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Vesicovaginal or Ureterovaginal Fistulas After Pelvic Surgery

What is a vesicovaginal fistula (VVF)?

A vesicovaginal fistula is a hole between the bladder and vagina. Depending on the size of the hole, the urine will drain continuously out the vagina, requiring multiple pullups or pads.

How does a VVF occur?

In the US, the most common cause for a VVF is bladder injury that occurs during a hysterectomy (uterus removal). Bladder injuries most commonly occur during open abdominal hysterectomies, followed by laparoscopic assisted vaginal hysterectomies. Bladder injury during a vaginal hysterectomy is very uncommon.

When does a VVF present?

Most VVF present within days of the hysterectomy. Initially, leakage from the vagina may be confused from peritoneal fluid that leaks from the vaginal cuff.

How is a VVF diagnosed?

VVF diagnosis is typically made in the office by performing what is called a “pad test”. Here a gauze pad is packed in the vagina. The bladder is then filled via a catheter with blue-dyed water. A blue stained vaginal gauze confirms a VVF. Aside from the pad test, the urologist will look in the bladder and vagina with a telescope (cystoscope), and perform a pelvic exam. About 10% of the time, aside from the VVF, there is also ureterovaginal fistula – a hole between the ureter and the bladder.

How is a ureterovaginal fistula (UVF) diagnosed?

UVF is usually diagnosed by a CT urogram of the pelvis. If the ureter is not well visualized on the CT, then dye can be injected into the ureter through a telescope placed in the bladder. A UVF can also be suggested by the vaginal “pad test” used to diagnose a VVF – here the patient is given an oral medicine that stains the urine orange-red. If the vaginal gauze stains orange-red, then a UVF is typically also present.

Evaluation of the ureter is always part of the VVF evaluation.

What is the best timing for VVF surgical repair?

Once the inflammation has gone down after hysterectomy surgery, a VVF surgical repair is safe to perform. If the fistula is still inflamed and friable, the success rate of repair goes down. For this reason, is important to wait a few weeks before undergoing repair. Waiting months for surgery is unnecessary and does not improve success.

How is a VVF surgically repaired?

There are two main methods of repairing VVF through surgery – one through the vagina and the other through an incision in the abdomen.

Most VVF can be repaired through a vaginal incision. If the hole is large, a pad of fat from the side of the vagina can be harvested and sewn as a patch to the fistula. This fat pad is called a “Martius flap” and harvesting it requires a separate incision on the side of the vagina. If the fistula is also the result of pelvic radiation, a muscle from the leg can be rotated off the leg and into the vagina to act as a patch.

Fistulas that are very high in the vagina and/or close to the ureter in the bladder often require an abdominal approach because the hole may be difficult to reach through the vagina. If the ureter is involved, it may need to be resewn to the bladder – which is much easier to perform via the abdomen. If the VVF is repaired though an abdominal incision, the fistula is sewn closed. The fistula is also patched with a fat pad taken from the stomach.

How is a ureterovaginal fistula (UVF) repaired?

A UVF is usually repaired by cutting the ureter and resewing it to the bladder. In select cases, a stent (plastic tube) can be placed via the bladder up the cut end of the ureter and into the kidney. If this stent can be placed, the UVF will often heal without the need for a major surgery.