A fistula is defined as an abnormal connection between two organs, vessels, or structures. They can often present in the genitourinary tract as a result of iatrogenic injury during pelvic surgery. In the United States, the prevalence of a urogenital fistula approaches less than 0.5% during an uncomplicated hysterectomy. There are many different types of fistulas and they are named based on their connections. In gynecology, the most common types of fistulas include vesicovaginal and rectovaginal connections. Often fistulas can cause continuous vaginal discharge and leakage. This video will illustrate a case of a mysterious fistula in the setting of persistent vaginal leakage. A 46-year-old female initially presents to the urologist as a referral for a questionable history of a vesicovaginal fistula and worsening vaginal leakage. She underwent a total abdominal hysterectomy several years prior without complications. Pelvic exam in the office was unremarkable and a tampon test was equivocal. Urodynamic testing did not reveal detrusor overactivity or stress urinary incontinence. A CT urogram was performed that showed a moderate amount of fluid in the upper vagina but no fistula tracts. Sinus dystoscopy was normal but vaginoscopy revealed a well epithelialized tract at the apex. A retrograde pylogram and vaginoscopy in the operating room ruled out any communication with the urinary system. A ureteroscope was introduced into the sinus tract at the vaginal apex for further exploration. Marked polypoid tissue was noted within this sinus tract. Biopsies of this finding returned as acutely inflamed granulation tissue. The patient elected to pursue laparoscopic removal of a vaginal sinus tract. Start of laparoscopy, the left fallopian tube was noted to be adhered to the vaginal cuff. Concurrent vaginoscopy was performed using a ureteroscope that was advanced up the vaginal sinus tract. The pelvis was simultaneously observed with the laparoscope. Illumination of the left fallopian tube was present as the ureteroscope was advanced further up the sinus tract. This finding confirmed the presence of a left salpingal vaginal fistula. Prior to left salpingectomy, the left ureter was identified very inferior to the course of the left fallopian tube. To proceed with the salpingectomy, sequential cross clamping, activation, and cutting with the harmonic scalpel was performed along the fallopian tube until its insertion at the vaginal cuff. The fallopian tube is grasped to provide counter traction while the harmonic scalpel cuts the underlying peritoneal tissue. The ureteroscope is reinserted in the vaginal sinus tract to help delineate the course of the fallopian tube. Now that the fallopian tube has been dissected down to its insertion point into the vaginal cuff, a bladder flap is developed. A large EEA vaginal sizer is placed in the vagina at the apex to provide counter traction. The overlying bladder peritoneum is grasped and tented up with the laparoscopic alice clamps to provide counter traction. The bladder peritoneum is incised with the harmonic scalpel, leading to gaseous distension further aiding in the creation of the bladder flap. Blunt and sharp dissection are also utilized in developing the bladder flap. The fallopian tube is dissected off of the vaginal cuff now that the bladder flap is created. The left fallopian tube is transected at its insertion point into the vaginal apex using the harmonic scalpel. A small defect in the vaginal cuff remained after the salpingectomy. This is repaired with a running 2-O-Vicryl suture. A large vaginal EEA sizer remains in the vagina to aid with suturing the defect. Following surgery, the patient had complete resolution of her symptoms. Three months later, an office vaginoscopy is performed and demonstrated a well-healed vaginal cuff. Through this double view technique, identification of a salpingovaginal fistula was possible. This case illustrates a stepwise approach for diagnosis and treatment of salpingovaginal fistulas using minimally invasive techniques both laparoscopically and vaginally.

vaginal leakage

vesicovaginal fistula

pelvic exams

urodynamic testing

salpingovaginal fistula