Exxcellence pearls: urinary fistulae

Question 0

How can pooled fluid in the vagina be assessed for urinary injury?

Answer 0

Creatinine above serum levels confirms the presence of urine.

Question 1

What are risk factors for urinary system injury during gynecologic surgery?

Answer 1

Embryologic anomalies such as double ureter
Prior surgeries such as C-sections or renal transplant
Fibroids especially paracervical
Severe endometriosis
Severe acute or chronic inflammatory disease including radiation
Cancer

Question 2

Describe the general principle regarding development of the vesicouterine plane.

Answer 2

Sharp rather than blunt dissection is advisable.

Question 3

Describe the “tampon test”.

Answer 3

Give IV methylene blue and have the patient walk around with a vaginal tampon in place. Presence of blue dye at the deep end suggests a defect from the bladder to vagina.

Question 4

If vaginal fistula is suspected but cannot be confirmed on exam, what imaging is indicated?

Answer 4

IV pyelogram or retrograde pyelogram

Question 5

How should postoperative fistulae be managed?

Answer 5

Conservative management with Foley drainage is often sufficient. Vaginal estrogen or urinary antibiotics may be helpful.