From the Guidelines
Yes, a urethrovaginal fistula (UVF) is a potential complication of urethral diverticulectomy. This surgical procedure, which involves removing a urethral diverticulum (an abnormal pouch or sac that forms along the urethra), carries a risk of creating an abnormal connection between the urethra and vagina. The reported incidence of UVF following diverticulectomy ranges from 0.9% to 5% of cases, as noted in various studies 1.
Key Considerations
- The surgical dissection takes place in a confined anatomical space where the urethral and vaginal tissues are in close proximity, increasing the risk of damage to both urethral and vaginal walls simultaneously, leading to fistula formation.
- Risk factors that increase the likelihood of UVF development include previous pelvic surgeries, radiation therapy, complex or horseshoe-shaped diverticula, and diverticula located at the distal urethra.
- According to the 2017 AUA/SUFU guideline, physicians should not utilize a synthetic MUS in patients undergoing concomitant urethral diverticulectomy, repair of urethrovaginal fistula or urethral mesh excision and SUI surgery 1.
- The decision to use synthetic materials should be based on the judgment of the surgeon and made in the best interests of the patient, considering the potential risks of subsequent urethral erosion, vaginal extrusion, urethrovaginal fistula, and foreign body granuloma formation 1.
Clinical Implications
- Patients who develop a UVF typically present with continuous urinary leakage through the vagina, recurrent urinary tract infections, and vaginal irritation.
- The most recent and highest quality study, the 2017 AUA/SUFU guideline 1, provides a clear recommendation against using synthetic MUS in patients undergoing concomitant urethral diverticulectomy, highlighting the importance of careful patient selection and surgical technique to minimize the risk of complications.
From the Research
Urethrovaginal Fistula as a Complication of Urethral Diverticulectomy
- Urethrovaginal fistula (UVF) is a potential complication of urethral diverticulectomy, as reported in several studies 2, 3, 4, 5.
- The occurrence of UVF after urethral diverticulectomy is attributed to various factors, including the surgical technique, location and size of the diverticulum, and patient-related factors 3.
- Studies have shown that UVF can occur as a result of transvaginal excision of urethral diverticulum, highlighting the importance of careful and meticulous surgical procedures to avoid such complications 2, 3.
- The management of UVF after urethral diverticulectomy typically involves surgical repair, which may include the use of a Martius flap to improve the likelihood of a successful outcome 5.
Risk Factors for Urethrovaginal Fistula
- Delayed diagnosis, size of the diverticulum over 4 cm, and lateral or horseshoe shape of the diverticulum are identified as significant risk factors for complications, including UVF, after urethral diverticulectomy 3.
- The location of the diverticulum, with posterior development being more common, may also influence the risk of UVF 3.
Surgical Considerations
- The choice of operative position, such as the Jackknife prone reverse-lithotomy position, can facilitate safe and accurate dissection and suturing, reducing the risk of complications like UVF 2.
- Adherence to principles of reconstructive surgery, including removal of the entire urethral diverticulum wall, watertight closure of the urethra, and preservation or creation of continence, is crucial to minimize the risk of UVF and other complications 4.