Two patients with diagnosis of ureterovaginal fistula after hysterectomy were referred to our center for higher level of care. The patient with the right-sided fistula is a 49-year-old who developed continuous leakage at 18 days post-op. She was living with fistula for two years before referral. The patient with the left-sided fistula is a morbidly obese 35-year-old who developed leakage on post-operative day 5. Before attempting surgery, we sent the patient to interventional radiology for stenting. This was unsuccessful. One day prior to our planned surgery, IR placed a 7 French cook lighted stent to the level of the fistula. A lighted stent was helpful because separation of the vagina from the ureter is rarely possible and dissection of the ureter can be very difficult due to lack of peristalsis, distortion of anatomy, and extensive fibrosis. Lacrimal duct probe is placed. Five ports are utilized for surgery. Lights from the lighted stent facilitate identification of the ureter. After confirmation of its location, dissection can begin confidently. Ureteral location is confirmed once again. The lacrimal duct probe demarcating the fistula's tract is now evident. The ureter is transected as distally as safely possible. With the distal ureteral stump and the fistula's tract are suture ligated, the bladder is mobilized. A cystotomy is created for tunneling of the ureter. The ureter is spatulated with a pot scissor. The ureter is partially anastomosed to the bladder. Intracorporeal stenting is performed. The anastomosis is completed and the bladder is filled. The repair is made watertight. Now we will discuss a left-sided ureterovaginal fistula repair. Identification of the ureter is difficult even at the level of the upper psoas muscle. Due to distortion, fibrosis, and lack of peristalsis, it is difficult to find the ureter. The lighted stent facilitates identification of the left ureter. While the ureter is transected, the offending suture becomes visualized. Two sutures are placed on the psoas muscle. A psoas hitch is performed on the left side. A cystotomy is made. The ureter is freshened. The ureter is spatulated. After partial anastomosis, intracorporeal stenting is performed. The anastomosis is completed. A drain is placed. After surgery, the drains were removed in 1-2 weeks for both patients. Stents were removed at approximately 6 weeks. CT urography after removal of stents showed intact repair and no narrowing. 4 months after repair, there was also no stenosis and normal flow of the ureter. The incidence of ureterovaginal fistula is between 0.5 and 2.5%. Most fistulas occur after a difficult abdominal hysterectomy. Risk factors for injury are obesity, endometriosis, PID, radiation, and cancer surgery. Vascular and colorectal surgery is also a risk factor. Ureterovaginal fistula can only occur if there is an injury to the distal 1-3rd of the ureter. After laceration or suture ligation, urine leaks out around the ureter forming a urinoma. If the urinoma dissects towards the vaginal cuff, a ureterovaginal fistula will result. Factors which promote this process include ischemia, infection, large injury, and radiation. Current recommendations for management of ureterovaginal fistula are the following. One should initially attempt to place a stent. If this is successful, remove it in 4-6 weeks and repeat imaging. If the stent placement is unsuccessful or repeat imaging shows persistent fistula, then ureteroneal cystostomy must be performed. If this can be done in a minimally invasive fashion, it will reduce morbidity and convalescence. Robotic-assisted laparoscopic ureterovaginal fistula repair is a minimally invasive procedure that has a high success rate if done properly. Dissection of the ureter is one of the most difficult parts of this repair. Lighted stents facilitate this surgery by enhancing visualization of the ureter.

ureterovaginal fistula

hysterectomy

interventional radiology

surgery

robotic-assisted laparoscopic