A ureterovaginal fistula is an abnormal passageway existing between the ureter and the vagina. It presents as urinary incontinence. Its impact on women is to reduce the “quality of life dramatically.”[rx]
Ureterovaginal fistula commonly follows ureteric injury during pelvic surgery and presents with continuous urinary incontinence in spite of normal micturition. Continuous urinary incontinence has a significant impact on the quality of life, thus requiring effective surgical intervention in order to restore health. We found no reported case of ureterovaginal fistula following spontaneous vaginal delivery with prolonged obstructed labor. Relevant history and simple diagnostic procedures were used for diagnosis and the patient had successful vaginal ureteroneocystostomy. This could be the first reported ureterovaginal fistula following spontaneous vaginal delivery with prolonged obstructed labor. Vaginal ureteroneocystostomy though scarcely reported, is feasible in selected cases.
A ureterovaginal fistula (UVF) is an abnormal channel between the ureter and vagina, which is a severely disabling complication resulting in incontinence, infection, and discomfort; it is often diagnosed postoperatively [rx]. The incidence of UVF has been increasing due to the growing use of the laparoscopic surgical technique [rx]. Traditionally, a laparotomy or laparoscopic surgery has been used to repair the delayed UVF [rx, rx];
Cause of Ureterovaginal Fistula
A rectovaginal fistula is a result of trauma, infection, pelvic surgery, radiation treatment and therapy, malignancy, or inflammatory bowel disease. Symptoms can be troubling for women especially since some clinicians delay treatment until the inflammation is reduced and stronger tissue has formed.[rx] The fistula may develop as a maternal birth injury from a long and protracted labor, long dilation time and expulsion period. Difficult deliveries can create pressure necrosis in the tissue that is being pushed between the head of the infant and the softer tissues of the vagina, ureters, and bladder.[rx]
Radiographic imaging can assist clinicians in identifying the abnormality.[rx] A Ureterovaginal fistula is always indicative of an obstructed kidney necessitating emergency intervention followed later by an elective surgical repair of the fistula.[rx]
Treatment of Ureterovaginal Fistula
Many women delay treatment for decades.[rx] Surgeons often will correct the fistula through major gynecological surgery. Newer treatments can include the placement of a stent and is usually successful. In 0.5-2.5% of major pelvic surgeries a ureterovaginal fistula will form, usually weeks later.[rx] If the fistula cannot be repaired, the clinician may create a permanent diversion of urine or urostomy.[rx] Risks associated with the repair of the fistula are also associated with most other surgical procedures and include the risk of adhesions, disorders of wound healing, infection, ileus, and immobilization. There is a recurrence rate of 5%–15% in the surgical operation done to correct the fistula.[rx]
Ureteroscopy
Under continuous epidural or general anesthesia, all 46 patients were placed in the flank-reclining, split-leg position for simultaneous antegrade and retrograde ureteroscopy. We inserted an F16 ureteroscope in the bladder through the urethra. First, we made a ureteroscopic observation to again rule out a vesicovaginal fistula. Then, a Zebra urological guidewire, carrying a ureteral scope, was inserted in the injured side of the ureter as far as the injury site. A Holmium laser was used when the cavity was too narrow or the surgery suture was met. Forty-six patients having a definitive diagnosis of delayed UVF were classified according to the lesion’s description, as follows:
- Class 1: The ureteric injuries were only fistulas, the ureteral mucosa was continuous, and the Zebra urological guidewire could be uplinked into the renal pelvis along the ureteral mucosa (34 cases).
- Class 2: More than half the diameter of the ureter was lacerated, a segment of the ureteral wall was a coloboma or collapsed, and the Zebra guidewire would not pass through the injury (9 cases).
- Class 3: The ureters were completely avulsed and the lacerated ends were filled in by the adjacent tissue (2 cases).
- Class 4: The injured ureter was completely atretic (1 case).
Ureteric stent placement
For Classes 1, two or three double-J (D-J) stents were indwelled over the injury through the Zebra guidewire, which uplinked into the renal pelvis along the ureter’s mucous membrane. The stents were confirmed to be in their appropriate positions during the operation with ultrasonography.
Endoscopic realignment for treatment [rx]
The ureters of Class 2 were injured so seriously that the guidewire could hardly pass through the damaged region to reach the pelvis by retrograde ureteroscopy. Percutaneous nephroscopy had to be used to admit a flexible ureteroscope into the injury and insert the guidewire into the retroperitoneal space. A rigid ureteroscope was inserted retrogradely through the distal ureter to the injury. Then, a double ureteroscopic joint exploration and realignment was accomplished.
The guidewire was detected by the rigid ureteroscope, which was seized by the tip with an endoscopic grasping forceps and pulled out from the urethra (using the foreign-body clamp in the ureteroscope to clip the guidewire outside the body through the diseased side of the distal ureter, bladder, and urethra), placing three D-J stents along the guidewire and over the fistula.
Treatment of ureteral occlusion
The ureters of Classes 3 and 4 were incomplete occlusion, with the ureteroscope and guidewire unable to open the occluded portion. Therefore, a “cut-to-the-light” technique was employed [rx], with the ureteral segments being aligned via ultrasonographic and endoscopic control. The room light was dimmed and the rigid ureteroscope’s light was turned off. Using the light source of the flexible ureteroscope that was inserted through the nephrostomy as a guide, we used the Holmium laser to restore ureteral continuity. A guidewire was indwelled across the area and uplinked to the renal pelvis, then three D-J stents were placed along the guidewire.
Treatment of secondary ureteric stricture
Ten patients had recurrent stenosis, which needed ureteroscopic endoureterotomy. First, we made an adequate longitudinal endoluminal incision of the strictured segment of the ureter and vaporized the scars until the periureteral fat was seen. Then, we indwelled three D-J stents for at least 6 weeks. We repeated the internal urethrectomy and replaced the stents after 6–12 months if the narrowing reappeared.
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