What is Fistula?

        It is generally defined as a channel between two organs that isn’t supposed to be present but emerged at later times. Such channels (fistula) occur due to post-operative complications or accidents. Such later formed channels emerge between the arteries and venous blood vessels, vagina and the intestines, and the vagina and the urination system. 2 systems, which are not supposed to be connected to each other, are connected by a pseudo path (fistula). Occurrence of a connection between the female organ and the urinary system is called “urovaginal fistula”. In such case, urine flows through the vagina throughout day and night. Connection between the vagina and the intestine called rectum is called rectovaginal fistula. In such case, stool and gas is discharged from the female organ. These represent social, psychological and hygienic problems that negatively impact the individual’s quality of life.

Causes of Fistula

  • Fistula (pseudo channel) mainly occurs pursuant to hysterectomy operation, which is the removal of the womb. Injuries occur in the bladder and the ureter during the hysterectomy operation (removal of womb). Urine begins to flow through the vagina.
  • Fistula occurs after surgical procedures performed on the vagina, perineum, anus, womb and intestines.
  • Another cause is the damaging of the urinary system during caesarean section.
  • Fistula may also owe to surgeries performed due to colon cancer and cervical cancer.
  • Fistula may occur due to radiotherapy applied to cancers in the pelvis region.
  • It may also owe to trauma or some inflammatory diseases.
  • Incisions made for widening the birth channel during difficult childbirths can lead to fistula (fistula associated with Episiotomy).

Symptoms of Fistula

  • Urine flows from the vagina throughout day and night.
  • Flow of gas and bad-smelling stool from the female organ.
  • Inflammations of the bladder and the urinary channel
  • Flow of gas from the urinary channel during urination
  • Rubescense and inflammation around the female organ accompanied with abdominal pain.

Diagnosis of Fistula

  • We evaluate the medical history of patients.
  • The patient is examined physically.
  • Contrasted tomography or MR is performed.
  • Cystogram: An X-ray image is taken by injecting contrast material into the bladder. The location of the fistula is identified.
  • Dye Test: Dyed material is injected into the bladder. The female organ is observed. We thus identify the region where leakage occurs.
  • Cystoscopy: The interior of the bladder is examined by a long & thin camera.
  • Sigmoidoscopy: We enter the interior of the intestines via anus and seek into the fistula by a camera.

Types of Fistula

Vesico vaginal fistula:

Such fistulas are between the bladder and the vagina. It generally owes to womb removal but may also occur when the child’s head is jammed in the birth channel due to difficult birth.

Uretero vaginal fistula:

It occurs when the ureter channel, which carries urine to the bladder from the kidneys, is injured due to womb removal or other pelvic organ injuries. In case of this fistula, the urine doesn’t flow to the bladder. It directly flows to the vagina from the ureter (the channel that carries urine to the bladder from the kidneys).

Urethro vaginal fistula:

This fistula occurs between the vagina and the urinary channel called urethra. In case of this fistula, urine flows to the vagina from the urinary channel.

Vesicouterine (uterovaginal) fistula:

It is an undesired connection between the bladder and the womb. It is rarely seen but it is nevertheless difficult to diagnose and operate. In this type of fistula, the urine in the bladder flows into the womb. And from the cervix, to the vagina.

Fistula Surgeries

        The repair of urovaginal fistula is also the subject of reconstructive urology. Surgeries especially become difficult when patents have experienced difficult childbirths and undergone several unsuccessful fistula operations. Any urologist that engages in fistula surgery should possess information and experience about all approaches.

        Fistulas that close by themselves are very rare. There is no drug treatment form them. Treatment is surgical. The surgical method is chosen according to the location and type of fistula. Many fistulas can be treated from within the female organ. Some require surgery over the abdomen. The surgical principle is to remove the connection between two organs, to reach health tissue and to close both organs by suturing them separately. These 4 types of urovaginal fistula have different surgical methods.

Surgery of Vesico Vaginal Fistula

        The most common cause of vesico vaginal fistulas is the infliction of injuries on the bladder while removing the womb. Hysterectomy is the removal of the womb due to cancer or other causes. Today, it is been concluded that up to 80% of hysterectomies are unnecessary. Ratio of hysterectomy in developed countries is gradually decreasing. Vesico vaginal fistula surgery can be performed by incisions made from 2 regions. These incisions are made from the vagina or the abdomen region.

        The advantage of the fistula repair, which is performed from by a vaginal incision, is that post-operative rehabilitation is easier. Many fistulas that didn’t undergo prior unsuccessful surgeries can be successfully repaired. Once the fistula forms, one should discuss the timing of fistula repair surgery. The classic view is to make the repair 3-6 months after the first injury. One waits during this period so that the tissues heal and the inflammation in the peripheral tissues disappears. But we prefer to operate within 2-3 weeks after the first injury regardless of whether the procedure will be vaginal incision or abdominal incision. That is because the flow of urine from the vagina continuously throughout the day and night is an important social, psychological and hygienic problem. Centers such as ours that are experienced on this subject prefer early repair (after 2-3 weeks) instead of late repair (after 3-6 weeks). This allows the patient to return to her normal life in a short time.

        The fistula region is removed during the procedure performed by vaginal incision. The bladder and the vagina are sutured and closed separately. Later, we may need to place health tissue between these 2 organs for preventing the future reoccurrence of fistula. Tissues with their blood stems preserved, which are taken from the larger vaginal lips (martius flap) or the leg muscle, are placed between the bladder and vagina.

Surgery of Uretero Vaginal Fistula

        Uretero vaginal fistula may as well owe to gynecological and general surgery operations as to closed surgical operations. In Uretero Vaginal Fistula, the ureter (the channel carrying urine from the kidneys to the bladder) is damaged partially or wholly. It is repair is possible by fully substituting and renewing the damaged ureter section by tissue transfer. Meaning that the construction of a new ureter channel is necessary. In addition to constructing a new ureter channel from the intestines, we can transfer tissue from the bladder to the ureter by a special technique and allow the patient to maintain a normal life. Ureter constructed from the intestines may cause systemic disorders over time as the interior surface of the intestine may absorb urine. For this reason, we prefer to construct a brand-new ureter by using the bladder of patients who have sufficient bladder capacities. Reconstructing the ureter is a difficult procedure. The kidney on that side may necessitate removal if the ureter isn’t reconstructed.

Surgery of Urethro Vaginal Fistula

        We encounter Urethro vaginal fistula as a complication of loose sling operations performed form inside the vagina. Repairing the urinary channel becomes difficult if it is associated with this complication. Urine continuously flows from the vagina in case of vesico vaginal fistula but in urethro vaginal fistula, the urine exits both through the vagina and the normal path only during urination. The reason is that the location of the urethro vaginal fistula below the sphincter, meaning the urine retaining mechanism. But if in urethro vaginal fistulas that owe to difficult childbirths, the sphincter (urine retainer mechanism) has also been damaged, the patient not only suffers urinary incontinence during urination, her urine continuously flows through the vagina.

        Depending on the dimension of urethro vaginal fistula, we either suture it by a simple repair or patch the fistula with a graft taken from the mouth mucosa and therefore ensure integrity in the urinary channel.

Surgery of Vesicouterine (Uterovaginal) Fistula:

        The most common cause of vesicouterine fistula is several caesarean section operations. The urine flows from the bladder into the womb and from there, to the vagina. There can be erroneous diagnosis as in vesicouterine fistula, sometimes there is no urine flow. It may be confused with stress-type of normal urinary incontinence. Its surgery is performed by an incision made from the abdomen. Another noteworthy finding is that the menstrual bleeding of these patients occurs through both the vagina and the normal urinary tract. These patients have sanguineous urine during the menstrual period.

        We free the bladder from its backside during vesicouterine (uterovaginal) fistula surgery and reach the fistula region. The bladder is sutured from behind and the womb is sutured from front in order to close this fistula (pseudo channel). The fistula connection is removed.

Recto Vaginal Fistulas

        Stool comes through the vagina in recto vaginal fistulas. Recto vaginal fistulas represent unwanted channels between the rectum and the vagina. It represents a social, hygienic and psychological problem for the patient. Recto vaginal fistulas mainly owe to the episiotomy incision performed to enlarge the vaginal opening and facilitate childbirth. Also without incision, this region may rupture due to resistance when the child’s head comes out. This is not noticed in the beginning but identified afterwards. Another cause is suppurated inflammations between the vagina and rectum. Such inflammations cause fistula (pseudo channel) between these separate organs.

        Type of treatment depends on the dimension, location and cause of the fistula. Ones that are above 3-4 cm of the vagina inlet are called low and medium level fistula. Those located at the cervix level are called high fistulas. Medium and low fistulas are repaired from the vagina. We enter the interim space between these organs with a vaginal incision. We reach the fistula zone and remove the fistula. We suture the vagina and rectum separately in several layers. We always lay filling material, which is transferred from healthy tissues, on the interim space. The ideal filling material for such fistula is taken from the leg muscle called gracilis.

Visuals of Fistula Surgery