urethrovaginal fistula

Learning moments about UVF

1. Learning moments Urethrovaginal fistula

2. 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).

3. Other causes of urethrovaginal fistulae include radiation therapy for pelvic malignancy , trauma (including pelvic fracture), and vaginal neoplasms.

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

5. 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 esicovaginal fistulae .

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

7. 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

8. Distal fistulae without associated voiding symptoms or incontinence may be observed or, alternatively, can be managed with an extended meatotomy ( Lamensdorf et al, 1977).

9. The repair of urethrovaginal fistulae is conceptually very similar to the vaginal flap repair of VVF

10. A variety of adjuvant procedures have been used in the repair of urethrovaginal fistulae, including , most commonly, a Martius labial fat flap, but also gracilis and rectus abdominis muscle, myocutaneous flaps, vaginal wall flaps, fibrin glue, and free labial skin grafts ( Keettel et al, 1978; McKinney , 1979; Tolle et al, 1981; Webster et al, 1984; Krogh et al, 1989 ; Leach, 1991; Izes et al, 1992; Candiani et al, 1993; Fall, 1995 ; Rangnekar et al, 2000b).

11. Stress incontinence (SUI) may persist following repair of urethrovaginal fistulae. Whether repair of SUI should be done concomitantly with the fistula surgery, or should be deferred until after repair of the fistula, is controversial

12. Blaivas and colleagues (1989) argued that sphincteric incontinenceshould be repaired at the time of fistula surgery with aMartius flap interposed between the fistula repair and a pubovaginal fascial sling. Webster and colleagues (1984) suggested that stress incontinence (SUI) associated with a proximal or midurethral urethrovaginal fistula should not be corrected until the fistula is closed and the patient reassessed for persistent incontinence.

13. These authors suggest, however, that SUI associated with distal urethrovaginal fistula can be repaired concomitantly . Overall, the success rate of urethrovaginal fistula repair is variable but is not generally considered to be as high as that for VVF repair (Gerber and Schoenberg, 1993). Not uncommonly, two or more procedures may be necessary to gain a satisfactory result (Webster et al, 1984).