Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: A systematic review and meta-analysis

Abstract

BackgroundVesicovaginal fistulas (VVF) are the most commonly acquired fistulas of the urinary tract, but we lack a standardized algorithm for their management. Surgery is the most commonly preferred approach to treat women with primary VVF following benign gynaecologic surgery.ObjectiveTo carry out a systematic review and meta-analysis on the effectiveness of operative techniques or conservative treatment for patients with postsurgical VVF. Our secondary objective was to define the surgical time and determine the types of study designs.MethodsPubMed, Old Medline, Embase and Cochrane Central Register of Controlled Trials were used as data sources. This systematic review was modelled on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, including a registration number (CRD42012002097).ResultsWe reviewed 282 full text articles to identify 124 studies for inclusion. In all, 1379/1430 (96.4%) patients were treated surgically. Overall, the transvaginal approach was performed in the majority of patients (39%), followed by a transabdominal/transvesical route (36%), a laparoscopic/robotic approach (15%) and a combined transabdominal-transvaginal approach in 3% of cases. Success rate of conservative treatment was 92.86% (95%CI: 79.54–99.89), 97.98% in surgical cases (95% CI: 96.13–99.29) and 91.63% (95% CI: 87.68–97.03) in patients with prolonged catheter drainage followed by surgery. 79/124 studies (63.7%) provided information for the length of follow-up, but showed a poor reporting standard regarding prognosis. Complications were studied only selectively. Due to the inconsistency of these data it was impossible to analyse them collectively.ConclusionsAlthough the literature is imprecise and inconsistent, existing studies indicate that operation, mainly through a transvaginal approach, is the most commonly preferred treatment strategy in females with postsurgical VVF. Our data showed no clear odds-on favorite regarding disease management as well as surgical approach and current evidence on the surgical management of VVF does not allow any accurate estimation of success and complication rates. Standardisation of the terminology is required so that VVF can be managed with a proper surgical treatment algorithm based on characteristics of the fistula.

Surgical repair of vesico-vaginal fistula: the need for an evidence-based approach

“…Two recently published systematic reviews have described the etiology, management and outcome of iatrogenic VVF in women. The authors echo the conclusion of previous studies that the outcome of repair is affected by the number, size and site of fistulas, the first attempt at fistula repair being the most successful, and the route of surgical approach depends mainly on the surgeons' preferences, reflecting their skill set [2,3]. However, the optimal timing of repair, necessity of interposing tissue after fistula closure and postoperative period of catheter drainage still lack consensus.…”

“…However, the optimal timing of repair, necessity of interposing tissue after fistula closure and postoperative period of catheter drainage still lack consensus. The success of conservative treatment using continuous catheter drainage is < 10% [2,3]. In recent years, minimally invasive techniques have been introduced to the surgical repertoire for VVF repair, such as laparoscopic repair introduced in the 1990s and robotic-assisted laparoscopic repair first reported in 2005.…”

A review of surgical procedures to repair obstetric fistula

“…report that iatrogenic fistulae are less likely to close spontaneously with bladder decompression, owing to location and size, and advise early transabdominal closure of this type. A recent meta‐analysis on iatrogenic VVF demonstrated that 8% of patients treated with bladder decompression experienced spontaneous closure . The same meta‐analysis noted a 93% success rate for vaginal closure, while avoiding the morbidity of an abdominal approach.…”

Incidence, type and management of ureteric injury associated with vesicovaginal fistulas: Report of a series from a specialized center

“…Editorial Comment to Incidence, type and management of ureteric injury associated with vesicovaginal fistulas: Report of a series from a specialized center In developing countries, the vesicovaginal fistula (VVF) is caused by obstetric processes, whereas in developed countries the etiology is derived from gynecological surgeries (hysterectomy), pelvic radiotherapy, trauma and malignant diseases; reporting an incidence that ranges between 0.13 and 2%. 1 The treatment of VVF is surgical in most cases, and can be carried out by the vaginal or abdominal approach. The choice of repair technique is controversial, and is subject to several factors that depend on the characteristics of the patient and the fistula, but mainly due to the preferences of the surgeon.…”

“…The majority occur consequent to gynecological or other pelvic surgery and/or pelvic radiotherapy for malignancy. 1 The most common surgical procedure leading to VVF formation is hysterectomy, which is reported to account for up to 80% of iatrogenic causes of VVF, with the laparoscopic approach having the highest risk (2.2:1000), and vaginal approach the least risk (0.2:1000). 2 This is in contrast to low-income countries where VVF is consequent to obstructed second stage of labor in >95% of cases.…”