Management and Outcomes of Urethrovaginal Fistula Repair

Barratt R1, Kotes S1, Pakzad M H1, Hamid R1, Ockrim J L1, Greenwell T J1

Research Type

Clinical

Abstract Category

Urethra Male / Female

Abstract 165
Open Discussion ePosters
Scientific Open Discussion Session 7
Wednesday 29th August 2018
12:40 - 12:45 (ePoster Station 10)
Exhibition Hall
Female Surgery Fistulas
1. University College London Hospital
Presenter
R

Rachel Barratt

Links

Poster

Abstract

Hypothesis / aims of study
Urethrovaginal fistulae (UVF) are a rare occurrence, particularly given recent improvements in obstetric care. As a result there is a paucity of literature on the management and outcomes for this condition. As a specialist referral centre for Genitourinary fistulae we evaluated our own cohort of patients undergoing UVF repair to report on the management and outcomes of this condition.
Study design, materials and methods
A prospective database was kept of patients with genitourinary fistulae at a single institution. This was interrogated to identify patients undergoing UVF repair over an 11 year period (March 2004-May2015). Data sets collected included: Demographics, aetiology, operative intervention, outcomes and post-operative continence. This analysis identified 24 patients with a median age of 53.3years (range 26-78years). Except for 2 patients with concurrent vesicovaginal fistulae (VVF), all patients underwent pre-operative video-urodynamics and peri-operative cysto-urethroscopy. Any women with post-operative incontinence underwent video-urodynamics to confirm aetiology and plan subsequent treatment.
Results
The aetiology of UVF in our cohort was varied but the majority were iatrogenic in nature. This is outlined in full in Table 1. 


23 (95.8%) patients underwent vaginal repair of UVF with modified martius fat pad interposition. All (100%) had successful anatomical closure. 
1 patient developed a complex urethra-vaginal-vesical fistula after obstructed labour and vaginal repair was not possible. Bladder neck closure with clam ileocystoplasty and mitrofanoff channel formation was performed. The patient is continent and has a functional, catheterisable channel at 13 years follow-up. 

The continence outcomes for patients undergoing vaginal repair of UVF is outlined in Figure 1.
Interpretation of results
Vaginal repair of UVF is feasible in the majority of cases and gave 100% anatomical closure in our cohort.  
In terms of continence outcomes, 6 patients (6/22) who underwent pre-operative video-urodynamics had urinary incontinence – 3 had pure urodynamic stress urinary incontinence (USUI) and 3 had mixed urinary incontinence (MUI). All patients with pre-operative urinary incontinence persisted post-operatively. 
For the patients with USUI, 2 patients achieved continence after insertion of a rectus fascial sling. 1 patient underwent a TVT-O which, unfortunately, failed with ongoing incontinence. In the patients with MUI the stress component was treated with a rectus fascial sling (n=3) and the urge component treated with sacral neuromodulation (n=1) and intravesical botulinum toxin (n=2). All patients in this group are continent. 
De novo USUI occurred in 2 patients (8.3%) and was treated successfully in both cases with colposuspension.
Concluding message
In this large cohort of patients, aetiology is often iatrogenic with mid-urethral tape insertion and urethral diverticulectomy being the commonest causes. Vaginal repair is possible in 95.8% of cases with 100% anatomical closure success rates. For complex cases bladder neck closure with continent urinary diversion is a viable alternative. Post-operative urinary incontinence, of any description, occurs in 34.8% of cases and requires surgical intervention with success rates of 87.5%.
Figure 1
Figure 2
Disclosures
Funding None Clinical Trial No Subjects Human Ethics not Req'd Audit of current practise - no experimental component Helsinki Yes Informed Consent No
27/03/2024 16:53:39