Chapter 77 - Urinary tract fistulae - Campbell's Urology

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Definition of fistula

AbN communication between 2 epithelial or mesothelium lined surfaces

What are the causes of fistulae?

Iatrogenic (most common), malignancy, RADs, parturition, ischemia, congenital anomalies, inflammation & infection

What are the principles of urinary tract fistula management (CHART)?

AEIOU: Adequate nutrition, Elimination of infection, Investigate for malignancy, Obstruction relieved/bypassed, Unobstructed urinary tract via stenting or drainage

Causes of persistent fistulae?

HIS FRIEND
High flow
Infection
Short fistula
Foreign body
Radiation
Ischemia
Epithelialization
Neoplasm
Distal obstruction

What are the principles of surgical repair of urinary tract fistulae? (CHART)

1) Adeuqate exposure of fistula tract with debridement of devitalized and ischemic tissue
2) Removal of involved FBs or syntheetic materials from region of fistula
3) Careful dissection or anatomic separation of involved organ cavities
4) watertight closure
5) use of well-vascularized healthy tissue flaps for repair (atraumatic handling of tissue)
6) Multi-layer closure
7) tension-free, non-overlapping suture lines
8) adequate urinary tract drainage or stenting after repair
9) treatment & prevention of infection
10) maintenance of hemostasis
*Fistula DOES NOT have to be exised in all cases
* Urethral + S/P cath likely best drainage strategy

What are the causes of VesicoVaginal Fistula (CHART)?

Industrialized world: Iatrogenic (>75%): Hysterectomy (abdo, vag), anti-incontinence surgery, anterior vaginal wall prolapse surgery (colporrhaphy), vaginal biopsy, vaginal laser procedures, other pelvic surgery
Developing world: Prolonged obstructed labour d/t pressure necrosis (95%) - tend to be larger, more distal & harder to fix
Other causes: Pelvic RADs (external or brachy), malignancies (cx, vag, endometrial), infectious/inflammatory (endometriosis, TB, IBD), FBs, external trauma, obstetrical (forceps, C-section trauma), congenital VVF (assoc with other GU abN'ities)

What is the most common procedure leading to VVF?

Abdo Hys: bladder injuries are 3x more common with abdominal hysterectomy vs vag hys, risk of bladder injury during abdo hys is 1%, risk of VVF after hys is 0.1%, usually due to unrecognized cystotomy near vaginal cuff or due to tissue necrosis from cautery or suture placement

What is the "obstructed labour injury complex"?

Varying degrees of urethral loss, VVF, SUI, Hydroureteronephrosis, renal failure, rectovaginal fistula, rectal atresia, anal sphincter incompetence, cervical destruction, amenorrhea, PID, secondary infertility, vaginal stenosis, osteitis pubis, foot drop

How common are VVFs after pelvic RADs?

Varies with type, dose and location of RADs - can occur several decades later
1.5% incidence after radiation for cervical Ca
Must R/O recurrence of malignancy - always bx before definitive repair

What are General risk factors for VVF after TAH?

DIAPeRS
Diabetes
Ischemia
Atherosclerosis
PID/Infection
RADs
Steroid use

What are the specific risk factors for VVF after TAH?

Make New C*nt PEE
Malignancy
Neurogenic bladder
C-section (uterine surgery)
Pessary use
Endometriosis
Endocervical conization (scarring)

What are 5 factors in preventing VVF during gynecologic surgery

1) Immediate detection of bladder injury with use of dyes, if necessary
2) Watertight closure of bladder
3) Satisfactory extravesical drain placement
4) Avoidance of vaginal incision if possible, after recognition of bladder injury
5) prolonged uninterrupted post-op bladder drainage

How do VVFs commonly present?

Constant urine per vagina
Recurrent cystitis
perineal skin irritation
vaginal fungal infections
pelvic pain (rare) - pain uncommon in VF unless hx of rads or skin irritation

What is the DDX of clear vaginal discharge after TAH?

SLUTS Pee
Seroma
Lymph
Uirne - ureterovaginal fistula, VVF, UVF, vesicouterine fistula, urinary incontinence
Tube - (fallopian) fluid
Spontaneous vaginal secretions
Peritoneal fluid

What is the W/U for potential VVF?

1) Hx - distinguish from SUI, DO, Overflow, assess for RFs for VVF
2) P/E - speculum exam to assess fistula +/- vaginosocpy, bimanual exam to assess surrounding inflammation and timing of repair, look for evidence of postmenopausal atrophy (may need estrogens), look for possible flaps (previous perineum, lower abdo, thigh surgery)
3) Lab tests - CBC, Cr, fluid for Cr, UA, C+S
4) Dye tests - visualize vagina after instillation of blue dye into bladder: Double dye or tampon test may be indicated (oral pyridium + blue dye in bladder) - can help distinguish UVF vs VVF
5) Cystoscopy - helps locate and characterize fistula( VVF near UO may req abdo approach and reimplant)
6) Imaging - cystogram +/- VCUG (laterally), IVP +/- retrograde pyelogram (10% of post-op VVFs have assoc'd ureteral injury or ureterovaginal fistula), can also utilize CT/MRI

How do you aproach the management of VVF?

Goal is rapid cessation of urine leakage - physical & psychological impact
1) Conservative treatment - if uncomplicated, small (3mm), oblique VVF + resolution of leakage w/ initial catheter. a) trial of catheter + Abx + anticholinergics for 2-3 wk vs b) coagulation of tract +/- fibrin sealant + catheterization for 2-3 wk
2) surgical correction 9best chance is first chance), if large uncomplicated or complicated VVF
- timing:3-6 mo delay with obstructed labour, 6 mo postrad, immediate repair for uncomplicated VVF post gyne sx
- Abdo vs vag: must consider size, location, need for other procedures and surgeon experience, transabdominal may be preferred if augment or reimplant needed
- Preferred approach based on surgeon (most amenable to transvag repair)
- Success rate for simple VVF repair is >90% regardless of abdominal or vaginal, decreases with complex VVF; consider interposition flaps/grafts for complex or re-do VVF repairs
- Failed VVF repairs or non-surgical candidates have other options - ileal conduit, ureteral occlusion + permanent NT, ureterosigmoidostomy

What is considered a complicated VVF?

>3cm diameter
Recurrent VVF
Prior rads
Associated with malignancy
fistula at trigone, BN or urethra
compromised area d/t poor healing

List methods used to maximize VVF repair outcomes

Wait until tract matures (immediate repair if uncomplicated post-gyne sx VVF
Completely mobilize fistula
multiple layer closure
non-overlapping suture lines
absorbable sutures
interposition of tissue (omentum, peritoneal flap)
abx
local estrogen cream to improve tissue quality

Compare abdo vs transvag approaches to VVF (CHART)

Timing of repair: A: delayed 3-6 mo, V: can be immediate if no infection or complication
Fistula location and exposure: A:difficult to access fistula low on trigone or near BN, V: difficult to access fistula high at vaginal cuff
Location of ureter relative to fistula: A: fistula near UO may need reimplant, V: may not be necessary if even if located near UO
Sexual Fn: A: no change in vaginal depth, V: risk of vaginal shortening
Use of adjunctive flaps: A: omentum, peritoneal, rectus, abdominus flaps, V: Martius flap, peritoneal, gluteal skin or gracillis myocutaneous flaps
Relative indications: A: large fistulae, located high in deep narrow vagina, radiation fistulae, failed TV approach, if augment or reimplant needed, unable to place lithotomy, V: uncomplicated low fistulae

List advantages & Disadvantages of a transvaginal approach to VVF?

Adv: avoids morbidity of laparotomy, short OR time, short hospital stay + early return to work, less post-op pain, minimal blood loss, no need to bivalve bladder, can do 3-4 layers closure, , dissection not affected by previous abdo/pelvic sx, can do concomitant anti-incontinence or prolapse sx, local interposition flaps are adjacent, if fails, abdominal approach still ok
Dis: lack of familiarity with vaginal approach, potential for vaginal shortening, hard to expose high or retracted fistulas near vaginal cuff in deep narrow vaginas, requires high lithotomy position, unable to perform concomitant abdo surgery if one is required

What are the popular TV approaches to VVF repair?

1) Raz-3-layer closure (4 layer with adjuvant flap)
- bladder, perivesical layer, vaginal flap, no excision of tract, catheter drainage x 2-3wk with cystogram, post-op antichol, vag pack x24hr and no sex x 3mo
2) Latzko high partial colpoclesis
- tissue surrounding VVF tract denuded circumferentially for 1-2 cm, denuded area reapproximated over tract, edges of vaginal wall reapproximated as 2nd layer +/- partial colpoclesis, less blood loss and no need for ureter reimplant, risk of vaginal shortening and direclty overlapping suture lines
3) Webster simple vaginal cuff excision
- excision of fistula tract leaving funnel-shaped defect from bladder to vagina, defect closed in 3-4 layers

What are the popular Abdo approaches to VVF repair?

1) O'Conor suprapubic approach
- extra-peritoneal approach to bladder, bladder bivalved to VVF and then tract is excised, bladder dissected off vagina for 2-3 cm beyond VVF, vagina closed, interpositional flap (omental) placed, and bladder closed in several layers. S/P tube + urethral catheter + anticholinergics
2) Gill-Vernet transvesical repair
- anterior cystotomy without bivalving, VVF tract circumscribed and excised transvesically, vaginal edges mobilized from bladder, then vagina & bladder closed sequentially, V-flap of posterior bladder wall can be used to close large gap or to minimize overlapping suture lines
3) Lap repair - limited data

How successful are transvaginal & transabdominal repairs of VVF?

>90% success rate
Outcomes worse with more complicated VVF - re-do, post rads, large fistulae, etc
- obstetrical fistulae associated with loss of BN & proximal urethra have high rates of persistent severe sphincteric incontinence, despite successful repair of VVF

What are the potential complications of vaginal VVF repair?

Intra-op: Bleeding - minimize cautery use, ureteral injury
Post-op: vaginal infection, bladders spasms, bleeding, vaginal shortening or stenosis, recurrence of VVF, dyspareunia

List the different types of adjuvant interposition flaps used in VVF repair

MOP GIRLS
1) Martius Flap (off int pudendal)
2) Omental flap
3) Peritoneal flap
4) Gracilis muscle flap
5) Intestinal flap (seromuscular)
6) Rectus abdominis flap
7) Labial myocutaneous flap
8) Skin flap (gluteal)
9) Others: bladder mucosa free graft

Describe a Martius flap and its use

For low or distal VVF (trigone, BN, urethra)
Blood supply to flap is from posterior labial vessels inferiorly (br of internal pudendal artery), superiorly by external pudendal & laterally by obturatory artery
- lateral blood supply sacrificed during mobilization and flap is divided inferiorly or superiorly leaving flap supplied by external pudendal or posterior labial respectively
- can leave JP or penrose in labial incision in operative bed

Describe a peritoneal flap and its use

For high laying, post-hysterectomy VVF
- harvested from disection just beyond posterior wall of bladder to access anterior cul-de-sac
- peritoneum is NOT opened, just mobilized and advanced
- must close any peritoneotomy made during mobilization

Describe an omental flap and its use

Mainly used during transabdominal approach, but can be used during TV VVF if brought down during prior surgery
- good blood supply, easily mobilized without tension, inherent lymphatic properties, heals even in the presence of infection, and epithelialization occurs easily on its surface
- Can be mobilized with blood supply from either side but R gastroepiploic is more robust and is more caudal and so pedicle is usually taken based on this arterial supply

What are the RF for ureterovaginal fistulae?

Fat SPERM
Obesity (fat)
Surgery (pelvic)
PID
Endometriosis
RADs
Malignancy (pelvic)

What are the common causes of ureterovaginal fistulae (CHART)?

1) Iatrogenic - gynecologic sx (most common): Lap hys, abdo and vag hys, radical hys, C-section, anterior colporrhaphy; other pelvic sx: vascular urologic, colon
2) Other: Locally advanced malignancy, RADs, pelvic trauma, chronic inflammatory diseases (actinomycosis)

How do ureterovaginal fistulae usually present?

Constant urine per vagina (most common) starting 1-4 wk post-op (unlike VVF where it is variable, will commonly have N voiding habits per urethra unless contralateral injury also), flank or abdo pain, nausea, low-grade fever

What is the work-up for a potential UVF?

1) Hx - distinguish from SUI, DO, overflow, assess for RFs of ureterovaginal fistula
2) P/E - speculum exam to assess fistula +/- vaginoscopy - R/O VVF
3) Dye tests - double dye or tampon test - pyridium + blue dye in bladder
4) Cystoscopy +/- VCUG - R/O VVF
5) Imaging - IVP +/- retrograde pyelogram: will likely see some degree of obstr or leakage into vagina; if vistula + continuity on retrograde should attempt stent insertion

What is the management options for ureterovaginal fistulae?

Goals are rapid resolution of urine leakage, prevent urosepsis & preserve renal fn
Cure rates > 95% - must be followed to R/O development of stricture/hydro, must R/O VVF
1) Drainage of collecting system (attempt stenting in all cases), percutaneous NTs
2) Conservative management (trial of 4-6 wks of stent, if placed and leakage stops), formal surgical repair indicated if unable to place stent or persistent leak despite stent
3) ureteroneocystostomy (reimplant) - must assess function of affected unit (especially if delayed presentation), early repair is preferred - some advocate 4-8 wks delay, +/- psoas hitch

What are the common causes of urethrovaginal fistulae?

1) Industrialized world - iatrogenic: anti-incontinence surgery, anterior vaginal wall prolapse surgery, urethral diverticulectomy
2) Developing world - obstructed labour: usually see urethral-VVF
3) Other causes - pelvic RADs for malignancy, trauma (pelvic #), vaginal neoplasms, urethral catheter erosion

How do UVFs usually present?

Depends on size & location
- small - minimal leakage
- large - continuous urine drainage
- near BN - continuous incontinence
- proximal fistula - SUI or constant incontinence
- distal fistula - may be completely asymptomatic or associated with splayed stream, may see vaginal voiding

What is the work-up for a potential urethrovaginal fistula?

1) P/E - speculum exam - may not be able to see small fistulae (vaginal rugation), look for evidence of postmenopausal atrophy (may need estrogen)
2) Cystourethroscopy + VCUG - need to locate and characterize fistula, need to R/O VVF-->occurs in 20% of cases
3) +/- VUDS - to characterize any associated incontinence, gives anatomic info & to R/O VVF

What are the management options for urethrovaginal fistula?

Can be more difficult than VVF repair - extensive soft tissue defects, lack of local viable tissue for multi-layer closure, success rates lower than VVF repair
Timing is controversial - early vs delayed
Consider abx or estrogen to optimize tissue before repair
1) small fistulae - multilayer closure (a la Raz) +/- Martius Flap
2) larger fistulae - may need extensive surgery, including urethral reconstruction
3) distal fistulae without associated voiding symptoms or incontinence: observation, extended meatotomy

What is involved in the post-op care after urethrovaginal fistula repair?

Urinary drainage controversial - S/P alone, S/P + urethral catheter, urethral catheter alone, anti-choinergics, drainage for 2wks post-op - VCUG prior to removal

What adjuvant flaps can be used to improve urethrovaginal fistula repair results?

Fistula excision + vaginal advancement flap alone associated with high failure rates
- Martius labial fat flap, vaginal wall flap, gracilis muscle flap, rectus abdominis muscle flap, myocutaneous flap, labial skin graft

When is the best time to address SUI that is often associated with Urethral vaginal fistula repairs?

Blaivas - same time with martijus flap interposed between repair and fascial sling
Webster - reassess after repair

What are the common causes of vesicouterine fistulae?

Rare (~100 reported cases)
1) C-section (low segment) most common by far
2) other obscure causes - abortion, placenta percreta, brachytherapy, high forceps, vag delivery, uterine rupture from obstructed labour, IUD, uterine artery embolization, traumatic bladder catheterization

How does vesicouterine fistulae usually present?

Constant urinary incontinence (incompetant cervix) - if cervix is competent, may not have constant incontinence
Menouria
Cyclic hematuria (must R/O endometriosis of bladder)

What is Youssef's syndrome?

Presenting symptom complex of vesicouterine fistula post-low-segment C-section
- menouria + cyclic hematuria + apparent amenorhea + infertility + urinary continence

How is the Dx of vesicouterine fistula made?

Cystoscopy - midline lesion on posterior wall, cytology shows endothelial cells
Imaging - cystogram will outline uterus, hysterosalpingogram will outline bladder, IVP, CT to r/o concomittant ureteral injury

What are the management options for vesicouterine fistula?

1) Conservative: A) fulguration of tract + bladder drainage (for small fistulae), B) hormonal induction of menopause - involution of puerpal uterus
2) Surgical management - depends on fertility wishes of pt
A) transabdominal hysterectomy + bladder closure - stents to identify ureters, omental flap over bladder closure to prevent VVF
2) Transabdominal vesiouterine fistula repair (O'Connor VVF repair approach), bladder bivalved to fistula and tract excised, uterus and bladder separated and closed separately, interpositional flap placed between two organs

What are the common causes of vesicoenteric fistula (CHART)?

Diverticulitis (70%) - most common cause overall, especially for colovesical, 2% with diverticulitis develop a colovesical fistula
Malignancy (10-15%) - colorectal ca accounts for most (CV fistula)
Crohn's (5%) - usually get ileovesical fistulae (most common small bowel fistulae to bladder), 2% with crohn's get enterovesical fistulae
RADs
Infection
Appendiceal abscess
Trauma - iatrogenic vs external penetrating trauma
FB

How do vesicoenteric fistulae usually present? (CHART)

Urinary tract symptoms more common than bowel symptoms
- Pneumaturia (50-70%), fecaluria (36-51%), LUTS (45%), non-specific GI symptoms (25%), abdo pain (25%), recurrent UTIs, hematuria, orchitis, urine per rectum

What is Gouverneur's syndrome?

Presentation of a vesicoenteric fistula - S/P pain, frequency + dysuria + tenesmus

What is the work-up for possible enterovesical fistula?

1) Hx & P/E - assess for RF and R/O acute infection/sepsis
2) Cystoscopy - abN findings found in >90%, but dx made in only ~40%, Bx to R/O malignancy
3) CT with contrast -most sensitive & specific overall(90-100% diagnostic); a) bladder wall thickening adjacent to thickened loop of colon, b) air in bladder (w/o recent instrumentation), c) presence of colonic diverticula
4) cystogram & barium enema - less likely to demonstrate fistula

What is the Bourne test?

Test after non-diagnostic enema
First voided urine after barium enema is centrifuged and then examined under x-ray
Radiodense particles in urine is considered a +ve test

What are the management options for vesicoenteric fistulae?

1) conservative - for non-toxic, minimally symptomatic patients with non-malignant cause (NPO + TPN + ABx + foley)
2) Operative management, goal is separate & close involved organs with minimal anatomic disruption & N long-term fxn. Approach based on location, cause of fistula, patient's general condition, presence of pelvic abscess, or colonic obstruction
a) single stage - removal of fistula, resection of bwel, closure of organs
b) 2-stage - removal of fistula + closure of organs + proximal diverting colostomy

What are the common causes of ureteroenteric fistulae?

IBD (most common cause) - terminal ileum is most likely segment
Diverticulitis
Stones
RADs
TCC
Trauma - iatrogenic vs external
TB

How are ureteroenteric fistulae diagnosed?

Presentation - bowel symptoms more common than urinary tract
- Investigations - retrograde pyelogram or CT urogram

What is the management of ureteroenteric fistulae?

Assess renal fxn prior to making definitive decision - if malignancy related, rx is different
1) Ureterolysis + possible bowel segment resection + stent
2) ureteral segment resection + UU + possible bowel segment resection + stent
3) Nephrectomy + possible bowel segment resection

What are the common causes of pyeloenteric fistulae?

R sided fistulae usually involve the duodenum, L-sided usually descending colon
- Chronic inflammatory disease (XGP, IBD) most common cause
- Trauma - iatrogenic (PNL), external
- Malignancy
- Ulcer diseaes
- Ingested FBs
- Complex stones

How are pyeloenteric fistulae diagnosed?

Presentation - most present with non-specific symptoms
- Fever and mailaise, urinary frequency, pyuria, non-specific GI symptoms, flank mass, flank tenderness
Ix - RPG, IVP, nephrostogram, barium swallow/barium enema

What is the management of pyeloenteric fistulae?

Historically treated with Nx + closure of bowel, assess renal fxn
1) Large NT + Ureteric stent + bowel rest + TPN + ABx + removal of any FB (stone, ingested)
2) If poorly functioning kidney, Nx + bowel closure

What are the common causes of rectourethral fistulae?

Congenital - assoc with imperforate anus
Acquired:
1) Iatrogenic: Rad P, TURP, Prostate cryo, brachy, HIFU, pelvic RADs, anorectal surgery, urethral instrumentation
2) External trauma
3) Malignancy - locally advanced PCa or rectal ca
4) Inflammatory/infectious - ruptured prostatic abscess, IBD, TB

How common are rectourethral fistulae after Rad P?

Occurs in <0.5% of men post-RP
Usually at level of anastomosis and associated with unrecognized rectal injury
Extremely uncommon if rectal injury (1-2%) is recognized intra-op and repaired
- RP most common cause b/c so common, but rectourethral fistulae are not common post-RP
- Prior pelvic rads, rectal surgery or TURP increases risk of rectourethral fistula post-RP

How common are rectourethral fistulae after other prostate procedures?

Cryotherapy - 0.5-2% after primary prostate cryo, 3% after salvage prostate cryo
Brachy - 0.5%

How are rectouretral fistulae diagnosed?

Presentation - variable: fecaluria, hematuria, UTIs, palpable tract on DRE, urine from rectum, N/V, fever, peritonitis, sepsis
Ix - cystourethroscopy, sigmoidoscopy - consider bx if malignancy an issue; VCUG, RUG (definitive dx with anatomic detail/info), RPG CT Urogram, IVP to R/O ureteral injury

What are the management options for rectalurethal fistulae?

Most require surgical repair
Conservative management - mainly for post-RP: Foley + NPO + TPN +/- fecal diversion, fulguration of fistula tract +/- fibrin glue, endoscopic suturing +/- fibrin glue
Surgical management - 1stage repair - iatrogenic, small fistulae not assoc'd with infection, abscess or poor bowel prep; staged: +/- fecal diversion, large & complex (rads, local/systemic infection, immunocompromised, poor bowel prep, etc), debate wheter to divert feces before GU tract repair, after GU tract repair or at all

What are the indications for fecal diversion

Poor control of symptoms with ABx + urinary diversion
Persistence of fecaluria despite conservative measures in presence of sepsis

What are the relative contraindications to a single stage repair?

RADs
Need for surgical diversion d/t uncontrolled local & systemic infection
Extensive or large rectal injuries leading to fistula formation
Immunocompromised states
Inadequate bowel prep at time of definitive closure
Prior anorectal dysfunction

What are the different repairs for rectourethral fistulae?

1) Transrectal - York-Mason (transrectal, trans-sphincteric (post), staged repair with fecal diversion prior to fistula repair - occasional can be done as single stage, good results with low morbidity
2) Transanal approach - Latzko - transanal, sphincter sparing, rectal mucosa surrounding fistula denuded + 3 layer closure over tract site, poor exposure OR rectal advancement flaps
3) Perineal approach - +/- interposition flaps - familiar to urologists with access to flaps, gracilis, dartos, penile skin, levator, bladder - excellent results
4) Transabdoinal approach - bad outcomes and morbid - risk of urinary & fecal incontinence, poor exposure

What are the sepcial considerations for rectourethral fistulae post-brachy or post-cryo?

May be extremely hard to fix - large fistulae with +++ induration, fibrosis, ischemia
May need urinary diversion in some cases

What are the common causes of renovascular or pyelovascular fistulae?

PCNL
Long-term indwelling NT
Infection
Open renal surgery (PNx)
External blunt and penetrating trauma

How do renovascular or pyelovascular fistulae usually present?

Hematuria
Flank pain
Bleeding from NT or NT site
hemorrhage and shock

What is the management of renovascular or pyelovascular fistulae?

Depends on presentation, etiology and hemodynamic stability of patient
- replacement of NT or if large mature tract, placement of foley
- embolization if persistent bleeding
-flank exploration +/- partial or simple Nx

What are the common causes of ureterovascular fistulae? (CHART)

Majority are uretero-iliac artery fistulae (some uretero-iliac vein and ureteroaortic)
- Prior GU or pelvic sx (68%)
- Ureteric stent (65%)
- Pelvic Rads (46%)
- Prior vascular sx or vascular disease (iliac aneurysm ) 20%
- Ureteric stricture balloon dilatation
- pelvic malignancy
- ileal conduit reconstruction
- Hx of ureterolithotomy
- external penetrating trauma
- pregnancy

How do you make the diagnosis of ureterovascular fistula?

Key is high index of suspicion in at risk pt
Presentation - microscopic hematuria, intermittent gross hematuria, life-threatening hemorrhage
Ix - Most routine urologic tests for hematuria are non-diagnostic - even non-selective arteriography; Selective angiography is best, and possibly therapeutic

What are the management options for ureterovascular fistulae?

consider early surgical intervention, especially b/c most present with severe hemorrhage + hypoTN and investigations are often non-diagnostic
- Vascular consult essential
- Vascular side - embolization, primary repair, ligation +/- bypass, endovascular graft (limb salvage important)
- Urologic side - repair & reconstruction often complicated d/t hx of rads, malignancy, vascular disease or prior sx. UU, TUU, Cutaneous ureterostomy, perc NT + ureteral ligation, Nx

What are nephropleural fistulae?

Causes: Infection (XGP, TB, renal abscesses), trauma, stones, PNL
Presentation: Cough, urine-like taste in mouth, fever, flank pain, rarely presents with recurrent lung abscesses
Rx - percutaneous drainage of any associated abscess, Abx for any associated infections, relief of any urinary tract obstuction, some PCNL access related iatrogenic fistulae can be managed non-operatively, surgical exploration + interposition of healthy tissue, Nx if poorly fn kidney

What are urocutaneous fistulae?

Causes: Renocutaneous: chronic pyelonephritis, external trauma, iatrogenic( PNL, PNx); Ureterocutaneous or vesicocutaneous: Often iatrogenic, even therapeutic, external penetrating trauma, malignancy, chronic infection
Rx - Renocutaneous: Nx if poorly functioning, ureteric stenting; Ureterocutaneous, vesicocutaneous - R/O distal obstruction, if assoc with infection, find soucr and treat, ensure adequate nutrition, r/o occult malignancy

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