Critical Reviews in Oncology/Hematology 48 (2003) 295304

Guidelines of how to manage vesicovaginal fistula

Roberto Angioli a, , Manuel Penalver b , Ludovico Muzii a , Luis Mendez b ,
Ramin Mirhashemi b , Filippo Bellati a , Clara Croc a , Pierluigi Benedetti Panici a
a

Department of Obstetrics and Gynecology, University of Rome Campus Biomedico, Via Longoni 69, 00155 Rome, Italy
b Department of Obstetrics and Gynecology, University of Miami School of Medicine, Miami, FL, USA
Accepted 26 November 2002

Contents
1.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

296

2.

Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1. Classification of fistula. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2. Diagnosis of vesicovaginal fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3. Timing of fistula repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.4. Treatment approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.4.1. Vaginal approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.4.2. Abdominal approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

296
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297
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297
300

3.

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1. Non-radiated fistulas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2. Fistulas in radiated tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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300
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4.

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Biographies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract
Vesicovaginal fistulas are among the most distressing complications of gynecologic and obstetric procedures. The risk of developing
vesicovaginal fistula is more than 1% after radical surgery and radiotherapy for gynecologic malignancies. Management of these fistulas has
been better defined and standardized over the last decade. We describe in this paper the success rate reported in the literature by treatment
modality and the guidelines used at our teaching hospitals, University of Rome Campus Biomedico and University of Miami School of
Medicine. In general, our preferred approach is a trans-vaginal repair. To the performance of the surgical treatment, we recommend a
minimum of a 46 weeks wait from the onset of the fistula. The vaginal repair techniques can be categorized as to those that are modifications
of the Latzko procedure or a layered closure with or without a Martius flap. The most frequently used abdominal approaches are the bivalve
technique or the fistula excision. Radiated fistulas usually require a more individualized management and complex surgical procedures. The
rate of successful fistula repair reported in the literature varies between 70 and 100% in non-radiated patients, with similar results when a
vaginal or abdominal approach is performed, the mean success rates being 91 and 97%, respectively. Fistulas in radiated patients are less
frequently repaired and the success rate varies between 40 and 100%. In this setting many institutions prefer to perform a urinary diversion.
In conclusion, the vaginal approach of vesicovaginal fistulas repair should be the preferred one. Transvaginal repairs achieve comparable
success rates, while minimizing operative complications, hospital stay, blood loss, and post surgical pain. We recommend waiting at least 46
weeks prior to attempting repair of a vesicovaginal fistula. It is acceptable to repeat the repair through a vaginal approach even after a first

Corresponding author. Tel.: +39-06-2254-1366; fax: +39-06-225-2294.

E-mail address: r.angioli@unicampus.it (R. Angioli).

1040-8428/$ see front matter 2003 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/S1040-8428(03)00123-9

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vaginal approach failure. In the more individualized management of fistulas associated with radiation, the vaginal approach should still be
considered.
2003 Elsevier Ireland Ltd. All rights reserved.
Keywords: Vescicovaginal fistula; Lazko procedure; Layered closure; Martius flap; Bivalve technique; Transvescical technique

1. Introduction
Vesicovaginal fistulas are one of the most distressing complications encountered in the field of obstetric and gynecology. In 1852, James Marion Sims, by many considered
the father of fistula repair, published the now classic On
the Treatment of Vesico-Vaginal Fistula. In a period where
women were generally left untreated, it was the first report
of a successful repair [1].
The vesicovaginal fistula can be a result of obstetric
trauma, surgery, infections, congenital anomalies, malignancy and malignancy treatment [2]. In the United States,
the majority of vesicovaginal fistulas arise as complications
of gynecologic surgery, with the preceding procedure most
frequently being a total abdominal hysterectomy [3]. In the
series by Lee et al., 90% of the vesicovaginal fistulas encountered were the result of surgical treatment for a benign
condition, with total abdominal hysterectomy accounting for
70% of the fistulas [4]. An operation for treatment of cancer, carries a higher risk of urologic complications. There is
approximately a 1% risk for ureteral and vesical injuries associated with radical hysterectomy as treatment for cervical
cancer [5]. Post-operative fistulas are usually an early complication, appearing approximately 10 days after hysterectomy [6], while radiation induced fistulas frequently occur
many years after treatment. Even though numerous predisposing factors in the development of the postoperative fistula
have been identified (i.e. infection, ischemia, arteriosclerosis, PID, previous uterine surgery, uterine myomata, cancer
treatments and diabetes), the vast majority occur under very
normal operative circumstances [7].
In cases associated with gynecologic cancers, the management of vesicovaginal fistula presents unique difficulties
due to the nature of the fistula. The fistula could be a result
of a surgical complication, radiation treatment, or due to the
presence of cancer. When surgery is performed in the presence of cancer, operations tend to be more radical than a
simple hysterectomy and they can cause hypovascularization
of the tissue, which not only predispose for the formation
of fistula, but also makes the repair of a fistula more difficult. Radiation treatment causes a progressive endoarteritis,
with consequent hypoxia, fibrosis and potentially necrosis.
Finally, fistulas due to the presence of neoplastic tissue are
not treatable by means different from diversion.
This paper reviews the success rate reported in literature
according to the type of treatment used for radiated and
non-radiated fistulas. We report the classification of fistula
and surgical procedures most commonly used to manage

vesicovaginal fistula at our teaching hospitals, The University of Rome-Campus Biomedico and The University of Miami School of Medicine. We will also present the guidelines
for evaluation and management followed by our residents
and fellows in training.

2. Guidelines
It is our policy to attempt a vaginal approach whenever
possible. In most instances the procedure is began vaginally
following an examination under anesthesia, unless there is
a clear contraindication to the vaginal approach.
2.1. Classification of fistula
Vesicovaginal fistulas can be classified in various ways
(Table 1). Simple fistulas are usually small in size ( 0.5
cm) and are present as single non-radiated fistulas; complex
fistulas include: previously failed fistula repairs or large sized
( 2.5 cm) fistulas, more often a result of or due to chronic
diseases or radiotherapy. Fistulas that develop in radiated
tissue are often multiple and difficult to treat. Most authors
consider intermediate size fistulas (between 0.5 and 2.5 cm)
as complex.
2.2. Diagnosis of vesicovaginal fistula
Postoperative patients with a vesicovaginal fistula usually
are easily diagnosed with urine leaking through the vagina.
The patient may only complain of leakage or fever. A significant leukocytosis may be present. Classically, fistulas occur
between the 7th and the 12th day after obstetric or gynecologic surgery. The diagnosis can be confirmed by filling
the bladder with a dilute solution of methyl blue. The vaginal vault is then directly inspected to visualize the fistula. If
no defect is clearly seen, then cystoscopy can be a valuable
diagnostic help. In a patient who is experiencing urinary
Table 1
Fistula classification
Type
Simple (small, non-radiated, single)
Complex (medium, large, radiated, multiple, recurrent)
Size
Small 0.5 cm
Medium, 0.62.4 cm
Large 2.5 cm

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297

incontinence the tampon test, where a tampon is inserted

into the vagina after filling the bladder with a dilute solution of methyl blue and the patient is ambulated, can help
confirm the diagnosis. In addition to the cystoscopy and the
cistourography, we recommend an intravenous pyeloureterogram to rule out concomitant ureteral fistulas before proceeding with the surgical repair. Indeed, Goodwin found that
12% of patients with a vesicovaginal fistula had a concomitant ureterovaginal fistula [8].

parameter is advocated, adherence to surgical technique is

the hallmark of successful fistula repairs, independent technique selected. Some single steps in the performance of the
technique are basic to achieve successful repair, such as mobilization of tissues, proper identification and excision of the
damaged parts, layer closure without tension. Surgical experience and skill are fundamental for this type of procedure.
The best time to repair a fistula is when the edema and
inflammation subside and there is no infection.

2.3. Timing of fistula repair

2.4. Treatment approaches

Once a fistula is diagnosed, the most important therapeutic decisions are on the type of procedures and the timing
as to when to perform the treatment. Initial repair is critical
since data reveals that the first attempt at repair is usually
the most successful (Table 2). One of the main controversies
is when to surgically correct a postoperative vesicovaginal
fistula. The classical teaching is to wait 24 months using
continuous drainage of the bladder. This allows resolution
of the postoperative inflammation and edema. This conservative approach usually results in a spontaneous fistula healing rate of at most only 1520% of cases, when the fistula is
simple and of small size [9]. Nevertheless, considering that
recurrent fistulas are always more difficult to repair, conservative treatment should be attempted. We use conservative
management for simple fistulas ( 5 mm, non-radiated and
single) (Fig. 1). If healing doesnt occur, and there is no
significant improvement within 2 months, we will then resort to surgical management. Some authors report a success
rate of up to 100% when fistulas were repaired in as short a
time as 6 weeks from diagnosis [1012]. Whatever timing

In general, simple fistulas are treated using simple vaginal

approaches, while complex fistulas are commonly treated
either vaginally using a myocutaneous flap or through an
abdominal approach.
2.4.1. Vaginal approaches
Regardless of the etiology of the fistula, the vaginal approach is our preferred approach. Therefore, we always evaluate patients who lack contraindication for a vaginal repair
under anesthesia, in the dorsal lithotomic position, in the
hope that a vaginal approach can be carried out. The main
absolute contraindication to a vaginal repair of vesicovaginal fistula is the concomitant presence of fistulas with other
abdomino-pelvic organs such as ureters, small and large
bowel and multiple vesicovaginal fistulas.
Other risk factors for failure such as radiated fistulas,
indurated fistulas, recurrent fistulas are not absolute contraindication, but are important factors to be considered by
surgeon in the decision of the route based on his/her personal experience.

Table 2
Non-radiated vesicovaginal fistulas results by treatment
Approach

Authors

Year

Number of
patients

Success rate

Procedure

Birkhoff [32]
Cruikshank [33]
Iloabachie [21]
Elkins [34]
Wang [30]
Enzelberger [27]
Tancer [3]
Raz [29]
Demirel [35]
Margolis [36]
Blaivas [28]
Iselin [37]

1977
1988
1989
1990
1990
1991
1992
1993
1993
1994
1995
1998

6
9
64
25
16
42
107
11
9
4
16
13

6 (100%)
9 (100%)
45 (70%)
24 (96%)
15 (94%)
41 (98%)
98 (92%)
9 (82%)
8 (89%)
3 (75%)
15 (94%)
13 (100%)

Labial fat pedicle

Early repair; no excision, layered closure
Vaginal
Modified Martius flap
Layered closure with vaginal flap
Chassar Moir
Latzko
Peritoneal flap
Latzko
Modified Martius flap
Vaginal
Vaginal cuff excision

Gil-vernet [38]

1989

39

39 (100%)

Motiwala [39]
Motiwala [39]
Moriel [12]
Demirel [35]
Blaivas [28]

1991
1991
1993
1993
1995

58
10
16
17
8

55 (95%)
9 (90%)
16 (100%)
16 (94%)
8 (100%)

Vesical autoplasty; transvesical,

extraperitoneal, or transperitpneovesical
Transvesical, simple layered
Transperitoneal, with omental flap if large
Modified OConortransvesical, no flap
OConor
Abdominal

Vaginal

Abdominal

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ALGORITHM OF MANAGEMENT OF VESCICOVAGINAL FISTULA

Fistula

Complex

Radiated

Wait 6 to 12 wks

Wait 4 to 12 months

Simple

Conservative
treatment x 4- 6 wks

Success
(improvement)

Abdominal approach
(OConor bivalve or
transvesical)

Failure

Latzko procedure or
Transvaginal layered repair

Vaginal approach with flaps,

OConor bivalve with
interpositional flaps;
Bladder resection with
augmentation

Failure
Failure

No further treatment

Repeat transvaginal layered repair or repeat

Latzko procedure (consider Martius flap)
Abdominal approach

Urinary diversion

Fig. 1. Algorithm of vesicovaginal fistula repair.

The two most commonly used repair techniques are the

Latzko technique and the layered closure. These approaches
can be performed with or without a fat pad or myocutaneous
flap.
2.4.1.1. Latzko procedure. The Latzko-partial colpocleisis is an excellent vaginal technique utilized by most the
gynecologists [13]. The procedure entails denudement of
the vaginal wall for approximately 1 cm around the fistula,
without excising the fistulous tract at the level of the bladder. There is then a layered imbricating closure of the bladder, vesicovaginal fascia and vagina separately (Fig. 2A, B,
and C). The advantages of this approach include minimal
blood loss and a technically simple procedure. An additional advantage is that the bladder is not entered, therefore,
the ureters and urethra should avoid injuring. Although it is
believed that this procedure can cause a shortening of the
vagina, Tancer et al. did not find this complication to be
a problem [14]. Using the Latzko technique, those authors
reported a success rate of 93% in the 43 patients treated.
The Latzko procedure has even been successfully utilized in
patients with recurrent fistulas who already had undergone
a primary Latzko procedure [14]. It is, therefore, accepted
to repeat the Latzko procedure in a recurrent fistula after a
previous failed attempted.
2.4.1.2. Layered closure. This technique is as popular as
the Latzko procedure and is our preferred method to surgically correct simple, small fistulas.

The excision of the fistula is performed after separating

the bladder from the vaginal mucosa and the underlying fascia for approximately 1.5 cms. The full thickness of the fistula is then excised and the bladder closed with interrupted
delayed absorbable 3-0 or 4-0 sutures in two layers. The first
layer is extramucosal and the second imbricates the first one.
The last layer is the closure of the vaginal wall with interrupted 2-0 delayed absorbable sutures. The main difference
between the Latzko and the layered closure consists in the
excision of the vesical mucosa during the layered closure,
while it is not excised during Latzko procedure. Post-repair
bladder drainage via urethral (or suprapubic) catheterization
is maintained for at least 7 days.The use of vaginal flap can
be considered to prevent failure.
2.4.1.3. Martius flap. In general the Martius flap is used as
treatment for complex fistulas, including recurrent, radiation
induced or large fistulas. The procedure involves the use of a
56 cm long and 23 cm wide fat pad along the length of the
labium majus which is elevated and tunneled subcutaneously
into the vagina to act as an inter-positional vascular flap [15].
This flap is classically developed by making a vertical incision along the external surface of the labia majora. We have
obtained good results making a similar incision at the medial
border of the labia majora to improve cosmesis. The flap is
supplied by the perineal branch of the internal pudendal and
the external pudendal artery and collaterals. When the fistula
is of complex type, and there is a significant deficit of blood
supply, the bulbocavernosus muscle (modified Martius flap)

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Fig. 2. Latzko technique. Excision of vaginal wall (2a); imbrication of bladder wall (2b); closure of vaginal wall (2c).

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can also be utilized, along with the subcutaneous and cutaneous tissue (myocutaneous flap). The flap can be uni- or
bilateral according to the anatomy of the fistula.
2.4.2. Abdominal approaches
Complex fistulas are usually the most troublesome. There
are instances when the vaginal approach can be employed
as management of a complex fistula. This situation usually
mandates the use of ancillary vascular supplies to the area
in the form of either Martius bulbocavernosus flaps or gracilis myocutaneous flaps. The abdominal approach can be
performed using a transvesical (fistula excision) or an extravesical (bivalve technique) approach. In reality both procedures involve the opening of the bladder.
2.4.2.1. Bivalve technique. This abdominal technique is
performed by mobilizing the bladder before incising it
[16,17]. The vertical incision is carried from the dome,
down to the fistulous tract, which is excised. The bladder
is usually well mobilized from the vagina. This allows for
direct visualization of the defect, resection and, should fistula repair involve the trigone, easy placement of ureteral
catheters (Fig. 3A and B). The vaginal wall has to be repaired separately from the bladder and a two-layer closure
should be performed, first closing vagina then bladder. This
approach also allows the interpositional of an omental J
flap or a peritoneal flap between the bladder and the vagina
in cases of poor tissue viability. A flap should always be
used when the conditions of the tissue are suboptimal (e.g.
radiation fibrosis, scar tissue).

2.4.2.3. Urinary diversion. Repair of radiation induced

vesicovaginal fistula or multiple fistulas is often difficult,
especially when the anatomy is distorted and the tissue
is fibrotic. The success rate in these conditions is poor,
and in rare occasions, a urinary diversion is indicated [5].
When the patient is young and free of tumor, a continent
form of urinary diversion is the recommended treatment
[20].

3. Results
The mean success rate of vesicovaginal fistula repair described in the literature (Tables 2 and 3), independent of
the access route and tissue conditions, approaches 90% and
varies between 40 and 100%. The vaginal route registers a
success rate between 40 and 100%, the abdominal route between 70 and 100% when radiated fistulas are included. The
most commonly used vaginal procedure is layered closure.
When the fistula is complex (including radiated fistulas) the
Martius flap is often used in association with the vaginal repair. The abdominal route is more frequently preferred for
selected cases (complex fistulas). Our preferred method is
the bivalve technique. When the fistula occurs in a radiated
field, various types of flaps (peritoneal, omental, myofascial,
intestinal) are potentially useful.
The most difficult fistulas to repair are those developed
in radiated tissue, therefore, we will evaluate separately
non-radiated from radiated fistulas.
3.1. Non-radiated fistulas

2.4.2.2. Transvesical. The transvesical repair is an abdominal approach performed by opening the bladder at the level
of the dome, so that the fistulas can be visualized [18]. The
fistula is then excised and the bladder is dissected from the
vagina transvesically, only around the fistulous tract. The
bladder around the fistulous tract excised is then closed perpendicularly to the closure of the vagina.
The advantage of this technique is that the vesicovaginal
dissection is minimal. Unfortunately, the exposure is limited
[39]. In addition, with this technique the interpositional flap
cannot be placed between the bladder and the vagina because
the vesicovaginal space has not been developed.

The success rate of unradiated vesicovaginal fistula repair

varies between 70 and 100% with a mean success rate of
92% (Table 3). The success rate of vaginal repair is between
70 and 100% and the success rate of abdominal approach
is 90100% (Table 3). The two approaches, vaginal and abdominal, have similar mean success rates, 91 and 96% for
vaginal and abdominal route, respectively. Most of the vesicovaginal fistulas are repaired vaginally (Table 3). Table 2
shows that recurrent fistulas still have a high likelihood of
being repaired successfully even when the technique utilized
is vaginal.

Table 3
Non-radiated recurrent vesicovaginal fistulas results by treatment
Authors

Year

Number of
points

Number of prior
procedure

Type of prior procedure

Success rate

Procedure

Birkhoff [32]
Arrowsmith [40]

1977
1994

6
98

14
13

6 (100%)
94 (96%)

Gil-Vernet [38]

1989

42

17

Vaginal or abdominal
Abdominal (OConor) or
vaginal (Martius)
Abdominal

Tancer [3]
Iselin [37]

1992
1998

9
7

1
12

Latzko
Suprapubic (5), vaginal
(2), endoscopic (2)

9 (100%)
7 (100%)

Vaginal (labial fat pedicle)

Abdominal (OConor) or
vaginal (Martius)
Abdominal (vesical
autoplasty, omental graft)
Latzko
Vaginal cuff excision

42 (100%)

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301

Fig. 3. Bivalve technique. Excision of fistula after cystotomy with ureteral stents in place (3a). Closure of the bladder after fistula excision (3b).

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Table 4
Radiated vesicovaginal fistulas results by treatment
Approach

Authors

Year

Number of
patients

Success rate

Procedure

Wein [19]
Gil-Vernet [38]

1980
1989

5
3

4 (80%)
3 (100%)

Bissada [41]

1992

1 (100%)

Salup [24]
Viennas [25]

1994
1995

1
1

1 (100%)
1 (100%)

Abdominal
Vesical autoplasty; transvesical extraperitoneal or
transperitoneovesical
Combined gastric and omental segment based on
R gastroepiploic
Bivalve; rectus abdominis myofascial flap
Transvesical rectus abdominis myocutaneous flap
(skin lined the blader inner wall)

Collins [42]
Boronow [22]
Zoubek [23]
Elkins [34]

1960
1986
1989
1990

5
6
4
5

2
3
2
5

Menchaca [2]
Mraz [43]

1990
1994

2
4

2 (100%)
4 (100%)

Abdominal

Vaginal
(40%)
(50%)
(50%)
(100%)

Vaginal
Martius flap
Martius flap
Modified Martius flap

Combined

Even a repeat Latzko procedure after a failed Latzko

procedure has a chance of success up to 100% [3]. The
success rate for repair of recurrent giant fistula is different, and has not been included in Table 4. When these
types of fistulas are repaired, the success rate is low especially if a single stage procedure is used as opposed to
two-stage repair (1229 vs. 100%, respectively) as described
by Iloabachie [21]. The two-stages repair, with an interval of 3 months between the first and the second procedure, gives to the repaired tissue the time necessary to heal,
and it is indicated in case of giant fistulas with scanty tissue to cover the defect, especially if fibrosis is significant
and involvement of urethrovesical junction is present. In
the two staged operation the dissection stop short of the
iuxta cervical aspect of the fistula in the first stage. Therefore, the second step is basically a repair of a smaller size
fistula.
3.2. Fistulas in radiated tissue
The success rate of radiation-induced vesicovaginal fistula repairs is between 40 and 100% (Table 4). Only few
case series with limited number of cases have been reported
in the literature. Most of the institutions prefer to perform
urinary diversion instead of repairing a radiated fistula, because the surgical procedures are usually complex and with
low success rates. For patients undergoing fistula repair, the
approach can still be either vaginal of abdominal but in both
cases flaps are involved to bring healthy tissue to the affected area. The flap can be simple, such as a bulbocavernosus flap (modified Martius flap) with a 50% chance for
success [22,23] or more complex such as rectus abdominis
flap with a success rate up to 100% in small case series
[24,25].

Excision of fistula; rectus abdominis muscle flap

Seromuscular intestinal graft (SMIG)

4. Discussion
Most gynecologic surgeons prefer the vaginal approach
(Table 3). This approach minimizes the operative complications, the hospital stay, the blood loss, and the pain
following the procedure, while still achieving comparable
success rates compared with the abdominal approach [3].
According to Dupont et al., prior transabdominal repair or
a radiation-induced vesicovaginal fistula does not preclude
a vaginal approach [26]. However, the vaginal approach is
not always the best approach, and it is not without faults of its
own. It can be associated with vaginal shortening (colpocleisis) and the formation of a dead space, where infection and
inflammation may begin [27]. Contraindications to vaginal
approach include: severely indurated vaginal epithelium
around the fistula, small capacity or poorly compliant bladder, repair requiring ureteral reimplantation, involvement of
other pelvic structures, vaginal stenosis, or inability to obtain proper exposure [6,28]. Still, Raz and, achieved a good
success rate (82%) performing vaginal repair in complex
fistulas [29], and Wang et al. achieved a 94% success rate
with a vaginal approach to the treatment of high lying fistulas [30]. Nevertheless, we feel that the vaginal approach
should always be considered when other pelvic organs are
not involved. The examination under anesthesia is the only
moment where the possibility to proceed vaginally, as opposed to abdominally, can be decided. Vesicovaginal fistula
developed in radiated tissue should always be repaired using
fresh blood supply such as flaps. In most of the cases due
to the anatomical changes the procedure is both vaginal and
abdominal, but if anatomy is preserved, a vaginal approach
with a flap should always be considered first.
Concerning the timing, there is not an absolute indication
on the exact timing when to surgically repair a fistula. As

R. Angioli et al. / Critical Reviews in Oncology/Hematology 48 (2003) 295304

shown in Fig. 1, we wait at least 46 weeks before repairing

a simple fistula, 612 weeks before repairing a complex fistula and 612 months when the complex fistula is radiated.
The best timing in general is when there is no edema, inflammation or any infection. Blaivas et al. came to the conclusion that the timing and route of surgical repair are best
tailored to the individual [28].
Fistulas also complicate the treatment of gynecologic
malignancies, though this is a rare occurrence. In Emmert
s series of patients treated for cervical cancer, only 0.42%
developed vesicovaginal fistulas. All these patients had
received radiation therapy in addition to other treatments
[31]. Overall, the incidence of fistula induced by radiation
appears to be between 1 and 5% [25]. Radiation induced fistulas develop and are recognized later when compared with
postoperative fistulas, in fact these can occur even 2030
years after the end of treatment [23]. Lee et al. go so far as to
say that invariably, the truly delayed fistula (occurring 30
days or more after operation) results only from irradiation
or an operation performed after radiation [4]. The surgeon
decides the techniques on the bases of tissue injury or necrosis. Typically, radiation-induced fistulas are associated with
a large amount of damaged tissue. In these cases, an abdominal approach with the use of a generous graft is favored in
order to aid the revascularization of the tissue [22]. Nevertheless we recommend that any fistula, including radiated
fistulas, should be considered for vaginal repair first, unless
there is a clear contraindication to a vaginal approach.

Reviewers
F.J. Montz, The Kelly Gynecologic Oncology Service,
The Departments of Gynecology and Obstetrics, and Oncology, The Johns Hopkins Hospital and Medical Institutions,
600 North Wolfe Street, Phipps 248, Baltimore, MD 21287,
USA.
Paul A. Pietro, Division of Gynecology VAH, Jackson
Memorial Hospital, 1611 NW 12th Ave, Room 3003, Miami,
FL 33136, USA.

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Biography
Roberto Angioli achieved his medical degree at the university of Rome in 1989. He completed the residency
program in Obstetrics and Gynecology at the University of
Miami in 1993, he is Board Certified in Italy as well as in
the United States. Professor Angioli completed a fellowship
in Gynecologic Oncology at the University of Miami in
1999. He served as direction of division of Research and
Director of Division of Gynecology at the University of
Miami School of Medicine/VA. At present time he works
as Associate Professor at the Department of Obstetrics and
Gynecology at the University of Rome Campus Biomedico.