Ureterovaginal fistula (UVF) is an uncommon complication of abdominal surgery or obstetrical trauma, and can have devastating consequences.  The most common cause in developed countries is gynecologic surgery, with an incidence of 0.5-2.5%.  The injury typically occurs at the level of the uterine artery.  Patients present early post-surgery with continuous leakage of urine per vagina, and the diagnosis is confirmed with vaginal exam and CT with contrast urography.  Cystoscopy and cystography are also required to rule out concomitant vesico-vaginal fistula.  Treatment involves endoscopic stenting, which has better success if done earlier.[1]  Failing a trial of stenting, ureteroneocystostomy is typically the preferred surgical approach with high success rates.  Transvaginal repair of UVF is rarely described but can be successful in select cases.[2]  Given the excellent reported outcomes of transvaginal repair of vesicovaginal fistulae (VVF), we have offered this approach to select women with UVF.[3]  We report on transvaginal UVF repair employing “exoscopic” visualization with the VITOM® 3-D system.

Transvaginal repair is offered to a patient with complex right UVF persisting after a period of stenting.  A fresh stent is first placed, then repair is commenced.  Visualization of the site of the fistula at the right vagina vault is facilitated by the VITOM® 3-D system, employing a camera suspended in front of the vagina around which the surgeon operates while viewing a HD 3-D monitor.  Similar to VVF repair, the fistula site is sharply circumscribed, then relaxing posterolateral incisions are made and flaps are widely dissected.  The fistula is not excised.  Following primary transverse closure of the fistula site the pubocervical fascia is mobilized and closed longitudinally over the site, then a fatty peritoneal flap broadly covers the area.

The patient is a 47 year old with endometriosis who underwent total laparoscopic hysterectomy, right salpingectomy, and excision of endometrioma encasing the right ureter.  She developed continuous vaginal leakage and was diagnosed 9 months later with suspected VVF despite normal CT cystogram, and 19 months following her initial surgery she returned to surgery for laparoscopic VVF repair by her surgeon.  Her leakage persisted, and right UVF was confirmed with CT urography, retrograde pyelography (Figure 1), and ureteroscopy (Figure 2).  The ureter was partially patent and a stent was successfully placed, though the leakage ultimately persisted. 

Transvaginal repair was completed in 91 minutes; estimated blood loss 75 ml; length of stay 23 hours.  No complications were observed.  Stent removal, retrograde pyelogram and vaginal exam were performed 4 weeks following repair, confirming resolution of leakage and patency of the ureter.  At 3 month follow-up the patient remains dry with no urinary complaints and KUB ultrasound is normal.

Transvaginal repair of UVF is feasible in select cases, and offers a minimally invasive approach with low morbidity and successful outcomes.  The VITOM® 3-D system provides enhanced visualization of the vaginal vault to facilitate fine dissection in this area.

Bahuguna G, Panwar VK, Mittal A, et al., Management strategies and outcome of ureterovaginal fistulae: A systematic review and meta-analysis. Neurourol Urodyn 2022; 41(2): 562-72.
Boateng AA, Eltahawy EA, and Mahdy A, Vaginal repair of ureterovaginal fistula may be suitable for selected cases. Int Urogynecol J 2013; 24(6): 921-4.
Shamout S, Anderson K, Baverstock R, et al., Evaluation of surgical approaches for vesicovaginal fistulae repair: the case for transvaginal repair as the gold standard. Int Urogynecol J 2021; 32(9): 2429-35.

Continence 7S1 (2023) 100791
DOI: 10.1016/j.cont.2023.100791