1. EXPERIENCE IN THE MANAGEMENT OF URETEROVAGINAL FISTULA IN SOUTH-EAST NIGERIA
DR. DANIYAN ABC

2. Authors Daniyan ABC1 Dantani D1 Sunday-Adeoye I1 Uguru SM1 Lengman S1
1 National Obstetric Fistula Centre, Abakaliki, Ebonyi State
Correspondence:
Daniyan ABC
National Obstetric Fistula Centre, Abakaliki
4/21/2017

3. ABSTRACT
Background:Ureterovaginal fistula is a well-recognized complication of pelvic surgeries. Objective: To document our experience in the management of women with ureterovaginal fistula at the National Obstetric Fistula Centre, Abakaliki Methodology: A retrospective study carried out at the National Obstetric Fistula Centre, Abakaliki from January 2011 to October The history, physical findings, diagnosis, operation notes and follow-up notes of the women were studied. Relevant information was extracted and entered into a proforma. The data was analysed using the SPSS version 20. Results: During the period of study, 40 patients had surgery for ureterovaginal fistula constituting 4.4% of surgeries for genital fistula. Fistula resulted from emergency caesarean section in 36 (90%) patients, hysterectomy for ruptured uterus in 2 (5%), total abdominal hysterectomy in 1 (2.5%) and congenital malformation in 1 (2.5%). Of the 38 women who developed ureterovaginal fistula following delivery, 37 (97.4%) had prolonged obstructed labour. Diagnosis was made clinically in 38 (95%) patients. All the patients had ureteroneocystostomy. The transabdominal route was used in 36 (90%) patients while transvaginal route was used in 4 (10%). In 26 (65%) patients, the left ureter was affected while the right was affected in 14 (35%). Post-operatively, 3 (7.5%) patients had anaemia, 2 (5%) had wound breakdown and 1 (2.5%) had sepsis. Conclusion: Emergency caesarean section for prolonged obstructed labour is the commonest cause of ureterovaginal fistula in this study and the left ureter is more commonly affected. Clinical diagnosis is reliable and ureteroneocystostomy gives excellent outcomes. Keywords: Ureterovaginal, Fistula, Injury
4/21/2017

4. INTRODUCTION
Ureterovaginal fistula is a communication between the ureter and the vagina
Urine flows directly from the ureter into the vagina without passing through the bladder 1
It is a dreaded complication of gynaecological surgeries, usually occurring following injury to the ureter
It has a profound impact on quality of life and psychosocial well-being due to the continuous leakage of urine that results 2
4/21/2017

5. The left ureter is more vulnerable 7,8
INTRODUCTION
Ureteric injury is due to the close proximity of the ureters to the uterus and cervix
Incidences varying from 0.2 – 1.2% during abdominal or pelvic surgeries have been reported 3,4
The injury detection rate is increased when intraoperative diagnostic cystoscopy is employed 5,6
The left ureter is more vulnerable 7,8
4/21/2017

6. The commonest site of ureteral injury is near the uterine vessels
INTRODUCTION
The commonest site of ureteral injury is near the uterine vessels
The injury may occur in the form crushing, ligation, transection, resection and devascularization
Early diagnosis using intraoperative cystoscopy and early repair advocated to prevent compromise of the ipsilateral kidney 5,6,9,10
4/21/2017

7. INTRODUCTION
When injury is unrecognised or repair is delayed, ureterovaginal fistula occurs from extravasation of urine
The presentation is that of continuous urinary incontinence after an abdominal/pelvic surgery 11
Unlike VVF, the patient experiences normal voiding and dye test is negative
Diagnosis is established by cystoscopy and intravenous urography (IVU) 12
4/21/2017

8. INTRODUCTION
When diagnosis is delayed, correction is by re-implanting the affected ureter into the bladder or by end-to-end anastomosis 11,12
We undertook a review of 40 patients to document our experience in the management of women with ureterovaginal fistula
4/21/2017

9. Methodology
A retrospective study carried out at the National Obstetric Fistula Centre, Abakaliki
The records of women who underwent surgical repair of ureterovaginal fistula over a period of four years from January 2011 to October 2014 were reviewed
The history, physical findings, diagnoses, operation notes and follow-up notes of these women were studied
Relevant data was extracted and entered into a structured proforma
The data was analysed for descriptive statistics using the Statistical Package for Social Sciences (SPSS) version 20 and presented in tabular form
4/21/2017

10. RESULTS
During the period of study, 915 patients had surgery for genital fistula
Out of these, 40 patients underwent repair of ureterovaginal fistula
Hence repair of ureterovaginal fistula accounted for 4.4% of all fistula surgeries carried out
The mean age of the patients was years.
Emergency caesarean section (EMCS) for prolonged obstructed labour was the cause in 36 (90%) patients
4/21/2017

11. Table 1 Causes of ureterovaginal fistula
Frequencies (%)
EMCS for prolonged obstructed labour
36 (90.0)
Hysterectomy for ruptured uterus
2 (5.0)
Total abdominal hysterectomy
1 (2.5)
Congenital malformation
Total
40 (100.0)
4/21/2017

12. Fetal outcomes Frequencies (%) Stillbirth 30 (78.9) Live neonate
Table 2 Fetal outcomes among women who developed ureterovaginal fistula following delivery
Fetal outcomes
Frequencies (%)
Stillbirth
30 (78.9)
Live neonate
8 (21.1)
Total
38 (100.0)
4/21/2017

13. Table 3 Mode of diagnosis
Frequencies (%)
Clinical
38 (95.0)
Intravenous urogram
2 (5.0)
Total
40 (100.0)
4/21/2017

14. Route Frequencies (%) Abdominal 36 (90.0) Vaginal 4 (10.0) Total
Table 4 Route of surgery
Route
Frequencies (%)
Abdominal
36 (90.0)
Vaginal
4 (10.0)
Total
40 (100.0)
4/21/2017

15. Affected ureter Frequencies (%) Left ureter 26 (65.0) Right ureter
Table 5 Affected ureter
Affected ureter
Frequencies (%)
Left ureter
26 (65.0)
Right ureter
14 (35.0)
Total
40 (100.0)
4/21/2017

16. Table 6 Complications of repair
Frequencies (%)
No complication
34 (85.0)
Anaemia
3 (7.5)
Wound breakdown
2 (5.0)
Sepsis
1 (2.5)
Total
40 (100.0)
4/21/2017

17. DISCUSSION
The vast majority of the cases of ureterovaginal fistula resulted from EMCS for prolonged obstructed labour
This finding is in sharp contrast to that of the developed world where hysterectomy is the commonest cause 2,3,12-15
It does appear however, that obstetric procedures are the main causes in the developing world 16,17
4/21/2017

18. Portends serious medico-legal implications
DISCUSSION
A study done in Enugu reported caesarean sections (38%) and caesarean hysterectomies (25%) as the leading causes of ureterovaginal fistula, together constituting up to 63% 18
Reflects the poor standard of care available to pregnant women in this environment
Portends serious medico-legal implications
4/21/2017

19. DISCUSSION
The diagnosis of ureterovaginal fistula was made clinically in 95% of the patients. IVU was used in 2 patients
The diagnosis of this condition usually involves cystoscopy, ultrasound scan, IVU and retrograde ureterography 3,12
However, these may not be feasible for extremely indigent patients seeking care in a resource-constrained setting
4/21/2017

20. DISCUSSION
To maximize the available resources, symptoms, signs and dye test were used to make diagnosis
Although the dye test may be used to differentiate ureterovaginal fistula from VVF, it does not identify the affected ureter. This was done intraoperatively
The use of such well-known, simple diagnostic methods in resource-constrained settings has been documented 16
4/21/2017

21. DISCUSSION
In 26 patients, the left ureter was affected while the right was affected in 14
This is consistent with findings from other
studies 7,8,15
Most surgeons operate from the patients’ right making the left ureter to be further away from them
Also, the left ureter is closer to the cervix than the right making it more prone to injury 19
The left ureter is also said to be 1cm shorter than the right 20. It has been suggested that this makes it less free, hence more vulnerable to injury when securing haemostasis
4/21/2017

22. DISCUSSION
All the patients had ureteroneocystostomy with ureteric stents which were removed after one week
They all had delayed repair as a result of late presentation
Immediate repair is however advocated when feasible 5,6,9,10,15
Another option is preliminary diversion via a percutaneous nephrostomy followed later by delayed repair 19
The abdominal route was used in 36 patients while vaginal route was used in 4 patients
4/21/2017

23. DISCUSSION
None of the patients had end-to-end anastomosis of the ureter, Psoas hitch or Boari flap
The choice of route/type of surgery had to do with familiarity on the part of the surgeon
Postoperative complications seen in 6 (15%) patients - anaemia in 3, wound breakdown in 2 and sepsis in 1
Outcomes were good - 100% continence rate at discharge and 95% at three months follow-up
4/21/2017

24. The left ureter is more commonly affected
CONCLUSION
Emergency caesarean section for prolonged obstructed labour is the commonest cause of ureterovaginal fistula in our environment
The left ureter is more commonly affected
Clinical diagnosis is reliable
Ureteroneocystostomy gives good outcomes
We strongly recommend improved access to quality maternity care
4/21/2017

25. REFERENCES
Burivong W, Leelasithorn V, Varavithya V. Common lower urinary tract fistulas: A review of clinical presentations, causes and radiographic imaging. International Journal of Case Reports and Images 2011;2:1-7.
Murtaza B, Mahmood A, Niaz WA, Akmal M, Ahmad H. Ureterovaginal fistula - etiological factors and outcome. JPMA 2012; 62:999.
Purandare CN. Urological injuries in gynecology. J Obstet Gynecol India 2007; 57:203-4.
Park JH, Park JW, Song K, Jo MK. Ureteral injury in gynecologic surgery: a 5-year review in a community hospital. Korean J Urol 2012; 53:
Ibeanu OA, Chesson RR, Echols KT, Nieves M, Busangu F, Nolan TE. Urinary tract injury during hysterectomy based on universal cystoscopy. Obstet Gynecol 2009;113: 6-10.
Gilmour DT, Das S, Flowerdew G. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol 2006; 107:
Obarisiagbon, EO, Olagbuji BN, Onuora VC, Oguike TC, Ande ABA. Iatrogenic Urological injuries complicating obstetric and gynaecological procedures. Singapore Med J 2011; 52:
Nnabugwu I, Amu O. Iatrogenic Ureteric injuries complicating open obstetric and gynaecological operations in South East Nigeria – case series. JWACS 2010; 1: 3
Sternschuss G. Ureteral injury in gynecologic laparoscopy. World J Lap Surg 2012; 5: 46-8.
Yu S, Wu H, Xu L, Li G, Zhang Z. early surgical repair of iatrogenic ureterovaginal fistula secondary to gynaecologic surgery. Int J Obstet Gynecol 2013; 123:
4/21/2017

26. REFERENCES
Rafique M, Arif MH. Management of iatrogenic Ureteric injuries associated with gynecological surgery. International Urology and Nephrology 2002; 34: 31-5.
Ares Valdes Y, Romero Diaz CA, Mederos Curbelo ON, Hernandez Silverio D, Alonzo Dominguez F, Cantero Ronquillo A. Ureteral lesions in gynecologic surgery. Arch Esp Urol 2003; 56:
Selzman AA, Spirnak JP, Kursh ED. The changing management of ureterovaginal fistulas. J Urol 1995; 153:
Mandal AK, Sharma SK, Vaidyanathan S, Goswami AK. Ureterovaginal fistula: summary of 18 years’ experience. Br J Urol 1990; 65:
Mahendran HA, Singam P, Ho C, Hong GE, Hee TG, Zainuddin ZM. Iatrogenic ureter injuries: eleven years experience in a tertiary hospital. Med J Malaysia 2012; 67:
Randawa A, Khalid L, Abbas A. Diagnosis and management of ureterovaginal fistula in a resource-constrained setting: experience at a district hospital in northern Nigeria. Libyan J Med 2009; 4: 41-3.
Bennani S, Joual A, El Mrini M, Benjelloun S. Ureterovaginal fistulas. A report of 17 cases. J Gynecol Obstet Biol Reprod (Paris) 1996; 25: 56-9.
Ozumba BC, Attah CA. Ureteral injury in obstetric and gynecologic operations in Nigeria. Int J Gynecol Obstet 1991; 36:
Onuora VC, al-Mohalhal S, Youssef AM, Patil M. Iatrogenic urogenital fistulae. Br J Urol 1993; 71:
Chan JK, Morrow J, Manetta A. Prevention of ureteral injuries in gynecologic surgery. Am J Obstet Gynecol 2003; 188:
4/21/2017

27. THANK YOU