From the Guidelines
The first step in therapy for a woman who develops a ureterovaginal fistula 14 days after a hysterectomy is to initially manage the patient with ureteral stent placement when possible, as this approach has reported success rates of 64%-100% in resolving the fistula without the need for further surgical intervention. This recommendation is based on the latest guidelines from the American Urological Association, as outlined in the 2020 urotrauma guideline 1. The use of ureteral stent placement is supported by evidence showing that it can effectively divert urine away from the fistula site, allowing the injured ureter to heal.
Key considerations in the management of ureterovaginal fistula include:
- Initial assessment to determine the feasibility of ureteral stent placement
- Performance of the stent placement procedure by a urologist under fluoroscopic guidance
- Maintenance of the diversion for 4-6 weeks to allow the fistula to heal spontaneously
- Monitoring for signs of infection, obstruction, or persistent leakage during the diversion period
As noted in the guideline statement, if stent placement fails, additional surgical intervention, such as ureteral reimplantation, may be pursued 1. However, the initial approach with ureteral stent placement is preferred due to its less invasive nature and potential for high success rates in resolving the ureterovaginal fistula.
From the Research
Ureterovaginal Fistula Therapy
The first step in therapy for a woman who develops a ureterovaginal fistula 14 days after a hysterectomy involves:
- Conservative management with ureteral stenting, as this approach has been shown to be successful in treating ureterovaginal fistulas in a significant number of cases 2
- Ureteral stenting is considered first-line therapy for posthysterectomy ureterovaginal fistulas, with high cure rates reported in carefully selected patients 2
- The stent is typically left in place for an average of 66 days, although the duration may vary depending on the individual case 2
Indications for Surgical Intervention
Surgical intervention, such as ureteroneocystostomy, may be necessary in cases where:
- Conservative management with ureteral stenting fails 3, 2
- There are complications, such as pyelonephritis or stricture, associated with ureteral stenting 2
- The patient has a concurrent vesicovaginal fistula or a history of ureteral injury with surgical repair during the index surgery 2
Surgical Approaches
Various surgical approaches can be used to repair ureterovaginal fistulas, including:
- Robotic-assisted ureteroneocystostomy, which provides a minimally invasive option for managing complex ureterovaginal fistulas 3
- Open or laparoscopic abdominal approaches, which are also effective in repairing ureterovaginal fistulas 2, 4
- Vaginal approach, which may be suitable for selected cases, providing a minimally invasive option for managing ureterovaginal fistulas 5