Sage Journals: Discover world-class research

Abstract

Urinary tract fistulas (UTFs) are abnormal connections between the urinary tract and adjacent structures such as the bowel, vagina, or blood vessels. UTFs result in significant personal, social, and financial challenges to patients worldwide. This review investigates the various causes, risk factors, symptoms, and historical evolution of repair techniques of UTFs. This focuses on the shift from open surgery to minimally invasive techniques, particularly the growing utilization of robot-assisted laparoscopic (RAL) approaches. This review emphasizes the growing role of RAL surgery in treating UTFs, citing its advantages of reduced blood loss, low recurrence rates, and decreased postoperative complications while acknowledging challenges such as limited access to the RAL platform and longer surgical times. The study concludes with advocacy for more widespread access to the RAL platform as well as more research, including randomized controlled trials, to further refine the body of evidence and promote patient outcomes.

Plain language summary

A comprehensive review of urinary tract fistulas: the evolution of etiologies, robotic surgical techniques, and contemporary outcomes

Introduction: Urinary tract fistulas (UTFs) are an inappropriate connection between the urinary tract and an adjacent anatomic structure such as small or large bowel, vagina, bone, or blood vessel. UTFs can present a significant challenge personally, socially, and financially to patients globally. This review article explores the myriad etiologies, risk factors, signs, and symptoms associated with UTFs and the historical evolution of surgical techniques used to repair UTFs. Specifically, we examine the transition from early surgical practices of open repairs to contemporary minimally invasive techniques, focusing on the growing role and utilization of the robotic-assisted laparoscopic (RAL) platform. Results: This comprehensive review article identified vesicovaginal fistulas (VVF) as the most common type of UTF, with etiologies including iatrogenic, parturition, and radiation sequelae. Surgical techniques to treat UTFs have evolved, leading to contemporary approaches such as laparoscopic and RAL surgery. Our results highlight the increasing prominence of RAL surgery in UTF management, offering favorable outcomes regarding minimal blood loss, low fistula recurrence rates, and minimal post-operative complications.1 However, factors such as the availability of the RAL platform and longer operative times still need to be improved. Conclusion: This study comprehensively explores UTFs, encompassing their historical evolution and contemporary surgical approaches. The findings underscore the efficacy of the RAL platform in UTF repairs, thus advocating for its increased utilization. Future research, including prospective and randomized clinical trials, is crucial for comparing open and RAL UTF repair outcomes and refining surgical techniques. Our study sets the stage for continued advancements in the surgical management of UTFs, emphasizing the potential for improved patient outcomes through integrating the RAL platform.

Keywords

fistula surgery meta-analysis history of fistula repair laparoscopic fistula repair robotic fistula repair robotic surgery disparities urinary fistula etiology urinary fistula repair urinary fistulas urinary tract injury

Introduction

Urinary tract fistulas (UTFs) are an inappropriate connection between the urinary tract and an adjacent anatomic structure. While most UTFs result from iatrogenic injuries, they can be a result of various etiologies, including parturition, congenital anomalies, malignancy, inflammation, infection, ischemia, radiation, foreign body erosion, and trauma.¹ In developed nations, gynecologic surgery is the leading cause of UTFs, with hysterectomy being the leading cause of vesicovaginal fistulas (VVF) and obstetric-related trauma being the most common cause of a rectovaginal fistula (RVF).² In developing nations, the most common UTF is a VVF as a result of childbirth, causing pressure necrosis of the pelvic floor, anterior vaginal wall, and trigone of the bladder.¹ Although women have a higher overall prevalence of UTFs than men, men at risk can develop enterovesical, colovesical, rectourethral, or pubovesical fistulas.³ UTFs can immensely burden patients on a personal, social, and financial level. UTFs are associated with poor quality of life, increased rates of pain and discomfort, numerous hospital and clinic visits, and higher rates of urinary tract infections (UTIs).⁴ The clinical presentation of a UTF can vary depending on the organs involved. Although some fistulae are diagnosed soon after a surgical procedure because of an acute onset of symptoms, many fistulae often present in a delayed manner with no immediate signs or symptoms, sometimes years after the index injury or insult.

In this review article, we aim to outline the various etiologies of UTFs, including associated risk factors, comorbidities, presenting signs and symptoms, and pertinent clinical details to consider. We will also briefly review the historical evolution of UTF management and the respective advancements in pelvic surgery, radiological cancer treatment, and obstetric care. This historical narrative describes how surgical techniques have evolved over the 19th and 20th centuries, leading to the introduction of minimally invasive procedures and how we manage UTFs today with contemporary surgical approaches such as robot-assisted laparoscopic (RAL) surgery. We highlight the advancements in imaging, surgical planning, and emerging data that support the increased use of RAL surgery in managing and repairing UTFs. Finally, we discuss future directions in the surgical management of UTFs, emphasizing emerging technologies in fistula management, potential areas for improvement in surgical techniques, and unmet needs in clinical research.

Methods

A narrative review was performed on January 30, 2024 on Medline, PubMed, Cochrane Library, and Embase databases using the following search terms: “urinary fistulas,” “urinary fistula repair,” or “urinary tract injury,” or “robotic fistula repair” or “history of fistula repair” or “robotic vs. open fistula repair” or “urinary fistula etiology” or “robotic vs. open surgery” or “fistula surgery meta-analysis” or “laparoscopic vs. robotic fistula repair” or “laparoscopic vs. open surgery” or “robotic surgery disparities.” The search was further filtered by year of publication and article language to limit the results to articles published in English from 1980 to the present. Included in this review were randomized controlled trials, meta-analyses, prospective multicenter comparative studies, case reports, literature reviews, and non-randomized case series. Excluded were studies on nonhuman models and the following article types: Conference abstracts, commentaries, and editorials. This study utilizes the narrative review guidelines from the Journal of Graduate Medical Education.⁵ Articles were reviewed for relevance by the authors, who excluded articles based on the title, followed by the abstract, and finally, the full text.

Results

Fistula types and etiologies

The most common type of UTF is a VVF, an abnormal connection between the bladder and the vagina.¹ In developing countries, this is most often due to prolonged obstructed labor that leads to pressure necrosis of the tissues separating the bladder and vagina with subsequent fistula formation. In industrialized countries, however, VVFs are usually iatrogenic.^1,6 VVFs can occur following gynecologic surgeries such as a hysterectomy and may happen secondary to an unrecognized bladder injury during the index procedure.^7,8 The rates of VVF development in post-hysterectomy patients and post-vaginal delivery are reported to be 1 in 1000.⁹ While repair of VVFs can be performed through a transabdominal approach or a transvaginal approach, a systematic review by Hillary et al. found that transvaginal repairs of VVFs were more likely to achieve closure.¹ The Latzko, transvaginal approach to VVF repair has been shown to be a highly effective management option for simple and complex fistulae and involves hydro-dissection of the epithelium from the underlying fascial attachments followed by identification and circumscription and purse-string closure of the fistula tract with subsequent closure of the defect through several layers of imbricating sutures.¹⁰

Ureterovaginal fistula (UVF) is an abnormal connection between the ureter and the vagina, which can develop after a distal ureteral injury in the setting of either endoscopic instrumentation, radiation, malignancy, trauma, pelvic surgery, endometriosis, or pelvic inflammatory disease.^11–13 Twelve to twenty-five percent of VVFs have an associated UVF.¹⁴ UVFs are traditionally closed through ureteroneocystostomy.¹⁵ Conservative management options for UVFs including ureteral stent placement or nephrostomy tube placement demonstrate favorable success rates.¹⁴ For fistulae that fail conservative management, ureteral reimplant is a viable surgical option using various methods depending on fistula characteristics including simple reimplant, ureteroureterostomy, Boari flap, and psoas hitch.¹⁴

Urethrovaginal fistula (UrVF), an abnormal connection between the urethra and the vagina, usually develops following transvaginal or pelvic surgeries but can also be associated with underlying risk factors similar to those listed above regarding UVFs.¹⁶ There are three standard urethral reconstructive techniques utilized to repair UrVFs including the use of anterior bladder flaps, posterior bladder flaps, and vaginal flaps.¹⁷ The use of a vaginal flap is generally considered to be the faster and easier approach and can be performed by primary closure, or in combination with labial pedicle flaps, peninsula flaps, or labial island flaps.¹⁷ Selection of an appropriate reconstruction method for urethral fistulas takes into account several fistula variables including the type and complexity, the location and size, the history of pelvic or perineal surgeries, and patient-specific health considerations.¹⁷ Urethral fistulas vary from simple, small, localized defects to complex, multisite, or large defects.¹⁷ More complex cases or repairs with compromised tissue integrity may require tissue flaps from adjacent tissues or mucosal grafts and surgical success depends largely on the surgeon’s ability to navigate such obstacles.¹⁷

Enterovesical fistula (EVF) is an abnormal connection between the bladder and any part of the bowel (small or large) that most commonly develops in colonic diverticulosis but can similarly develop secondary to malignancy, inflammatory conditions, trauma, and radiation therapy.¹⁸ The incidence of EVF development in diverticulosis is 2%, and the risk of EVF resulting from colonic malignancy is under 1%.¹⁹ Repair of EVFs is usually performed by either a one-stage or two-stage resection of the involved bowel segment with the goal of fistula removal.¹⁸ Rectourethral fistula (RUF), an abnormal connection between the urethra and the rectum, can occur after either radical prostatectomy, anorectal surgery, pelvic radiation therapy, brachytherapy, or cryotherapy for the prostate, trauma, or secondary to underlying inflammatory conditions—the rate of RUF development after radical prostatectomy is estimated to be 0.5%.²⁰ While RUFs are often treated with temporary colostomy and concurrent urethral catheter, those that fail this option require surgical closure with excision of the tract and primary repair.²⁰

Urovascular fistulas (UVaFs), abnormal connections between the urinary tract and a blood vessel, are rare but most commonly develop between the ureter and a nearby blood vessel (e.g., branches of the iliac artery) secondary to prior percutaneous procedures, ureteral or vascular stents, vascular disease or grafts, pelvic surgeries, radiation, and inflammatory conditions.²¹ For fistulae originating from smaller blood vessels, selective embolization can be performed. However, for UVaFs originating from large vessels or those unresponsive to embolization, surgical ligation or the fistula tract with excision of the involved ureteral segment and possibly concurrent vascular reconstruction have been described.²²

Lastly, vesicouterine fistula (VUtF) is an abnormal connection between the bladder and the uterus that is rare and usually occurs secondary to a low-transverse cesarean section.^23,24 Injury to the lower urinary tract during a low-transverse cesarean section appears 0.1% to 0.3% of the time, and VUtFs represent 1% to 4% of UTFs.²⁵ Although, small fistulae discovered postpartum often resolve spontaneously with conservative management, larger fistulae or those that do not resolve require surgical repair.²⁵ Although transvesical and transabdominal approaches have been described, the transabdominal approach has shown better rates of surgical success.²⁵ Transvesical techniques utilize fulguration of the fistula opening and transabdominal techniques involving excision of the tract, often in conjunction with a tissue graft considering tissue ischemia is common.²⁵

The signs and symptoms of UTFs vary widely depending on the anatomical structure to which the urinary tract is inappropriately connected. VVFs, UVFs, UtVFs, and UrVFs tend to present with leakage of urine through the vagina that is interpreted by the patient as constant urinary incontinence and can occur within weeks after an offending surgery or years if the etiology is radiation.²⁶ RUFs present with foul-smelling urethral discharge as a result of stool or bowel gas traversing the fistula and can ultimately result in symptoms of recurrent UTIs.¹⁹ Likewise, EVFs present with UTIs due to stool in the urinary tract.¹⁹ The dominant sign of UVaFs is gross hematuria.²²

Voiding cystourethrogram (VCUG), CT urography, pelvic MRI, and other imaging techniques are frequently used to investigate suspected UTFs, depending on the presenting symptoms and associated comorbidities. Short of direct visualization of the UTF via cystoscopy, radiographic findings can suggest the existence of a fistula, such as air in the bladder, contrast extravasation into the bowel or vagina, and bladder wall thickening. When underlying malignancy is suspected in a patient with UTF, a pelvic CT or MRI is recommended to better visualize potentially involved pelvic structures.

The different types of UTFs discussed in this section as well as their corresponding etiologies, risk factors, symptoms, and diagnostic methods are summarized in Table 1.

Table 1.

Overview of urinary tract fistulas: types, etiologies, risk factors, symptoms, and diagnostic methods.

Fistula type	Etiologies and risk factors	Symptoms	Diagnostic methods
VVF^1,2	- Obstetric trauma - Gynecologic/pelvic surgeries - Pelvic malignancies	- Continuous vaginal urine leakage - Recurrent UTIs	- Physical exam - Dye test - Cystoscopy - CT urogram
UrVF¹⁶	- Surgical Trauma - Obstructed labor - Urethral procedures	- Post-void vaginal urine leakage - Vaginal inflammation	- Dye test - MRI or CT imaging - Endoscopy
RVF^60,61	- Inflammatory bowel disease - Diverticulitis - Radiation therapy - Colorectal cancer	- Pneumaturia - Fecaluria - Recurrent UTIs	- Colonoscopy - CT scan with contrast - Cystoscopy
VUtF^23–25	- Cesarean section - Obstetric trauma - Placenta percreta - Uterine surgeries	- Vaginal urine leakage - Cyclic hematuria	- MRI - Cystoscopy - Dye test
UVF^{11–14,62,63}	- Pelvic or abdominal surgery complications	- Continuous vaginal urine leakage - Flank pain	- Intravenous pyelogram - Cystoscopy - Dye test
UVaF²¹	- Trauma - Post-surgical complications - Invasive cancer - Radiation therapy	- Gross hematuria - Flank or abdominal pain - Hemodynamic instability	- Angiography - CT angiogram - Cystoscopy
EVF^3,18,19,58	- Diverticulitis - Inflammatory bowel disease - Abdominal or pelvic cancers - Radiation therapy	- Pneumaturia - Fecaluria - UTIs	- CT scan with contrast - Cystoscopy - Colonoscopy
RUF^3,20,64	- Prostate surgery - Pelvic trauma - Radiation therapy - Pelvic malignancies	- Fecaluria - Pneumaturia - Recurrent UTIs - Rectal urine leakage	- Physical exam - Cystoscopy - MRI - CT scan with contrast
CVF^3,58,59	- Inflammatory bowel disease - Pelvic/abdominal surgery - Radiation therapy	- Pneumaturia - Fecaluria - Recurrent UTIs - Abdominal pain	- CT scan with contrast - Colonoscopy - Cystoscopy

CVF, colovesical fistula; EVF, enterovesical fistula; RUF, rectourethral fistula; RVF, rectovesical fistula; UrVF, urethrovaginal fistula; UTI, urinary tract infection; UVaF, urovascular fistula; UVF, ureterovaginal fistula; VUtF, vesicouterine fistula; VVF, vesicovaginal fistula.

Historical surgical repair techniques

The history of UTF surgery has been detailed by Elkins in their paper “Fistula surgery: past, present, and future directions.” Elkins break down five periods of theory and innovation for UTF surgery. The “Pre-Leak” period (1000 BC–1300 AD) was characterized by repeated accounts of urinary incontinence following difficult and prolonged labor.²⁷ The “Mend-the-Leak” period (1300–1940 AD) was a time of discovery with constant progress in medical knowledge and debate on various surgical methods and principles.²⁷ The “Mega-Leak” period (1940–1990AD) involved rapid medical advancement, increased scope of pelvic surgeries, and the introduction of radiation therapy for cancer treatment, which would later lead to a significant etiology of UTF formation.²⁷ The “Para-Leak” period (1990–2000 AD) was characterized by a transition toward effectively managing and repairing fistula-related complications as well as other pelvic floor-related disorders that resulted in urinary incontinence.²⁷ Lastly, the “Never-Leak” period (2000 AD–Present) focuses on fistula prevention and effectively managing those that occur.²⁷

In the mid-1800s, J. Marion Sims, an American surgeon, demonstrated consistent success in the repair of obstetric urogenital fistulas.²⁸ However, it must be mentioned that Sims has been strongly criticized over the years for his use of enslaved patients who were in very vulnerable and desperate positions.²⁷ Sims’ method of closing VVFs included visualization of fistula edges followed by closure with temporary interrupted wire sutures.²⁷ In the next 100 years, there were incremental improvements in surgical techniques and tools with continued debate over the intricacies of suturing techniques, patient positioning, and tissue planes.²⁷ Nevertheless, success rates steadily rose with the advancement of surgical methods.²⁷

As access to and advancement in obstetric care grew in the United States and worldwide, the rates of prolonged obstructed labor fell drastically.²⁷ Concurrently, however, intraabdominal and pelvic surgical approaches for numerous indications exponentially rose, as did the use of radiation therapy, effectively ushering in a new age of iatrogenic UTF development.²⁷ As invasive gynecologic surgeries became more widespread and standardized throughout the mid-1900s, lower urinary tract injuries, and subsequent fistula formation became increasingly common.²⁹

As radiation therapy for the treatment of cancer grew, so too did radiation-induced fistulas. In a meta-analysis of more than 22,000 patients with exposure to pelvic radiation between 1970 and 2019, it was found that the risk of UTF formation overall was 1% (p = 0.00) but increased to 7% (p = 0.037) when patients had previous exposure to pelvic radiation, and 3% (p = 0.006) in patients with concurrent chemotherapy.³⁰ These fistulas presented a complex obstacle for surgeons when appropriately managing and surgically repairing UTFs. As our understanding of the pathophysiologic foundation of endarteritis obliterans grew more robust, it became clear to surgeons that radiation-induced fistulas were more likely to be successfully repaired using tissue grafts and flaps.³¹ Similar to surgical techniques, radiation therapy improved and advanced over time, decreasing the risk of UTFs and dropping the overall fistula rates.³² With advancements in radiotherapy technology, high-dose radiation can now be delivered more precisely to a targeted area with decreased risk to surrounding healthy tissue.³³ In addition, an improved understanding of resistance mechanisms and factors impacting tumor sensitivity to radiotherapy has facilitated the development of radiosensitizer and radioprotective adjuncts that maximize efficacy while minimizing dose and adverse effects.³³

In the 1980s and 1990s, surgeons broadened their expectations from simply completing a successful fistula closure to aspiring toward improved postoperative care and eliminating complications such as vaginal atresia after VUtF repairs and stress incontinence after sub-urethral fistula repairs.³⁴ Significant efforts were made throughout this era to prevent obstetric fistula development by disseminating primary maternal healthcare worldwide. This period also broadened the popularity of utilizing urodynamics in the diagnosis and preoperative planning for UTF repairs as well as the use of skin flaps to preserve vaginal depth, the loss of which had previously been an accepted consequence of fistula repair.^35,36 As we shift our focus to contemporary surgical approaches in the management of UTFs, the historical narrative gives way to a discussion of modern repair techniques, which have evolved significantly to encompass a range of surgical methods tailored to the complexity, location, and expertise required for an effective and long-lasting repair. As the use of the robotic platform emerged and grew throughout the 1990s and early 2000s, so did its role in the surgical management of UTFs. In 2005, Melamud et al. published the first case report of RAL repair of VVF.³⁷ This report described improved visualization and surgical precision provided by the robotic platform as well as shortened learning curves in comparison to standard laparoscopy bringing hope that robotics will eventually provide more urologists with the technical proficiency to provide patients with this minimally invasive approach.³⁷

Discussion

Modern repair techniques

Repair techniques of UTFs have evolved over time to accommodate emerging trends in minimally invasive surgery. Early in the history of UTF repair, open approaches dominated. Accordingly, patients were exposed to drawbacks of open surgery in comparison to newer minimally invasive approaches including larger incisions and longer postoperative recovery. As surgical technology advanced, laparoscopy gained popularity boasting smaller incisions, shorter recovery time, decreased surgical pain, and lower rates of complications such as infection. The emergence of robot-assisted surgery represented the beginning of a paradigm shift in minimally invasive surgery allowing surgeons to perform more complex repairs while taking advantage of the advantages of laparoscopy over open surgery. While data to more thoroughly delineate robot-assisted versus laparoscopic outcomes are needed, intuitive conclusions about the advantages of robot assistance can be drawn. Robot-assisted laparoscopy gives surgeons more intuitive, natural hand-eye coordination while traditional laparoscopic devices restrict the freedom of movement and dexterity of the surgeon limiting the ability to accomplish complex fistula repairs.³⁸ Robotic platforms also provide three-dimensional, binocular visualization while laparoscopic is monocular. Further, many surgeons struggle with magnification of physiologic tremors when using rigid laparoscopic instruments while robotic platforms are able to compensate for this and provide smoother, more precise movements.³⁸ While studies specifically comparing robot-assisted to traditional laparoscopic repair of UTFs are still needed, there have been many studies in various other areas comparing the two approaches. A 2014 systematic review comparing robot-assisted to standard laparoscopy in colorectal surgery found that use of the robotic platform demonstrated less blood loss, shorter hospital stays, lower complication and reoperation rates, and comparable oncological outcomes.³⁹

Conservative measures aimed at urinary diversions, such as a foley catheter, ureteral stent, or percutaneous nephrostomy tube placement, are viable management options for UTFs. There is no consensus on how long stents, catheters, or nephrostomy tubes should be left in place for optimal success rates. A retrospective cohort study of 20 patients with ureterovaginal fistulae demonstrated success in 65% (n = 13) of patients managed with ureteral stent placement for 6 to 8 weeks.¹⁴ Generally, at least 6 weeks of stenting is considered sufficient to maximize the chance of fistula closure. In addition, hyperbaric oxygen therapy (HOT) has been proposed as adjunctive therapy for the management of various fistula types. HOT has been shown to aid in stem cell mobilization, tissue oxygenation, growth factor upregulation, and decreased inflammation.⁴⁰ A 2024 systematic review and meta-analysis by Dokmak et al. demonstrated that HOT is both a safe and effective management option for fistulizing Crohn’s disease. They found that, among the 164 patients across 16 studies, the overall clinical response rate was 87% with a low rate of adverse events of about 52 per 10,000 sessions.⁴¹ In the HOT-REVA study of patients with Crohn’s disease complicated by RVF, they found that HOT was ineffective when used in isolation and had unclear benefits when used adjunctively.⁴⁰ While results in the HOT-REVA study were disappointing for those optimistic about the theoretical benefits of HOT in the management of UTFs, there exist opportunities for future randomized controlled trials more specifically targeting this question.

The optimal timing of inciting events to surgical correction of UTFs has been the topic of several studies. However, there is still a lack of consensus on the definitions of “early” and “late” repair. A retrospective study of “early” versus “late” repair of VVFs defining the former as within 12 weeks of inciting event and the latter as greater than 12 weeks found that once acute inflammation had subsided, which was within the study designers’ “early” window, there was no additional benefit to be gained from further delaying surgical correction.²⁹ While there have been efforts to define arbitrary time intervals for surgical correction of these fistulae, existing literature supports a patient-centered approach taking into account the fistula type, etiology, and other patient-specific factors.⁴²

Surgical reconstruction is the mainstay treatment for UTFs that fail conservative management and can range from simple to complex reconstruction. The most common approaches to UTF repairs include transvaginal, transabdominal, or laparoscopic approaches.⁴³ The fistula complexity, location, and expertise ultimately determine the strategy utilized for the repair. The O’Conor technique, introduced in 1972, was the primary VVF repair technique.⁴⁴ This involves an open abdominal approach and a cystotomy to identify and repair the fistula. In the 1990s, laparoscopic extravesical repairs became more appealing as a minimally invasive alternative.^43,45 In line to achieve long-lasting results with minimal surgical complications, RAL fistula repair has become an increasingly effective technique in managing urinary fistulas.^46–48 This transition from open to robotic surgery is a trend in various urologic surgeries. This field has widely adopted the robotic platform and, in many cases, has deemed it the standard of care.⁴⁹ We present a case (Supplemental Video 1) of a 33-year-old female who underwent a laparoscopic-assisted vaginal hysterectomy whose postoperative course was complicated by fever, pelvic pain, and constant vaginal drainage. She was found to have a UVF, and a CT urogram confirmed the presence of a UVF and a duplicate collecting system. She opted for definitive repair of her fistula and underwent a RAL fistula repair and concurrent ureteral reimplantation. Supplemental Video 1 highlights the technical approach to RAL UVF repair.

In addition to the adoption of minimally invasive platforms, the use of tissue flaps and grafts has grown in popularity in many reconstructive urological procedures, including in the management of UTFs. Grafts and flaps using the ileum, peritoneum, omentum, bladder, rectal mucosa, vaginal mucosa, buccal mucosa, appendix, fascia lata, and other structures have been described.⁵⁰ In general, flaps and grafts are used for interposition, ureteral substitution, structural and nutritional support, and as alternatives to mesh implants.⁵⁰ The utility of these flaps and grafts has grown alongside the adoption of the robotic platform, taking advantage of the improved dexterity and visualization offered by this platform.⁵⁰ As the employment of these techniques and associated literature continue to expand, more dedicated comparative studies are needed to characterize the benefits and limitations of each of the various types of flaps and grafts.

As previously discussed, most genitourinary fistulas in developed countries result from iatrogenic procedures such as hysterectomy. In contrast, most genitourinary fistulas in the developing world are a result of obstetric complications from childbirth. Although the robotic platform is not readily available in all developing nations and in all regions, it is becoming increasingly accessible across medical centers in the United States, even in areas that are traditionally underserved.⁵¹ Currently, the main limitations to the utilization of the robotic platform are the availability of surgeons and bedside assistants and the longer operative times, which can have financial implications for hospital systems.⁵² Despite these factors, for many Genitourinary fistulas, the robotic platform may offer benefits regarding postoperative pain, blood loss, low recurrence rates, and hospital length of stay. Additionally, the robotic platform provides better access and improved visualization for UTF in the deep pelvis.

This concept of improved outcomes in robotic surgery versus open surgery is demonstrated well in the RAZOR trial published in The Lancet in 2018.⁵³ This was a large, randomized clinical non-inferiority trial comparing outcomes in robotic versus open cystectomies for bladder cancer patients. Aside from the oncologic recurrence rates in the study, which do not apply to fistula disease, the robotic approach offered improved outcomes in blood loss, hospital stay, and postoperative pain. However, this paper’s applicability to UTF is limited by the different nature of bladder cancer and cystectomies compared to fistulous diseases. Furthermore, this non-inferiority study did not conclude that using the robotic platform was superior to open surgery.

UTFs are often complex; however, with the proper expertise and utilization of robotic techniques, they can be treated successfully with minimal postoperative complications, reduced recurrence rates, and a shorter stay. Future steps in the field should include additional prospective and randomized clinical trials comparing outcomes of open versus robotic GU fistula repairs. In addition, further research into the techniques proficiently utilized by urologists with the robotic platform is necessary to improve surgical outcomes and reduce complications.

Systematic review analyses on surgical outcomes

The data discussed in this section are summarized in Table 2. Bora et al. studied 30 patients who underwent RAL VVF repair (11 had complex VVFs, and 27 had supratrigonal VVFs).⁵⁴ The mean age of the patients in this study was 43.5 years. The median blood loss was 50 ml. The median drain placement and hospital length of stay were 3 and 7.5 days, respectively. The median duration of follow-up was 38 weeks, and no recurrence was seen in 93% (n = 28) of patients.

Table 2.

Clinical studies evaluating success and complication rates after urinary tract fistula repair.

Study	Fistula type	Repair technique	No. of cases	Success rate (%)^a	Complication rate (%)
Bora et al.⁵⁴	VVF	RAL	30	93	0
Jairath et al.⁵⁵	VVF	RAL	8	100	0
Kurz et al.⁵⁶	VVF	RAL	3	100	0
Lecoanet et al.⁵⁷	VVF	RAL	22	100	18
Wong et al.⁶⁵	cVVF	RAL	1	100	0
Granieri et al.⁵⁸	EVF	Open	637	95.6	21.6
		Laparoscopic	121	98.4	25.5
		RAL	20	98.3	29
Sahay et al.⁵⁹	CVF	RAL	1	100	0
Sotelo et al.⁶⁰	RVF	RAL	1	100	0
Sayegh et al.⁶¹	RVF	RAL	4	100	0
Yuan et al.⁶²	UVF	RAL	4	100	0
Laungani et al.⁶³	UVF	RAL	3	100	0
Bhalla et al.⁶⁴	cRUF	RAL	1	100	0

Defined by no recurrence.

cRUF, congenital rectourethral fistula; CVF, colovesical fistula; cVVF, congenital vesicovaginal fistula; EVF, enterovesical fistula; RAL, robot-assisted laparoscopic; RVF, rectovesical fistula; UVF, ureterovaginal fistula; VVF, vesicovaginal fistula.

Similarly, in a study by Jairath et al., eight patients who underwent a RAL VVF repair had a mean age of 39 years with an average time of 9 months between discovery of fistula and repair.⁵⁵ The mean size of the fistula was 13.37 mm, with a mean operative time of 117.5 min. They did not report any intraoperative complications. The mean length of stay was 6.6 days, with no postoperative fistula recurrence at publication. Kurz et al. examined three patients with supratrigonal VVFs undergoing RAL repair with peritoneal flap inlay.⁵⁶ At a mean follow-up of 23 weeks, all three patients remained continent without signs of fistula recurrence.

In another study by Lecoanet et al., which included 22 cases of robotic VVF repairs using either a transvesical approach (n = 13) or an extravesical approach (n = 9), they reported a 100% cure rate, which was defined by the absence of clinical recurrence.⁵⁷ The median age of the participants was 43, and 5 patients had a history of previously attempted fistula repair. They reported four postoperative complications (three minor and one major). All 22 patients were free of clinical recurrence at a median follow-up of 15 months.

A systematic review and meta-analysis by Granieri et al. analyzed 22 studies with 861 patients undergoing surgery for EVFs and found an overall recurrence rate of 5%.⁵⁸ The surgical approaches included in the survey varied, with 18 studies (637 patients) utilizing an open approach, 7 studies (121 patients) using a laparoscopic approach, and only one study (20 patients) utilizing a robotic approach. Of note, the rate of conversion to open surgery from laparoscopic was reported as 23%, while there were no necessary conversions to open surgery from the robotic approach.

Sahay et al. reported a case in 2024 of a colovesical fistula (CVF) in a 71-year-old male with sigmoid diverticular disease.⁵⁹ At the same time, there was no colonoscopic visualization of the fistula; the patient presented with a 6-month history of pneumaturia and fecaluria. Postoperative recovery was without complication, and he was discharged on postoperative day 4. A cystoscopy performed 1 month after surgery revealed a healthy bladder, and at 1 year of follow-up, the patient was without recurrence of symptoms or UTI. Similarly, a 2008 Sotelo et al. case report outlines a patient undergoing robotic repair of an RVF following an open radical prostatectomy.⁶⁰ The patient’s suprapubic tube was removed at 2 months following a normal cystography, and bowel continuity was restored at 4 months. At 1 month follow-up, there was no fistula recurrence.

In 2023, Sayegh et al. published a case series including four patients with RVF with concurrent vesicourethral anastomotic stricture following radical prostatectomy.⁶¹ The median age of these patients was 68.5. No intraoperative or postoperative complications were reported. There were no recurrent fistulas at a median follow-up time of 16.25 months.

A 2021 study by Yuan et al. evaluated four cases of UVF at a single institution treated with robotic ureteral reimplantation.⁶² The mean age of the included cases was 50.3, and all four UVFs were due to a previous hysterectomy. There were no intraoperative complications. None of the patients experienced side progressive hydronephrosis or urinary incontinence during the 6 to 24 months of follow-up. 100% of the cases were successful without fistula recurrence. In another study of robotic repair of UVFs by Laungani et al. from 2008, three patients who developed UVF following hysterectomy underwent robotic surgical repair.⁶³ All three cases were without intraoperative complications and were discharged completely dry with an indwelling stent. However, follow-up data from these cases was not reported in this study.

The robotic platform is also making its way into the pediatric urologic population and has successfully been used to treat pediatric UTFs. In a 2022 case report by Bhalla et al., a 2-year-old male with febrile UTI was found to have a congenital RUF via VCUG.⁶⁴ This fistula was successfully repaired via a RAL transperitoneal approach. The postoperative course was unremarkable, with a urethral catheter removal at 2 weeks, normal voiding, and regular bowel movements. Another case report in 2018 by Wong et al. detailed the robot-assisted repair of a congenital VVF masquerading as a cystocele with recurrent UTI in a 10-year-old female patient.⁶⁵ They conducted a RAL congenital VVF closure with a vaginoplasty. Recovery was uneventful, and at a 2-year follow-up, the patient was free of UTI or other urinary tract symptoms.

The content of this article and any conclusions drawn are limited by inconsistent study design and outcome reporting metrics for analyzed studies. Likewise, surgeon experience with and availability of the robotic platform, which were not controlled for in any of the mentioned studies, are critical factors and therefore contribute to the limitations of this work. There is great potential value in future studies evaluating the influence of surgeon experience including data from high-volume versus low-volume practices on success rates for surgical correction of UTFs as the current body of literature is lacking this level of analysis.

Conclusion

Our comprehensive analysis delves into the multifaceted realm of UTFs, exploring their diverse etiologies, identifying key risk factors and comorbidities, and the historical evolution of surgical approaches leading to contemporary UTF repairs. The historical narrative, spanning distinct periods of thought and innovation, highlights the evolution of surgical techniques from historical times to the present day, emphasizing the shift toward minimally invasive procedures and focusing on UTF prevention and quality of life. This transition is marked by advancements in imaging, surgical planning, and a growing preference for utilizing the robotic platform. Our systematic review further supports the efficacy of RAL UTF repairs, emphasizing favorable outcomes regarding blood loss, hospital stay, minimal complications, and a meager recurrence rate. Looking ahead, we advocate for future research endeavors, including prospective and randomized clinical trials comparing open and robotic GU fistula repairs. The pursuit of refined techniques and a deeper understanding of the nuances associated with robotic surgery is paramount in improving surgical outcomes and providing optimal patient care. The studies reviewed demonstrate promising results, laying the groundwork for continued advancements in the surgical management of UTFs. As we navigate the evolving landscape of urologic surgery, the integration of the robotic platform stands as a beacon for improved patient outcomes and enhanced surgical precision.

Footnotes

Acknowledgements

Special thank you to Karen Doersch, MD and Margaret Higgins, MD for their contributions to this project.

Declarations

ORCID iDs

Noah Nigro

Shujian Lin

Supplemental material

Supplemental material for this article is available online at [Supplemental Video 1].

References

Hillary

Osman

Hilton

, et al. The aetiology, treatment, and outcome of urogenital fistulae managed in well- and low-resourced countries: a systematic review. Eur Urol 2016; 70(3): 478–492.

Serna-Gallegos

Jeppson

PC.

Female pelvic fistulae. Obstet Gynecol Clin North Am 2021; 48(3): 557–570.

Golabek

Szymanska

Szopinski

, et al. Enterovesical fistulae: aetiology, imaging, and management. Gastroenterol Res Pract 2013; 2013: 617967.

Pyra

Szmygin

, et al. Uretero-vaginal fistulas—clinical presentation, treatment and literature overview. Ginekol Pol 2022; 93(6): 501–505.

Sukhera

Narrative reviews: flexible, rigorous, and practical. J Grad Med Educ 2022; 14(4): 414–417.

Wall

Karshima

Kirschner

, et al. The obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004; 190(4): 1011–1019.

Aarts

Nieboer

Johnson

, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2015; 2015(8): Cd003677.

Teeluckdharry

Gilmour

Flowerdew

Urinary tract injury at benign gynecologic surgery and the role of cystoscopy: a systematic review and meta-analysis. Obstet Gynecol 2015; 126(6): 1161–1169.

Chinthakanan

Sirisreetreerux

Saraluck

Vesicovaginal fistulas: prevalence, impact, and management challenges. Medicina (Kaunas) 2023; 59(11): 1947.

10.

Kieserman-Shmokler

Sammarco

English

, et al. The Latzko: a high-value, versatile vesicovaginal fistula repair. Am J Obstet Gynecol 2019; 221(2): 160.e1–160.e4.

11.

Bai

Huh

Jung

, et al. Urinary tract injuries during pelvic surgery: incidence rates and predisposing factors. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17(4): 360–364.

12.

Shaw

Tunitsky-Bitton

Barber

, et al. Ureterovaginal fistula: a case series. Int Urogynecol J 2014; 25(5): 615–621.

13.

Vakili

Chesson

Kyle

, et al. The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy. Am J Obstet Gynecol 2005; 192(5): 1599–1604.

14.

Al-Otaibi

KM.

Ureterovaginal fistulas: the role of endoscopy and a percutaneous approach. Urol Ann 2012; 4(2): 102–105.

15.

Mandal

Sharma

Vaidyanathan

, et al. Ureterovaginal fistula: summary of 18 years’ experience. Br J Urol 1990; 65(5): 453–456.

16.

Badlani

De Ridder

DJMK

Mettu

, et al. Urinary tract fistulae. Campbell-Walsh Urol 2016; 3(11): 2103–2139.

17.

Lawal

Abdul-Salam

Bello

, et al. Outcome of urethral reconstruction among vesico-vaginal fistula patients: a cross-sectional study. Afr J Urol 2021; 27(1): 44.

18.

Moss

Ryan

Jr.

Management of enterovesical fistulas. Am J Surg 1990; 159(5): 514–517.

19.

Shaydakov

Pastorino

Tuma

20.

Thomas

Jones

Jäger

, et al. Incidence, clinical symptoms and management of rectourethral fistulas after radical prostatectomy. J Urol 2010; 183(2): 608–612.

21.

Nelson

Fried

FA.

Iliac artery-ureteral fistula associated with Gibbons’ catheter: a case report and review of the literature. J Urol 1981; 125(6): 878–880.

22.

Bergqvist

Pärsson

Sherif

Arterio-ureteral fistula—a systematic review. Eur J Vasc Endovasc Surg 2001; 22(3): 191–196.

23.

Porcaro

Zicari

Antoniolli

, et al. Vesicouterine fistulas following cesarean section: report on a case, review and update of the literature. Int Urol Nephrol 2002; 34(3): 335–344.

24.

Rajamaheswari

Chhikara

AB.

Vesicouterine fistulae: our experience of 17 cases and literature review. Int Urogynecol J 2013; 24(2): 275–279.

25.

Alkatib

Franco

Fynes

MM.

Vesicouterine fistula following Cesarean delivery—Ultrasound diagnosis and surgical management. Ultrasound Obstet Gynecol 2005; 26(2): 183–185.

26.

Ghoniem

Warda

HA.

The management of genitourinary fistula in the third millennium. Arab J Urol 2014; 12(2): 97–105.

27.

Elkins

TE.

Fistula surgery: past, present and future directions. Int Urogynecol J Pelvic Floor Dysfunct 1997; 8(1): 30–35.

28.

Sims

JM.

On the treatment of vesico-vaginal fistula. 1852. Int Urogynecol J Pelvic Floor Dysfunct 1998; 9(4): 236–248.

29.

Blaivas

Heritz

Romanzi

LJ.

Early versus late repair of vesicovaginal fistulas: vaginal and abdominal approaches. J Urol 1995; 153(4): 1110–1112; discussion 1112–1113.

30.

Sadighian

Hakam

Amend

, et al. PD22-08 risk of radiation-induced fistula is low and may be increased in patients with prior pelvic radiation or concurrent chemotherapy: a systematic review and meta-analysis. J Urol 2022; 204–208.

31.

Gowing

NFC

. Pathological changes in the bladder following irradiation. Br J Radiol 1960; 33(392): 484–488.

32.

Boronow

RC.

Management of radiation-induced vaginal fistulas. Am J Obstet Gynecol 1971; 110(1): 1–8.

33.

Chen

HHW

Kuo

. Improving radiotherapy in cancer treatment: promises and challenges. Oncotarget 2017; 8(37): 62742–62758.

34.

Elkins

TE.

Surgery for the obstetric vesicovaginal fistula: a review of 100 operations in 82 patients. Am J Obstet Gynecol 1994; 170(4): 1108–1118; discussion 1118–1120.

35.

Schleicher

Ojengbede

OHA

Elkins

TE.

Urologic evaluation after closure of vesicovaginal fistulas. Int Urogynecol J 1993; 4(5): 262–265.

36.

Margolis

Elkins

Seffah

, et al. Full-thickness Martius grafts to preserve vaginal depth as an adjunct in the repair of large obstetric fistulas. Obstet Gynecol 1994; 84(1): 148–152.

37.

Melamud

Eichel

Turbow

, et al. Laparoscopic vesicovaginal fistula repair with robotic reconstruction. Urology 2005; 65(1): 163–166.

38.

Sussman

Peyronnet

Brucker

BM.

The current state and the future of robotic surgery in female pelvic medicine and reconstructive surgery. Turk J Urol 2019; 45(5): 331–339.

39.

Köckerling

Robotic vs. standard laparoscopic technique—What is better?

Front Surg 2014; 1: 15.

40.

Lansdorp

Buskens

Gecse

, et al. Hyperbaric oxygen therapy for the treatment of rectovaginal fistulas in patients with Crohn’s disease: results of the HOT-REVA pilot study. BJS Open 2021; 5(3): zrab042.

41.

Dokmak

Sweigart

Orekondy

, et al. Efficacy and safety of hyperbaric oxygen therapy in fistulizing Crohn’s disease: a systematic review and meta-analysis. J Clin Gastroenterol 2024; 58(2): 120–130.

42.

Fearl

Keizur

LW.

Optimum time interval from occurrence to repair of vesicovaginal fistula. Am J Obstet Gynecol 1969; 104(2): 205–207.

43.

Mellano

Tarnay

CM.

Management of genitourinary fistula. Curr Opin Obstet Gynecol 2014; 26(5): 415–423.

44.

Nesrallah

Srougi

Gittes

RF.

The O’Conor technique: the gold standard for supratrigonal vesicovaginal fistula repair. J Urol 1999; 161(2): 566–568.

45.

Porpiglia

Fiori

Morra

, et al. Laparoscopic vesico-vaginal fistula repair: our experience and review of the literature. Surg Laparosc Endosc Percutan Tech 2009; 19(5): 410–414.

46.

Pietersma

Schreuder

HWR

Kooistra

, et al. Robotic-assisted laparoscopic repair of a vesicovaginal fistula: a time-consuming novelty or an effective tool? BMJ Case Rep 2014; 1–3.

47.

Govorov

Vorobeva

Komlichenko

EV.

Robotic repair of the symptomatic vesicouterine fistula. Int Urogynecol J 2021; 32(7): 1945–1947.

48.

Sandhu

Cheung

Robotic-assisted surgery—a highly effective modality for vesicovaginal fistula repairs. Curr Urol Rep 2023; 24(3): 117–120.

49.

Brassetti

Ragusa

Tedesco

, et al. Robotic surgery in urology: history from PROBOT(®) to HUGO(TM). Sensors (Basel) 2023; 23(16): 7104.

50.

Doersch

Hines

Ajay

Narrative review of flaps and grafts in robotic reconstructive urologic surgery. Ann Laparosc Endosc Surg 2024; 9: 5.

51.

Hughes

Rai

Madaan

, et al. The availability, cost, limitations, learning curve and future of robotic systems in urology and prostate cancer surgery. J Clin Med 2023; 12(6): 2268.

52.

Zahid

Ayyan

Farooq

, et al. Robotic surgery in comparison to the open and laparoscopic approaches in the field of urology: a systematic review. J Robot Surg 2023; 17(1): 11–29.

53.

Parekh

Reis

Castle

, et al. Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial. Lancet 2018; 391(10139): 2525–2536.

54.

Bora

Singh

Mavuduru

, et al. Robot-assisted vesicovaginal fistula repair: a safe and feasible technique. Int Urogynecol J 2017; 28(6): 957–962.

55.

Jairath

Sudharsan

Mishra

, et al. Robotic repair of vesicovaginal fistula - initial experience. Int Braz J Urol 2016; 42(1): 168–169.

56.

Kurz

Horstmann

John

Robot-assisted laparoscopic repair of high vesicovaginal fistulae with peritoneal flap inlay. Eur Urol 2012; 61(1): 229–230.

57.

Lecoanet

Madanelo

Tricard

, et al. Robot-assisted vesicovaginal fistula repair: comparison of the extravesical and transvesical techniques. Int Urogynecol J 2023; 34(10): 2479–2485.

58.

Granieri

Sessa

Bonomi

, et al. Indications and outcomes of enterovesical and colovesical fistulas: systematic review of the literature and meta-analysis of prevalence. BMC Surg 2021; 21(1): 265.

59.

Sahay

Mangla

Kesarwani

, et al. Robotic-assisted colovesical fistula repair: a case report. Cureus 2024; 16(2): e54404.

60.

Sotelo

de Andrade

Carmona

, et al. Robotic repair of rectovesical fistula resulting from open radical prostatectomy. Urology 2008; 72(6): 1344–1346.

61.

Sayegh

La Riva

Perez

, et al. Robotic simultaneous repair of rectovesical fistula with vesicourethral anastomotic stricture after radical prostatectomy: step-by-step technique and outcomes. Urology 2023; 175: 107–113.

62.

Yuan

Wang

Cheng

, et al. Robotic ureteral reimplantation for the management of ureterovaginal fistula: four cases at a single center. Transl Androl Urol 2021; 10(10): 3705–3713.

63.

Laungani

Patil

Krane

, et al. Robotic-assisted ureterovaginal fistula repair: report of efficacy and feasiblity. J Laparoendosc Adv Surg Tech A 2008; 18(5): 731–734.

64.

Bhalla

Adams

, et al. Robotic-assisted laparoscopic repair of a congenital rectourethral fistula with duplicated urethra. J Pediatr Urol 2022; 18(3): 404–405.

65.

Wong

Tam

Pang

KKY

, et al. Robotic repair of congenital vesicovaginal fistula masquerading as a ureterocele in a 10-year-old girl. Urol Case Rep 2018; 20: 48–50.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

A comprehensive review of urinary tract fistulas: the evolution of etiologies,surgical techniques,and contemporary outcomes

Abstract

Plain language summary

Keywords

Introduction

Methods

Results

Fistula types and etiologies

Historical surgical repair techniques

Discussion

Modern repair techniques

Systematic review analyses on surgical outcomes

Conclusion

Footnotes

Acknowledgements

Declarations

ORCID iDs

Supplemental material

References

Supplementary Material