracy as high as 90% to 100% (Goldman et al, 1985; Jarrett and Vaughan, 1995). The high diagnostic accuracy of CT in detecting enterovesical fistulae relates to its ability to detect even a very small amount of air in the bladder (Fig. 77–36). Although air in the bladder on diagnostic imaging is very suggestive of colovesical fistulae, false positives may be created by recent instrumentation (catheterization, cystoscopy) or an active UTI with a gas-forming organism. CT scanning should be done after the administration of oral contrast but prior to the administration of intravenous contrast to permit detection of barium within the bladder. Ultrasonagraphy has also been reported to be useful in the diagnosis of colovesical fistulae. A characteristic “beak” sign may be noted; however, this study is not usually performed in the routine evaluation of the patient with a suspected enterovesical fistula (Chen et al, 1990).

Although commonly used, cystography and transrectal contrast studies (e.g., barium enema) are generally less likely to demonstrate the fistula. Rao and colleagues (1987) reported that 14 of 24 barium enemas either demonstrated or were suspicious for colovesical fistulae in a series of surgically treated patients. Barium enemas and/or colonoscopy may be valuable adjunctive studies in evaluating for colonic disease, such as malignancy, as a cause of the fistula; the preoperative knowledge of such a condition can considerably alter management decisions. Nevertheless, barium enemas have limited utility in the diagnosis of enterovesical fistulae due to low sensitivity (Amendola et al, 1984). The Bourne test, however, can be a useful adjunctive study in the evaluation of colovesical fistulae (Bourne, 1964). As described, the Bourne test is performed following a nondiagnostic barium enema. The first voided urine following the barium enema is immediately centrifuged and then examined radiographically. Radiodense particles in the urine are considered a positive test and evidence for a vesicoenteric fistula. Amendola and colleagues (1984) reported a positive Bourne test in 9 of 10 patients with colovesical fistulae; the Bourne test was the only evidence for a colovesical fistula in 7 such patients who had an otherwise negative evaluation with a combination of other diagnostic studies.

The diagnosis of vesicoenteric fistulae may be confirmed by the oral administration of activated charcoal which, in the setting of a fistula, will appear in the urine as black particles (Geier et al, 1972). This test provides no anatomic information regarding the location of the fistula but is useful in confirming the diagnosis in suspect cases. Intrarectal administration of vital dyes has been advocated for the diagnosis of occult colovesical fistula; however, the dye may be absorbed and then excreted in the urine, giving a false positive test (Deshmukh et al, 1977).

Management

Nonoperative management is a viable option in selected patients with vesicoenteric fistula. Amin and colleagues (1984) reported on 4 of 30 patients with colovesical fistulae secondary to diverticulitis who were observed without active intervention for 3 to 14 years. There were no significant long-term sequelae in this select patient population. In nontoxic, minimally symptomatic patients with nonmalignant causes of enterovesical fistulae, a trial of medical therapy including intravenous total parenteral nutrition (Dudrick et al, 1999), bowel rest, and antibiotics may be warranted. This may be the preferred initial approach, especially in patients with Crohn disease, in whom the notion of immediate exploratory laparotomy and bowel resection is often discouraged due to the chronic relapsing nature of the disease (Evans et al, 2003a). There is also the potential for successful medical management of other fistulae resulting from inflammatory bowel disease (Mahadevan et al, 2003; Parsi et al, 2004).

The goal of operative management is to separate and close the involved organs with minimal anatomic disruption and normal long-term function of both systems. Unfortunately, enterovesical fistulae may be complicated by intense pelvic inflammation, pelvic abscess, and phlegmon formation (in some cases), requiring complex staged reconstructions (Shackley et al, 2000). Bowel resection and/or partial cystectomy may be necessary to obtain viable tissue margins to ensure adequate, watertight closure of the involved viscera. An interpositional flap of greater omentum is often placed between the repaired bowel and urinary bladder to prevent overlapping suture lines and provide a well-vascularized surface for healing.

Both single and multistage procedures have been advocated, depending on the clinical circumstances (Morse and Dretler, 1974; Castro, 1975; Ray et al, 1976; Morrison and Addison, 1983; Mileski et al, 1987; Pollard et al, 1987; Rao et al, 1987; Shackley et al, 2000; Walker et al, 2002; Najjar et al, 2004). A one-stage procedure involves removal of the fistula, closure of the involved organs, and primary reanastomosis of the bowel following resection of the involved bowel segment. A two-stage approach advocates removal of the fistula, closure of the involved organs, and creation of a temporary proximal diverting colostomy, with a later return to the operating room for colostomy takedown once the fistula tract is demonstrated to be closed. The choice of whether to proceed with a one-stage or two-stage repair is influenced by the location and cause of the fistula, the patient’s general condition, the presence of a pelvic abscess, and the presence of colonic obstruction (McConnell et al, 1980). Patients with an inflammatory cause of the fistula, but without gross contamination, can be treated with a one-stage procedure, whereas those with an unprepared bowel, gross contamination, or abscess may require a multistage procedure (Mileski et al, 1987; Shackley et al, 2000). As noted previously, most patients with colovesical fistulae present electively with lower urinary tract symptoms, not emergently in extremis with sepsis (Mileski et al, 1987). Therefore adequate preoperative support, including bowel preparation, nutritional supplementation, and appropriate antibiotics can be used in the majority of cases allowing an elective one-stage approach.

Laparoscopic management of colovesical fistulae has been reported, albeit with a relatively high rate of conversion to open repair (Joo et al, 1997).

Etiology and Presentation

The incidence of rectourethral fistulae following radical retropubic prostatectomy (RRP) is low, but due to the frequency with which the operation is performed, it is the most common etiology of RUF in most modern series (Stephenson and Middleton, 1996; Nyam and Pemberton 1999; Renschler and Middleton, 2003). Rectal injury during radical prostatectomy occurs in less than 1% to 2% of patients (Igel et al, 1987; Borland and Walsh, 1992; McLaren et al, 1993; Guillonneau et al, 2003). In a Mayo RRP series, there were 27 documented rectal injuries in 2212 patients (McLaren et al, 1993). In this series, 26 of 27 injuries were recognized intraoperatively and repaired. Six patients underwent temporary colostomy and 4 patients developed RUF. In a community-based practice, Harpster and colleagues (1995) reported rectal injuries in 7 of 516 patients undergoing RRP (1.4%) and in 1 of 17 patients undergoing radical perineal prostatectomy (Harpster et al, 1995). Five rectal injuries were recognized and repaired intraoperatively. There were three RUF reported in this series; none closed with conservative management and all required formal repair. In 2003, Rassweiler and colleagues reported one RUF in a series of 219 patients undergoing RRP but seven RUF in 538 patients undergoing laparoscopic radical prostatectomy. All operations were performed by the same surgical team. Guillonneau and colleagues (2003) reported a 1.3% incidence of rectal injury in 1000 consecutive patients undergoing laparoscopic radical prostatectomy. Eleven of 13 injuries were recognized and repaired intraoperatively with a two-layer closure. One of these patients subsequently underwent temporary colostomy for complications related to the injury. Both patients with rectal injuries that were recognized postoperatively underwent colostomy. One of the 2 patients presenting late with a rectal injury developed a RUF requiring a primary surgical closure.

In the setting of radical prostatectomy, a prior history of pelvic radiation therapy, rectal surgery, or TURP is associated with an increased risk of RUF (Thompson and Marx, 1990; McLaren et al, 1993). RUF that occur following radical prostatectomy are usually seen at the vesicourethral anastomosis and are often due to an unrecognized rectal injury at the time of surgery. However, when a rectal injury is recognized and repaired intraoperatively, RUF is extremely uncommon. Borland and Walsh reported 10 rectal injuries in 1000 nonirradiated patients undergoing radical prostatectomy at Johns Hopkins Hospital; however, no patient developed a rectourethral fistula (Borland and Walsh, 1992). Nine of 10 patients had a two-layer closure performed with an omental interpositional flap at the time of injury. One patient underwent a temporary diverting colostomy as the rectal injury was diagnosed and repaired postoperative day 2. Anal sphincter dilation performed on all patients, and they received 7 to 14 days of postoperative antibiotics.

The reported incidence of RUF following cryosurgical ablation as primary therapy for localized carcinoma of the prostate is between 0.5% and 2% (Zippe, 1996; Long et al, 2001), whereas the rate of RUF following cryotherapy as salvage therapy for prostate cancer is somewhat higher at approximately 3.3% (Chin et al, 2001). The incidence of RUF following brachytherapy for prostate cancer, reported by Theodorescu and colleagues (2000), is 0.4%. Rectourethral fistulae have also been reported following high-intensity focused ultrasound treatment (HIFU) (Uchida et al, 2002; Blana et al, 2004), HIFU combined with external beam radiotherapy (6% incidence) (Gelet et al, 2004), laparoscopic radical prostatectomy (Guillonneau et al, 2003; Katz et al, 2003; Rassweiler et al, 2003; Dafnis et al, 2004), and transurethral thermotherapy for benign prostatic hyperplasia (BPH) (Norby and Frimodt-Moller, 2000). The incidence of RUF in Crohn disease is estimated to be approximately 0.3% (Stamler et al, 1985) (Fig. 77–38). Fistulae due to Crohn disease are complex, and management should be individualized (Stamler et al, 1985; Fazio et al, 1987; Santoro et al, 1995; Cools et al, 1996; Rius et al, 2000).

The presentation of rectourethral fistula is variable. Symptoms may include fecaluria, hematuria, UTI, nausea, vomiting, and fever. Peritonitis and sepsis may occur as well. Digital rectal examination often permits palpation of the fistula tract along the anterior rectal wall. Cystoscopy and sigmoidoscopy (Shin et al, 2000) visualize the fistula tract in the vast majority of cases and provide a mechanism for biopsy. In patients with a history of pelvic malignancy, biopsy of the fistula is suggested to evaluate for a local recurrence of the tumor (Shin et al, 2000). Voiding cystourethrography (VCUG) or retrograde urethrography (RUG) usually provide a definitive diagnosis of RUF (Fig. 77–39). The exact anatomic location and size of the fistula is also usually well delineated on VCUG or RUG, providing important information in surgical planning. Lateral projections may be necessary to visualize small fistulae, because contrast in the rectum or urethra can sometimes obscure extremely thin fistulous tracts. Upper tract imaging should be performed in patients with rectourethral fistulae to exclude a related ureteral injury. It is important to make an assessment of continence and sphincteric function in patients with RUF following radical prostatectomy. Given the location of most RUF at or near the vesicourethral anastomosis and the membranous urethra, there is a risk for persistent severe stress incontinence postoperatively following RUF repair (Ghoniem et al, 2008). In patients with RUF and severe stress incontinence, closure of the RUF may not be sufficient to bring about continence in many patients. Additional procedures may be needed to bring about a satisfactory result in these patients; this is an important issue to discuss in preoperative patient counseling.

Management

Most RUF will require surgical repair (Bukowski et al, 1995; Stephenson and Middleton, 1996) although it is clear that some will close with conservative management. RUF following open or laparoscopic prostatectomy may heal spontaneously with catheter drainage, bowel rest, and intravenous hyperalimentation. In some cases, fecal diversion is necessary. Rassweiler and colleagues (2003) reported that 6 of 8 RUF patients were treated successfully in such a manner. Two patients required a temporary colostomy. Noldus and colleagues (1999) reported closure with conservative management in 7 of 13 patients with RUF following radical prostatectomy or cystoprostatectomy. Six patients eventually were successfully closed with a transanal Latzko procedure (see below). Successful minimally invasive management has been reported, as well, using endoscopic suturing, fulguration of the fistula tract, and the application of fibrin glue (Wilbert et al, 1996).

Surgical repair of RUF can be challenging, and the basic tenets of operative fistula repair are especially relevant in these cases (see Table 77–2). Several surgical approaches have been advocated and are outlined below. Single and staged repairs have been described for the repair of RUF. The controversy surrounding the staged repair centers on the issue of whether or not to perform fecal diversion at all, or to perform it prior to or at the time of repair of the urinary tract. Some authors have advocated fecal diversion and staged repair of all RUF (Shin et al, 2000). This is considered the standard conservative approach and, in combination with an indwelling urethral catheter, permits a trial of spontaneous healing of the fistula without open manipulation of the urinary tract. In support of the single-stage repair, a successful one-stage approach limits the potential morbidity and cost of multiple procedures that, by design, accompanies the staged repair. Suggested guidelines for cases in which a one-stage approach might be appropriate include surgically induced, small RUF not associated with infection, an abscess, or a poor bowel preparation (Wood and Middleton, 1990; Nunoo-Mensah et al, 2008). Staged repairs might be considered in cases of large fistulae, those associated with radiation therapy, uncontrolled local or systemic infection, immunocompromised states, or inadequate bowel preparation at the time of definitive repair (Stephenson and Middleton, 1996; Nunoo-Mensah et al, 2008).

Transrectal approaches with and without division of the anal sphincter have been described for the operative repair of RUF. The York-Mason procedure is a transrectal, transsphincteric approach that has been found to be effective and with low morbidity (Henderson et al, 1981; Prasad et al, 1983; Wood and Middleton, 1990; Stephenson and Middleton, 1996; Fengler and Abcarian, 1997; Renschler and Middleton, 2003). Classically, this is a staged repair with fecal diversion performed prior to repair of the RUF. However, in patients with small, nonirradiated fistulae, a single-stage approach can be used, provided that a vigorous bowel prepapration and broad-spectrum antibiotics are used (Renschler and Middleton, 2003). For repair of the urinary tract, the patient is placed prone on the operating room table in the jack-knife position. A full-thickness incision through the posterior anus and dorsal rectal wall is performed and deepened down to the level of the coccyx through the external anal sphincter (Fig. 77–40). Care is taken to mark or tag each layer of the anal sphincter as it is divided. Later in the procedure during closure, careful anatomical reapproximation of the layers of the external anal sphincter is necessary to avoid the devastating complication of anal incontinence postoperatively. The anorectal incision as described provides excellent exposure of the fistula in the anterior rectal wall. The fistula tract is excised, and the anterior rectal wall is mobilized circumferentially around the fistula margins. The urethra is closed, and then the anterior rectal wall is closed. Finally, the rectal mucosa is reapproximated, providing a three-layer closure. Alternatively, following excision of the RUF, an anterior rectal wall flap can be developed and advanced over the fistula (al-Ali and Kashmoula, 1997), similar to the transvaginal repair of VVF using the vaginal wall (see previous discussion under VVF repair). Closure of the incision is performed by reapproximating the posterior rectal wall and then sequentially closing the layers of the anal sphincter in an anatomic fashion. Results with the York-Mason procedure have been excellent. In the largest series of patients undergoing the York-Mason procedure, Renschler and Middleton (2003) reported a successful repair in 22 of 24 patients. One of the two failures was subsequently repaired with another York-Mason procedure. No serious complications were reported, and no patient developed anal incontinence or anal stenosis. Similar excellent results have been noted by other authors (Prasad et al, 1983; Bukowski et al, 1995; Fengler and Abcarian, 1997).

In contrast to the transrectal, transsphincteric approach, the transanal approach to RUF repair does not involve division of the anal sphincter. Exposure of the fistula is provided by dilation of the anus and fixed retraction. The Latzko procedure is one such approach (Noldus et al, 1999; Hata et al, 2002). Similar to the Latzko method described previously for transvaginal VVF repair (see prior discussion), the fistula tract and surrounding rectal mucosa is denuded in all four quadrants. The fistula is then closed in three layers. The major disadvantage to this approach is the relatively poor exposure and lack of maneuverability within the operative field. Rectal advancement flaps have also been used to successfully treat RUF through a transanal approach (Fazio et al, 1987; Dreznik et al, 2003; Garofalo et al, 2003).

A perineal approach to RUF has been advocated by some authors in selected cases of RUF (Bukowski et al, 1995; Nyam and Pemberton, 1999; Youssef et al, 1999; Zmora et al, 2003). Anatomically, this is a familiar approach for many urologists and has the added advantage of local access to a variety of potential interpositional flaps. Excellent results have been obtained with the perineal approach in combination with an interpositional flap, including gracilis muscle (Ryan et al, 1979; Rius et al, 2000; Zmora et al, 2003; Ghoniem et al, 2008; Gupta et al, 2008), pedicled Dartos muscle (Venable, 1989; Youssef et al, 1999; Yamazaki et al, 2001; Varma et al, 2007), penile skin (Morgan, 1975), levator muscle (Goodwin et al, 1958), and bladder (Kokotas and Kontogeorgos, 1983). Transabdominal approaches to RUF have been described with limited success (Bukowski et al, 1995; Nyam and Pemberton, 1999; Shin et al, 2000). The principal advantage of this technique is the availability of greater omentum for an interpositional flap. Potential disadvantages include the morbidity and prolonged postoperative convalescence associated with a laparotomy incision, poor exposure of the operative field (with limited maneuverability in the deep pelvis), and the risk of urinary and fecal incontinence.

The repair of rectourethral fistulae following external beam radiotherapy, (Chrouser et al, 2005), combined radiotherapy (Marguet et al, 2007), brachytherapy (Lane et al, 2006), or cryosurgical ablation of the prostate can be especially difficult (Izawa et al, 2000a; Elliott et al, 2006). These fistulae may be large and are associated with considerable induration, fibrosis, and ischemia for a variable distance around the fistula limiting reconstructive options. Urinary reconstruction may not be possible in some of these cases, necessitating urinary diversion. Moreira and colleagues (2004) reported on 11 cases of RUF following brachytherapy for the treatment of prostate cancer, all of whom underwent diverting colostomy. Three patients with satisfactory baseline continence underwent primary repair by a York-Mason approach with a gracilis flap; 7 patients underwent urinary diversion combined with radical pelvic surgery (6 cystoprostatectomy, 1 prostatectomy); and 1 refused repair. Izawa and colleagues (2000b) reported on the management of severe complications of cryosurgical ablation of the prostate, including two cases of prostatopubic fistulae and one rectourethral fistula. Two of these patients underwent cystoprostatectomy, and one had a bladder neck closure and continent reconstruction.