What is the best next step for a patient with a vesicovaginal fistula?

Management of Vesicovaginal Fistula

The best next step for a patient with a vesicovaginal fistula is diagnostic imaging with CT using intravenous contrast to confirm the fistula and determine its etiology before planning surgical repair. 1

Diagnostic Approach

Initial Imaging

• CT with intravenous contrast is the preferred initial imaging modality, with a diagnostic sensitivity of 76.5% for fistula detection and 94.1% for defining the etiology 1, 2
• Water-soluble contrast should be placed in the bladder to help opacify the fistulous tract during imaging 2
• The bladder can be opacified retrograde (CT cystogram) or antegrade with delayed imaging after IV contrast administration 2

Additional Diagnostic Studies

• Cystography has shown high detection rates (90%) for vesicular fistulae in some studies and should be considered if CT findings are equivocal 2
• MRI pelvis with IV contrast provides superior soft tissue resolution for evaluating fistulous tracts and is particularly useful for detecting active inflammation 1
• Vaginography may be helpful in certain cases, with reported sensitivity of 79% and positive predictive value of 100% for identification of fistulous tracts 2

Treatment Planning

Timing of Repair

• A minimum waiting period of 4-6 weeks from the onset of the fistula is recommended before attempting surgical repair 3
• This waiting period allows for resolution of inflammation and edema, which improves the success rate of repair 3

Surgical Approach Selection

• Transvaginal repair should be the preferred initial approach for most vesicovaginal fistulae 3, 4
• Transvaginal repairs achieve comparable success rates to abdominal approaches (91% vs 97%) while minimizing operative complications, hospital stay, blood loss, and post-surgical pain 3
• For complex fistulae (large size, prior failed repair, or radiation-induced), an individualized approach may be necessary 4

Specific Surgical Techniques

• Transvaginal repair techniques include modifications of the Latzko procedure or a layered closure with or without a Martius flap 3
• Abdominal approaches include the bivalve technique or fistula excision 3
• Laparoscopic repair is a feasible minimally invasive approach with high success rates (93%) in select patients 5

Special Considerations

Previously Failed Repairs

• It is acceptable to repeat the repair through a vaginal approach even after a first vaginal approach failure 3
• Success rates of 70-100% have been reported for non-radiated vesicovaginal fistulae repair 3

Radiation-Induced Fistulae

• Fistulae in radiated patients are more challenging to repair, with success rates between 40-100% 3
• These cases often require more complex surgical procedures and may need tissue interposition 4

Post-Repair Care

• Close follow-up is essential to monitor for recurrence or complications 6
• Patients should be informed that closure of the fistula tract does not guarantee continence, as there may be underlying damage to the bladder 6

By following this structured approach to diagnosis and management, the best outcomes for patients with vesicovaginal fistulae can be achieved, improving their quality of life and reducing morbidity associated with this condition.