BLADDER AND URETER INJURY AFTER GYNECOLOGICAL SURGERY.
Gynecological surgery like removal of uterus is a very safe procedure. However in complicated cases there may be severe adhesions between the bladder and the vagina and uterus. In these cases there remains a possibility of injury to the bladder and the ureter in approx. 1% of cases.
These cases can be successfully repaired today with minimal invasive approach thereforeallowing the patient to recover to lead a normal life.
WHAT IS A VESICO VAGINAL FISTULA?
The term fistula means an abnormal communication between two structures. Therefore in this context it means a hole connecting the bladder (which contains urine) to the vagina. Therefore the bladder starts leaking the urine into the vagina.
WHAT ARE THE SYMPTOMS OF A FISTULA BETWEEN THE BLADDER AND THE VAGINA?
These patients generally present one to three weeks after the surgery with urine discharge via the vagina. Since the patient is able to hold urine via the normal passage which is the urethra, but the vagina normally does not hold the urine, therefore when the patient starts leaking urine from the bladder to the vagina she becomes incontinent. This is unaware incontinence wherein the patient dribbles urine all the time without any urge to pass urine and without any stress over the abdomen.
HOW ARE THESE PATIENTS EVALUATED?
These patients are evaluated by a dye study called Cystogram wherein the dye is instilled into the urinary bladder and then radiological pictures are taken to demonstrate the hole connecting the bladder to the vagina- that is the fistula. She also undergoes an IVP test to rule out any ureteral injury. Very often I evaluate these patients by a Flexibe Cystoscope to check the location of the fistula directly by visualization.
WHICH PATIENTS CAN BE MANAGED CONSERVATIVELY?
For small and recent fistula, a reasonable approach is to keep the patient on a catheter for a few weeks. This is usually performed after the fistula site has been fulgurated to destroy the mucosal lining which can prevent healing of the tract. The patient however must be counselled that this method is successful only in very small and recent fistula. Therefore if this approach fails then more definitive treatment has very high success rate.
WHAT ARE THE POSSIBLE METHODS OF REPAIR OF THE VAGINAL FISTULA?
The fistula can be approached via two methods either Transvaginally in case of low fistula or via the abdomen in case of large or high fistula. Also if the ureter orifice is very close to the fistula site then the abdominal approach is better since in these cases the ureter is reimplanted along with the repair of the fistula.
WHICH PATIENTS CAN BE MANAGED BY VAGINAL APPROACH?
Patients who have low down and small fistula can be managed by this approach. This approach avoids an abdominal incision and therefore the patient has lesser pain and bleed and recovers faster.
WHAT IS LAPAROSCOPIC REPAIR OF THE VAGINAL FISTULA?
When the fistula is higher up on the bladder or the bladder is small in capacity and needs to be augmented or the ureter need to be reimplanted then an abdominal approach is preferred. Today laparoscopic approach provides equal success rate to open surgery while avoiding the need for a larger incision and therefore the patient can recover better and faster.
WHAT IS THE SUCCESS RATE OF THESE REPAIRS?
Most of the these fistulas can be repaired by either of these approaches and the success rate is very high nearing 95-97 %. The patient can return to full normal life within a few months after this procedure.
WHAT IS TISSUE INTERPOSITION?
Since the bladder and the vagina are weakened due to the prior surgery and then the development of the fistula further weakens the walls. As a result the walls of these structures may not have enough strength to allow a successful repair in some cases. Therefore in these cases interposition of good strong tissue with good blood supply prevents a recurrence of the fistula. The most commonly used tissue is the fat within the labia majora in a vaginal approach and the free floating omental fat apron in an abdominal approach.
HOW ARE THESE PATIENTS MANAGED IN THE POST OPERATIVE PERIOD?
These patients usually complain of bladder pain and spasms therefore a liberal use of bladder calming drugs like flavoxate are used to relieve the pain and spasms. The patients usually regain full urinary holding capacity within a few months of the surgery.
WHAT ARE URETERO VAGINAL FISTULA?
Like the bladder, the ureter may also be injured in some cases of gynecological surgery. These are usually very complicated gynecological surgeries as in cases of Endometriosis. In these cases which are generally less than one in hundred gynecological surgeries the ureter may be injured. These patients also may present with leakage of urine via the vagina after one to three weeks after the surgery.
HOW DO THEY PRESENT ?
These patients may present with leakage of urine all the time. Also the leakage may persist even if the patient is catheterized. They may also present with pain in the flank region of the kidney.
WHAT IS THE MANAGEMENT OF THESE CASES?
In these cases also surgery is the best option. If the fistula is small and recent then a trial of stent placed ureteroscopically may be attempted. But in most cases the best option is to perform a laparoscopic repair of the ureter wherein the damaged and weakened ureter is removed and the healthy ureter is then reimplanted into the bladder. This is a reliable surgery wherein a large majority of cases are cured in the first attempt. Very often we fashion a tube from the urinary bladder, this tube is called the Boari flap. This tube is then attached to a healthy ureter therefore allowing a wide and healthy passage for the ureter to drain into the bladder.