Learning moments about UVF

1. Learning moments
Urethrovaginal fistula

2. • In the industrialized world, urethrovaginal
fistulae most commonly occur as a result of
vaginal surgery, including
• anti-incontinence surgery, anterior vaginal
wall prolapse surgery, and urethral
diverticulectomy (Henriksson et al, 1982b;
Webster et al, 1984; Blaivas, 1989; Glavind
and Larsen, 2001).

3. • Other causes of urethrovaginal fistulae include
• radiation therapy for pelvic malignancy,
trauma (including pelvic fracture), and vaginal
neoplasms.

4. • Symptoms of urethrovaginal fistulae are
largely dependent on the size and location of
the fistula along the urethral lumen.

5. • Proximal fistulae can be associated with stress
incontinence, or, if they are located at the
bladder neck, continuous incontinence may
result, similar to that associated with
esicovaginal fistulae.

6. • Distal fistulae beyond the sphincteric
mechanism may be completely asymptomatic
or may be associated with a splayed urinary
stream.

8. • The surgical repair of urethrovaginal fistulae is
challenging and can often be more difficult
than repair of VVF. This is due to several
factors, including extensive soft tissue defects
as well as the lack of local viable tissue for a
multilayer repair

9. • Distal fistulae without associated voiding
symptoms or incontinence may be observed
or, alternatively, can be managed with an
extended meatotomy (Lamensdorf et al,
1977).

10. • The repair of urethrovaginal fistulae is
conceptually very similar to the vaginal flap
repair of VVF

13. • A variety of adjuvant procedures have been used
in the repair of urethrovaginal fistulae, including,
most commonly, a Martius labial fat flap, but also
gracilis and rectus abdominis muscle,
myocutaneous flaps, vaginal wall flaps, fibrin
glue, and free labial skin grafts (Keettel et al,
1978; McKinney, 1979; Tolle et al, 1981; Webster
et al, 1984; Krogh et al, 1989; Leach, 1991; Izes et
al, 1992; Candiani et al, 1993; Fall, 1995;
Rangnekar et al, 2000b).

14. • Stress incontinence (SUI) may persist following
repair of urethrovaginal fistulae. Whether
repair of SUI should be done concomitantly
with the fistula surgery, or should be deferred
until after repair of the fistula, is controversial

15. • Blaivas and colleagues (1989) argued that
sphincteric incontinenceshould be repaired at the
time of fistula surgery with aMartius flap
interposed between the fistula repair and a
pubovaginal fascial sling. Webster and colleagues
(1984) suggested that stress incontinence (SUI)
associated with a proximal or midurethral
urethrovaginal fistula should not be corrected
until the fistula is closed and the patient
reassessed for persistent incontinence.

16. • These authors suggest, however, that SUI
associated with distal urethrovaginal fistula can
be repaired concomitantly.
• Overall, the success rate of urethrovaginal fistula
repair is variable but is not generally considered
to be as high as that for VVF repair (Gerber and
Schoenberg, 1993). Not uncommonly, two or
more procedures may be necessary to gain a
satisfactory result (Webster et al, 1984).