Por Dr. Rafael Clavijo
Vesicovaginal fistula is a problem that considerably affects the quality of life of the patient because it alters her biological, psychological and social life; although relatively infrequent, the condition causes severe suffering for many of the women affected, forcing them to live secluded and depressed.
Vesicovaginal fistula is defined as an abnormal communication between the vagina and the bladder, and represents the most frequent type of urogenital fistulas.
It usually occurs as a result of complications of gynecologic surgery, with hysterectomy (removal of the uterus) as the most frequent. The exact cause of the formation is not completely understood, but it is attributed to inadvertent injury to the bladder through which leaking urine accumulates and then goes into the vagina forming the fistula.
The first clinical manifestation is the flow of urine through the vagina, which occurs between the first and third week after gynecological surgery. In addition, there may be fever, vaginal pain or bleeding when urinating on subsequent days.
This condition represents a catastrophic event for women, directly altering their personal and professional lives. The constant loss of urine and permanent wetness, besides the odor and the risk of infections, cause anxiety and low self esteem and limit social and work activities.
There are some simple tests to confirm the leak of urine into the vagina, which involve the application of a dye into the bladder and then sterile gauze is placed in the vagina, which, if there is any urinary leakage, will be painted with the dye which was applied to the bladder. To confirm the diagnosis, different imaging studies are done that pinpoint the origin and the fistulous tract, among which are voiding cystography, computerized tomography, and among the most effective are the combination of cystoscopy (direct vision of the bladder) plus vaginoscopia (direct view of the vagina), which make it possible to accurately determine the location of the fistula.
Once the diagnosis is made, the treatment is decided according to the characteristics of the patient and the location and size of the fistula. For small fistulas the placement of a urinary catheter for a few weeks can be useful, which can help close small fistulas. Also, endoscopic procedures such as cauterization of the fistula can be tried, although with this technique high risk of recurrence and low success rates (15%) have been reported.
Usually, gynecologists perform vaginal surgeries which are successful in the majority of patients. However, when the fistula is large or there are multiple fistulas, or when the fistula is located very close to the urethral meatus and additional procedures are required, such as ureteral re-implantation, abdominal surgery or combined vaginal-abdominal are recommended -, which should be conducted in conjunction with the urologist and through conventional surgery (open), or by laparoscopic and robot-assisted surgeries which have proven to be highly effective (95%).
Minimally invasive surgical techniques, such as laparoscopic and robot-assisted, offer greater security by significantly reducing the risk of bleeding, while offering less postoperative pain, shorter hospital stay and quicker return to normal activities.