Postoperative Urinary Fistulae
Editor: Ronald T. Burkman, MD
Although it has been estimated that the risk of injury to the urinary tract is 1% during pelvic surgery, particularly hysterectomy, many of these injuries are occult. When routine cystoscopy is performed following hysterectomy, bladder injury is identified in about 3% of patients and ureteral injury in about 2%.
While fistulae can result following surgery in an anatomically normal field, the most common risk factor associated with urinary fistulae after pelvic surgery is anatomical distortion. Common causes include embryologic anomalies (e.g. double ureters), prior surgeries (e.g. cesarean delivery, renal transplant), fibroids (especially paracervical), severe endometriosis, severe acute or chronic inflammatory disease (including fibrosis from prior surgery or radiation), and cancer. Fistulae also are more common with abdominal and laparoscopic hysterectomies.
When recognized at the time of surgery, injuries should be repaired immediately if possible. Occult injuries to the bladder or ureters may lead to leakage of urine outside of the collection system, usually tracking to the vaginal cuff, resulting in either a vesicovaginal or ureterovaginal fistula.
Preventive strategies are important. During surgical procedures, optimal exposure of adjacent anatomical structures should be maximized. In general, sharp, rather than blunt dissection is advised, especially for the vesicouterine plane following one or more cesarean deliveries. While some suggest placement of ureteral stents preoperatively, others contend that they increase the risk of injury to the ureter. In general, ureteral stents are not required to aid in the identification of normal anatomy.
If fluid of uncertain origin is pooling in the vaginal vault in a postoperative patient, it can be sent for a creatinine level. A result significantly above the serum creatinine confirms that the fluid is urine.
The simplest diagnostic test for a vesciovaginal fistula is the “tampon test”. Sponges or tampons are placed in the vagina and the bladder is filled with an identifiable fluid, usually methylene blue or Indocyanine Green (Indigo Carmine is no longer available). The patient is then asked to walk for a short interval before being examined. The presence of blue or green dye on the tampon or sponge suggests a defect from the bladder to the vagina. If there is no staining, but a urinary fistula is strongly suspected, phenazopyridine 200 mg orally may be administered. Orange staining, usually within 1-2 hours, confirms the diagnosis of a ureterovaginal fistulae. Further imaging should be performed to evaluate for possible ureteral obstruction.
Many small vesicovaginal fistulae will close if the bladder is continuously drained with a Foley catheter. The addition of estrogen or urinary antibiotics may facilitate healing. If a ureteral defect is noted, it may also spontaneously heal if a ureteral stent can be placed. If conservative management is not possible or successful, surgical intervention may be necessary to resolve the defect. These procedures are usually carried out 3-4 months after the injury.
American Urogynecology Society. Position Statement: Indigo Carmine Shortage. July 2014. Accesses at: https://www.augs.org/assets/1/6/AUGS_Indigo_Carmine_7.22.14.pdf, August 5, 2016
Sharp HT, Adelman MR. Prevention, recognition, and management of urologic injuries during gynecologic surgery. Obstet Gynecol. 2016 Jun;127(6):1085-96. doi: 10.1097/AOG.0000000000001425.
Initial approval December 2009. Revised and reaffirmed September 2016, Reaffirmed January 2018.
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