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Uretero vaginal fistula (UVF)

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Uretero vaginal fistula (UVF)

Symptoms
  • Clear drainage per vagina
  • Unilateral hydroureteronephrosis and flank pain secondary to partial ureteral obstruction.
  • Flank pain, nausea, fever, and clear vaginal drainage following pelvic surgery is very suggestive of ureteral injury.
Risks

Risk factors for ureteral injuries include a prior history of pelvic surgery, endometriosis, radiation therapy, and pelvic inflammatory disease.

Up to 12 percent of vesicovaginal fistulae may have an associated ureterovaginal fistula.

Treatment

Therapy: Percutaneous drainage and possible antegrade or retrograde stenting. If high-grade partial obstruction exists in the setting of sepsis, percutaneous drainage and a course of antibiotic therapy is indicated prior to definitive repair If retrograde stenting is unsuccessful but the pyeloureterogram shows continuity of the ureteral lumen, then an attempt at antegrade stenting can be made.

Surgery: When stenting is unsuccessful, ureteral reimplantation (with or without psoas hitch) is performed. Fistulas resulting from advanced pelvic malignancy may best be treated by urinary diversion

Causes
  • Most are secondary to unrecognized distal ureteral injuries sustained during gynecologic procedures.
  • Abdominal or vaginal hysterectomy
  • Cesarean section
  • Anti-incontinence surgery

Other causes:

  • Endoscopic instrumentation
  • Radiation therapy
  • Pelvic malignancy
  • Penetrating pelvic trauma
  • Other pelvic surgery (vascular, enteric, etc.).
Exams and Tests

Intravenous urography: A urogram may demonstrate partial obstruction, hydroureteronephrosis, and drainage into the vagina.

Cystoscopy and retrograde pyelography : These are performed to evaluate for bladder injury and to visualize the distal ureteral segment if not well seen on the urogram. An attempt at retrograde stenting is reasonable if the pyeloureterogram demonstrates ureteral continuity.Prolonged internal diversion with ureteral stenting may result in resolution of the fistula.

CT/MRI: Cross-sectional imaging can be useful to evaluate for pelvic malignancy when indicated or evaluate for an urinoma in patients with persistent fevers.

Cystogram or cystometrogram: In cases where a long segment of distal ureter is involved and a Boari flap is being considered for reconstruction Can also be useful to evaluate the bladder capacity and vesicoureteral reflux.