margin, the ureteral length is usually adequate

can visualize the fistula tract along the posterior

for ureteroneocystotomy. Psoas hitch or Boari

bladder wall. Urine cytology may reveal endo-

flap can provide additional length for a tension

metrial cells during workup of hematuria.

free anastomosis. In patients with extensive ure-

Cystogram or hysterosalpingogram can identify

teral damage, trans-ureteroureterostomy, ileal

the abnormal flow of contrast via the fistula

interposition, or renal autotransplant can be an

tract from urinary to genital tracts. In cases of

option. If extensive renal injury has already

continuous incontinence, VCUG and CTU can

occurred, nephrectomy may be the most expedi-

be utilized to rule out the presence of VVF or

tious form of management. Successful repair of

ureterovaginal fistula.

ureterovaginal fistula occurs in greater than 90%

Successful treatment of vesicovaginal fistula

of cases.11,66

has been well documented using conservative as

well as surgical management. Watchful waiting

Vesicouterine Fistula

with spontaneous fistula resolution, urinary

diversion with prolonged catheterization, and

Etiology and Presentation

hormonally induced uterine involution have all

been described with successful outcomes.76-78

Vesicouterine fistula are rare forms of urogyne-

Surgical intervention can include hysterectomy

cologic fistula, with less than 100 cases reported

with primary closure of the bladder. If the

in recent literature.70 Caesarean section is the

patient desires fertility, uterine sparing surgery

most common etiology of this type of fistula,

can be performed in a technique similar to the

with the majority occurring during repeat sec-

O’Conor transabdominal VVF repair with or

tions.71 Numerous case reports of other etiolo-

without omental interposition.

gies include vaginal deliveries after caesarean

section, radiation, iatrogenic catheter trauma, or

placenta percreta.72-75 Following uterine rupture

Uro-Enteric Fistula

during labor, the posterior bladder wall can be

torn along the margin of the rupture leading to

eventual

vesicouterine fistula

formation.

Vesicoenteric Fistula

Unrecognized injury to the bladder at the time

of uterine surgery or incorporation of the blad-

Vesicoenteric fistula is most likely to occur in

der into a uterine suture line can also result in

the setting of bowel diseases such as diverticuli-

fistula. The most common location for vesicou-

tis, colorectal carcinoma, and Crohn’s disease.

terine fistula is from the posterior midline blad-

Less commonly, radiation, infection, trauma, or

der wall to the uterus above the proximal cervical

iatrogenic surgical injury can result in fistula

margin. Because the cervical os is generally

formation. Approximately 2% of patients with

closed, patients may not present with inconti-

diverticulitis will develop vesicoenteric fistulas

nence. Continuous incontinence can occur in

secondary to their disease, and these patients

cases of cervical incompetence, or just following

account for approximately 70% of all diagnosed

vaginal delivery.70 Patients may also present with

colovesical fistulas.79-81 Ileovesical are more

menouria and cyclic hematuria in the setting of

common in Crohn’s disease patients, who have a

urinary

continence. “Youssef’s

syndrome”

2% incidence of vesicoenteric fistula forma-

describes the symptom complex of menouria,

tion.82 Symptoms of vesicoenteric fistula can be

cyclic hematuria, apparent amenorrhea, infertil-

gastrointestinal or urologic. Pneumaturia is the

ity, and continence of urine.70 This must be dif-

most common presenting symptom, occurring

ferentiated from endometriosis of the bladder.

in 70% of cases.83 Persistent or recurrent UTI or

cystitis refractory to antibiotic management

Diagnosis and Management

may suggest colovesical fistula.84

Endoscopic and radiologic imaging can be

A history of prior uterine surgery in the setting

helpful in diagnosis. Cystoscopic examination is

of compatible symptoms as described above is

sensitive for detecting mucosal abnormalities

strongly suggestive of a vesicouterine fistula.

such as erythema or bullous edema in >90% of

Cystoscopy, hysteroscopy, and radiologic imag-

cases, but is not definitive for a fistula diagno-

ing can assist in definitive diagnosis. Cystoscopy

sis.85 A biopsy is indicated at the time of

492

Practical Urology: EssEntial PrinciPlEs and PracticE

endoscopic evaluation to rule out malignancy.

internal stenting may result in fistula resolu-

CT scan is the most sensitive and specific modal-

tion.90 Definitive treatment includes open pri-

ity for the diagnosis of colovesical fistula.80

mary repair for nephron sparing or nephrectomy

Identification of the bladder adjacent to a thick-

with bowel closure for a poorly functioning

ened loop of colon, air within the bladder, and

renal unit.

colonic diverticula are highly suggestive of a

possible fistula.86 If there is question of a sub-

Urethrorectal Fistula

clinical fistula, the diagnosis can be confirmed

by oral administration of activated charcoal,

Acquired rectourethral or prostatorectal fistula

which will appear in the urine as black

(RUF) has been reported in association with a

particles.87

Conservative management of vesicoenteric

variety of clinical situations. Fistula can result

from prostatic or rectal malignancies, inflam-

fistula includes bowel rest with total parenteral

matory disorders of the prostate or bowel, local

nutrition and antibiotics in patients with mini-

trauma, or surgical intervention for benign or

mal symptoms and no evidence of toxicity.88 In

accordance with the general principles of fistula

malignant prostatic or rectal.38 The most com-

mon contemporary etiology of RUF is radical

repair, optimization of nutritional status is

retropubic prostatectomy (RRP) due to an

important. Surgical intervention can be compli-

unrecognized bowel injury at the level of the

cated due

to the inflammation and scarring

vesicourethral anastomosis. Nevertheless, the

associated

with fistula formation. Dissection

overall incidence of

fistula following RRP is

should continue until viable tissue margins are

extremely low, less

than 0.2% in one large

obtained for bladder closure. An omental flap

series.96 Prior history of pelvic radiation, rectal

38

can be used to prevent overlapping suture lines.

surgery, or TURP increases the risk of RUF for-

If the patient is acutely ill, or abscess or obstruc-

mation following surgical intervention.96 Fistula

tion complicates the procedure, bowel diversion

formation following

alternative therapies for

with later reanastomosis (two stage repair)

prostatic malignancy such as cryoablation and

should be considered.89

brachytherapy has also been reported, with an

incidence of approximately 0.5% and 0.4%,

Pyeloenteric Fistula

respectively.97,98 Salvage cryoablation has a 3.3%

incidence of RUF formation following radiation

Pyeloenteric fistula can develop from inflamma-

therapy.99 Larger series of laparoscopic and

tory diseases of the kidney, such as xanthogran-

robotic techniques for radical prostatectomy

ulomatous pyelonephritis, tuberculosis, chronic

have similar rectal injury rates when compared

pyelonephritis, or inflammatory diseases of the

to traditional open retropubic radical prostatec-

bowel, such as Crohn’s disease.90-92 Iatrogenic

tomy,97,100,101 and a 0.1% rate of subsequent fis-

trauma from percutaneous nephrolithotomy

tula formation.101 Similar to other types of

access and lithotripsy has been associated with

fistula, recognition of an iatrogenic injury and

an increasing number of fistulas, involving the

immediate intraoperative repair can decrease

duodenum during right renal procedures and

the rate of subsequent fistula formation.

the colon in left sided intervention.93

Patients may present with urologic complaints

Cryoablation or alternative minimally invasive

of UTI, fecaluria, pneumaturia, hematuria, or

renal tumor surgery can result in fistula forma-

gastrointestinal problems such as nausea, vom-

tion.94 The majority of patients have nonspecific

iting, or peritonitis. Direct visualization via cys-

symptoms of malaise, mild GI symptoms, uri-

toscopy or sigmoidoscopy may identify the

nary frequency, flank mass, or tenderness; how-

fistula tract and provide a means for biopsy in

ever, many fistulas are diagnosed incidentally on

cases of suspected concomitant malignancy.

radiographic imaging.90,95 If there is a suspected

Voiding cystourethrogram or retrograde ure-

pyeloenteric fistula, urinary or GI contrast-

throgram can allow definitive diagnosis and

based imaging with traditional or CT urography,

provide details of anatomic location and fistula

retrograde pyelogram, nephrostogram, barium

size (Fig. 35.6). In consideration of surgical

swallow, or contrast enema can confirm the

intervention, continence must be assessed and

diagnosis. Conservative management with large

discussed as RUF repair may initiate or exacer-

nephrostomy tubes, bowel rest, antibiotics, or

bate stress incontinence.