The prevention and management of gynaecological fistulas always remains a big challenge. In gynaecological fistulas, most common are vesicovaginal fistula, then ureterovaginal fistula followed by vesicouterine fistula. The rate was highest among women who had hysterectomy for  cervical cancer. Isolated ureterovaginal fistula is rare. Patients with ureterovaginal fistula usually presents with continuous urinary incontinence with normal voiding in between, constitutional symptoms of fever, chills, malaise if infection or pelvic collection and some times flank pain secondary to hydronephrosis. Patient can present lately with poorly functioning of kidney. So early diversion or corrective surgery is warranted in this condition. Most common site involved is lower ureter near uterine vessels. The aim of this study is to describe our experience of management of iatrogenic uretero-vaginal fistula resultant of gynecological surgery  over a span of 10 years and outcomes.

We reviewed our database from 2011-2020 and followed up this cohort of patient prospectively for outcomes.

A total of 26 patients with uretero-vaginal fistula were identified. None of this cohort of patients had concurrent vesico-vaginal fistula. Mean age of patient was 39 years.  Six patients had laparoscopic hysterectomy, 17  open transabdominal hysterectomy ( including 3 caesarean hysterectomy for hemorrhage), 3 underwent transvaginal hysterectomy. Most common indication of hysterectomy was fibroid uterus. Mean time to develop symptoms was 5 days after surgery.  All patients presented with continuous urine leak with normal voiding in between. Diagnosis was made with Contrast enhanced CT KUB with CT Urogram scan in all patients. Mean time for  corrective surgery was 9 months (1 month-3 years). 14 patients had percutaneous nephrostomy placed prior to surgery as a diversion measure. Kidney function was preserved in all patients. Before definitive surgery, check cystoscopy to rule out vesicovaginal fistula and nephrostogram was done in all patients. 23 patients underwent open extraperitoneal ureteroneocytostomy. 2 out of 23 patients needed Boari reconstruction as an adjunctive to ureteroneocystostomy. 1 patient underwent robot assisted and 1 underwent laparoscopic ureteroneocystostomy (transperitoneal). All the procedures used modified Lich-Gregoir technique for ureteric reimplantation. 1 patient was treated with just DJ stenting, which was attempted due to partial injury.Mean time to discharge after primary surgery leading to iatrogenic fistula was 17 days. Urethral catheters were removed at a mean of 10 days and DJ stents were removed at a mean of 4 weeks. Mean follow up of patient is 5 years (1-10 years). None of the patient had recurrent symptoms and all the patients are completely dry at present.

Immediate DJ stenting can be attempted in a case of partial injury. Otherwise all need ureteric reimplantation with or without Boari's flap.

Ureterovaginal fistulae are complicated by virtue of their cause and can be well managed by minimally invasive or open surgery. At times Psoas hitch or Boari's reconstruction is warranted.