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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 4  |  Page : 658-661
Neo-bladder vaginal fistula: An unusual complication after orthotopic urinary diversion


Department of Urology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

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Date of Web Publication8-Jul-2009
 

   Abstract 

Development of neo-bladder vaginal fistula is not an unknown complication after cystectomy and orthotopic urinary diversion in females. Compared to native bladder, the wall of the neo-bladder is much thinner that may render it vulnerable to fistulization. Injury to the vagina during cystectomy is the most important predisposing factor. Herein, we present a case of neo-bladder va­ginal fistula and discuss the potential surgical and clinical factors contributing to its occurrence as well as the treatment options available.

Keywords: Neo bladder vaginal fistula, Orthotopic urinary diversion, Radical cystectomy, Carcinoma bladder

How to cite this article:
Kumar A, Das SK, Trivedi S, Dwivedi US, Singh PB. Neo-bladder vaginal fistula: An unusual complication after orthotopic urinary diversion. Saudi J Kidney Dis Transpl 2009;20:658-61

How to cite this URL:
Kumar A, Das SK, Trivedi S, Dwivedi US, Singh PB. Neo-bladder vaginal fistula: An unusual complication after orthotopic urinary diversion. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2020 Feb 18];20:658-61. Available from: http://www.sjkdt.org/text.asp?2009/20/4/658/53296

   Introduction Top


Orthotopic lower urinary tract reconstruction has revolutionized urinary diversion following cystectomy. [1] Neo-bladder vaginal fistula (NVF) is a known complication after cystectomy and orthotopic diversion in women. [2] Women account for 26% of the cases of bladder cancer, [3] and or­thotopic urinary diversion is being used more frequently in women after radical cystectomy because of improved surgical skills and better understanding of female pelvic anatomy. There­fore, understanding the development of such fistulae and knowledge of its treatment options is necessary.


   Case Report and Management Top


A 48 year old female patient presented to us with hematuria of 5-6 months duration with passage of clots, burning micturition and in­creased frequency. She denied loss of weight, loss of appetite, bone pains or jaundice. Hemo­gram, renal functions and liver functions were normal. Ultrasound showed a 4 × 4 cm growth along the right posterolateral aspect of the bladder with right hydronephrosis. MRI scan showed a 4 × 4 cm muscle invasive growth along the right half of the bladder involving the right vesicoureteric (VU) junction. Cystoscopy con­firmed the finding and histopathology of the re­sected tissue showed high grade transitional cell carcinoma (TCC) with muscle invasion. The pa­tient underwent classic anterior pelvic exentra­tion with bilateral pelvic iliac lymphadenopathy. Orthotopic neo-bladder reconstruction was done by Hautmann's technique modified by the prin­cipal author. [4] Five days after the surgery; the patient started having urinary leakage from the vagina which did not subside with conservative management. Suprapubic and perurethral cathe­ters were removed on the 21st post operative day. Micturating cystogram performed three months after surgery demonstrated NVF [Figure 1]. Cystoscopy revealed a 2 × 2 cm fistula just pro­ximal to the bladder neck. Patient was again ta­ken up for surgery. The neo-bladder was opened in an attempt to repair the fistula. The fistulous opening was surrounded by dense solid tissue occupying the pelvis. Biopsy was taken and re­pair was deferred. In view of the suspected re­currence, the patient underwent ileal conduit. Histopathology was positive for transitional cell carcinoma and the patient has been referred for radiotherapy.


   Discussion Top


Orthotopic neo-bladder (ONB) reconstruction after radical cystectomy has been shown to be a viable option in women undergoing radical cys­tectomy. Classic radical cystectomy in women involves enbloc removal of the bladder, uterus,  Fallopian tube More Detailss, ovaries, anterior vaginal wall and urethra. [5] In recent years, ONB reconstruc­tion in women has undergone modifications and refinements to decrease morbidity and improve quality of life. ONB offers several benefits but because the vagina and reservoir lie immediately adjacent to one another, the risk of NVF in­creases in these patients.

Suture line proximity, disturbed tissue planes between the posterior bladder neck and the un­derlying vagina during extirpative procedures and, possibly compromised tissue vascularity due to surgical dissection are the possible risk fac­tors for fistula formation. [6] Poor vascularity of the tissue as after radiotherapy, [7] and local tissue recurrence are also described risk factors. [8] How­ever, injury to the vaginal wall during dissec­tion is the single most important contributing factor. [8] Rapp et al [8] noted that two patients out of four, who developed NVF after ONB cons­truction, had injury to the anterior vaginal wall during surgery. Chang et al [1] described one patient (out of 21) who developed fistula due to an incision made in the anterior vaginal wall during surgery, and despite primary repair and interposition of an omental pedicled flap, a NVF developed.

Therefore, every precaution should be taken to prevent injury to the vagina during dissection of the vesico-vaginal plane. Risk of injury to the vagina is greatest during the most distal dissec­tion of the vesico-vaginal plane in the region of the urethra. Rapp et al [8] had refined their tech­nique by minimizing blunt dissection in the vi­cinity of the bladder neck and sharply dissec­ting the posterior urethra.

Our institute has vast and long experience in ileal-neobladder. [9] In the last 16 years, we have performed 126 ileal neo bladders. Of them, the present case was the fourth neo-bladder in fe­males. The earlier three patients had uneventful recovery. In our technique, we dissect the ure­thral and vaginal stumps separately to have easy anastomosis at the neck of the neo-bladder, thereby avoiding fistula formation [Figure 2]. In this patient, probably due to vascular injury, the patient developed fistula and subsequently had local recurrence of the malignancy due to which the fistula could not be repaired.

Some authors have advocated that preserving the anterior vaginal wall during cystectomy sig­nificantly decreases the risk of NVF and im­proves functional results by preventing vaginal descent. [1] Others have advocated vaginal sparing cystectomy. [10] Vaginal sparing cystectomy has also been used in an attempt to preserve both vaginal size and the surrounding neurovascular anatomy that contributes to the sexual functions. [10] Studies have shown that preserving reproduc­tive organs in modified radical cystectomy is feasible without jeopardizing the oncological basis of the operation [5] ,[10] [Table 1].

Avoidance of the overlapping suture line bet­ween the vagina and bladder neck as well as omental flap interposition prevents fistulization. A modified technique suggested by Ali-El-Dein et al [2] to prevent NVF, includes the following: vaginal transection so as to obtain a longer an­terior than posterior vaginal flap, embedding of the vaginal stump (after the latter is closed) to ensure a posterior facing vaginal stump suture line away from the urethra-ileal anastomosis, suture fixation of the peritoneal edge from the anterior rectal wall to the top of the vaginal stump and most importantly, suturing of a mo­bile pedicle omental flap (based on the left gas­troepiploic vessels) on the anterior vaginal flap as a pedicle interposition flap between the va­ginal stump and urethra ileal anastomosis.

When a NVF develops, treatment options in­clude a transvaginal repair of the fistula or con­version to an ileal conduit. Martius flap is ex­tremely useful to protect fistula repair. [6] ,[11] For more complex and/or failed cases of NVF re­pair, an abdominis rectus muscle flap, myocuta­neous gracilis flap or myocutaneous obturator flap technique can be used. [8] Although several reports describe various techniques that can be used successfully to treat NVF after ONB, even with the use of tissue interposition, surgical re­pair has yielded poor long term results. Rapp et al [8] attempted surgical repair in three out of four patients who developed NVF; the repair was successful in only one patient and other three were managed with ileal conduit/continent cuta­neous diversion. Hautmann et al [12] reported the immediate conversion to a conduit in two pa­tients who developed NVF. Hornblas et al [5] did continent reservoir diversion after three unsuc­cessful attempts at repair of a NVF in the same patient. However, Ali-El-Dein et al [2] could re­pair NVF in three patients trans-vaginally with­out subsequent impairment of the continence.

Thus, NVF formation is a devastating compli­cation which can be prevented by meticulous surgical technique and proper dissection. How­ever, once NVF has developed, treatment options are limited and these patients may end up with a urinary conduit diversion with resultant de­crease in quality of life.

 
   References Top

1.Chang SS, Cole E, Cookson S, Peterson M, Smith JA Jr. Preservation of the anterior vaginal wall during female radical cystectomy with orthotopic urinary diversion: Technique and results. J Urol 2002;168:1442-5.  Back to cited text no. 1    
2.Ali-El-Dein B, El-Sobky E, Hohenfellner M, Ghoneim MA. Orthotopic bladder substitution in women: Functional evaluation. J Urol 1999;161: 1875-80.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Lee CT, Hafez KS, Sheffield JH, Joshi DP, Montie JE. Orthotopic bladder substitution in women: Nontraditional applications. J Urol 2004;171:1585-8.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Singh PB, Mahmood M, Tandon V, et al. Ileal neobladder: A decade experience with "Pouch first and ileal-Neourethra" our modification. Urooncol 2004;4(1):35-7.  Back to cited text no. 4    
5.Horenblas S, Meinhardt W, Ijzerman W, Moonen LFC. Sexuality preserving cystectomy and neo­bladder: Initial results. J Urol 2001;166:837-40.  Back to cited text no. 5    
6.Pruthi RS, Petrus CD, Bundrick WE Jr. New onset vesicovaginal fistula after transurethral collagen injection in women who underwent cystictomy and orthotopic neobladder creation: Presentation and definitive treatment. J Urol 2000;164:1638-9.  Back to cited text no. 6    
7.Gschwend JE, May F, Paiss T, Gottfried HW, Hautmann RE. High dose pelvic irradiation fol­lowed by ileal neobladder urinary diversion: Complications and long term results. Br J Urol 1996;77:680-3.  Back to cited text no. 7  [PUBMED]  
8.Rapp DE, O'Connor RC, Katz EE, Steinberg GD. Neo Bladder vaginal fistula after cystic­tomy and orthotopic neobladder reconstruction. BJU Int 2004;94:1092-5.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Singh PB, Sarraf SK. Ileal Neo-bladder: 5 year followup. Indian J Urol 1997;13(2):75-8.  Back to cited text no. 9    
10.Schoenberg M, Hortopan S, Schlossberg L, Marshall FF. Anatomical anterior exenteration with urethral and vaginal preservation: Illustra­ted surgical method. J Urol 1999;161:569-72.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Quek ML, Ginsberg DA, Wilson S, Skinner EC, Stein JP, Skinner DG. Pubovaginal slings for stress urinary incontinence following radical cystectomy and orthotopic neobladder recons­truction in women. J Urol 2004;172:219-22.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]
12.Hautmann R, Paiss T, de Petriconi R. The ileal neo bladder in women: 9 years of experience with 18 patients. J Urol 1996;155:76.  Back to cited text no. 12    

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Correspondence Address:
Pratap Bahadur Singh
Department of Urology, Banaras Hindu University Institute of Medical Sciences, Varanasi 221 005
India
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PMID: 19587512

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    Figures

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This article has been cited by
1 Vaginal repair of neobladder-vaginal fistula: A case report and review of the literature
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International Urogynecology Journal and Pelvic Floor Dysfunction. 2013; 24(1): 175-178
[Pubmed]



 

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    Abstract
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