Current status of Vesico-uterine fistula

Vesicouterine fistula (VUF) is a rare urogenital complication accounting for 1-4% of the

genitourinary fistulas and is considered the least common type of genitourinary fistula. It was first described by Knipe in 1908 and the vast majority of the VUF follow a low-transverse cesarean section and result from the apposition of an unprepared uterine incision and an occult bladder injury. Alternatively, the incorporation of the bladder in the hysterotomy closure of other uterine incisions can also result in VUF.

Most commonly, the fistulous tract is located between the uterine corpus immediately cephalad to the internal isthmus of the cervix and the posterior bladder. Unlike VVF and UVF, patients with

VUF often do not present with constant urinary incontinence owing to the competence of the

cervix. Instead, the classical presentation of VUF involves cyclical hematuria (menouria),

amenorrhea, first-trimester spontaneous abortions, and lack of urinary incontinence. This

constellation of symptoms is known as Youssef syndrome. However, incontinence may be present if the connection is below the internal cervical os or if the cervix is relatively incompetent.

VUF is typically managed surgically, although spontaneous closure has been reported in 5% and fulguration along with long term catheterisation has also shown some success. The timing of surgical repair is also debated with some advocating immediate repair whereas other opting for an interval of 3 months prior to re-intervention. The choice of surgical procedure these days is minimally invasive trans-abdominal uterine sparing approach. However, if child-bearing is no

longer desired, then a concomitant hysterectomy can be performed along with the fistula repair.

With the advent of robotic platforms, robotic VUF repair is gaining acceptance and either an

O’Connor type transvesical or an extravesicle approach can be adopted and an interposition graft either omentum or peritoneum is usually placed. Post repair, a pregnancy rate of 25% has been reported in the literature however, the patients should be counselled about the risks of uterine rupture and an elective caesarean section is usually advocated.

By Dr Sandeep Kumar VMMC & SJH, New Delhi