Fistulas

A genitourinary fistula is an abnormal epithelialized communication between the urinary tract and another viscus, body cavity, or the skin. Most acquired GU fistulas in the developed world are iatrogenic — the consequence of pelvic surgery, radiation, or obstetric injury — and nearly all are reconstructed by the urologic reconstructionist or urogynecologist. This section organizes fistulas by the patient population in which they occur, because the anatomic relationships, surgical approaches, and interposition options differ substantially between men and women.

For the operative origins of these injuries, see Procedures Causing GU Injury and Intraoperative Consultation.

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Fistulas in Females

• Vesicovaginal FistulaThe most common acquired GU fistula in the developed world — iatrogenic after gynecologic surgery; obstetric in low-resource settings.
• Vesicouterine FistulaBladder-to-uterus communication — classically Youssef syndrome after cesarean delivery; menouria, amenorrhea, and preserved urinary continence.
• Ureterovaginal FistulaUreter–vagina communication after pelvic surgery; presents like VVF but requires a distinct diagnostic workup and upper-tract management.
• Rectovaginal FistulaRectum-to-vagina communication — obstetric, inflammatory bowel disease, radiation, or surgical injury; often encountered alongside urinary fistulas in complex multi-compartment cases.
• Obstetric FistulaProlonged-obstructed-labor fistula — the global paradigm of obstetric GU injury; distinctive geography, staged repair, and integrated rehabilitation.

Fistulas in Males

• Rectovesical FistulaBladder-to-rectum communication — post-prostatectomy (rare), radiation, pelvic malignancy, or traumatic.
• Rectourethral FistulaAlmost exclusively in men — post-prostate-cancer treatment (radical prostatectomy, radiation, cryotherapy, HIFU); demands coordinated urologic and colorectal reconstruction.
• Urethropubic FistulaUrethra-to-pubic-bone communication after pelvic fracture urethral injury or radical prostatectomy with osteitis pubis; often requires combined reconstruction with pubectomy.
• Urethrocutaneous FistulaThe most common cutaneous GU fistula — complication of hypospadias repair, urethroplasty dehiscence, perineal trauma, or Fournier's gangrene.
• Urethroperineal FistulaUrethra-to-perineum communication — Fournier's sequela, complex urethroplasty failure, or perineal trauma.

Fistulas in Both Genders

• Pyeloenteric FistulaAbnormal communication between the renal pelvis / collecting system and bowel — most commonly duodenum, colon, or jejunum; usually secondary to infection, calculus disease, or penetrating trauma.
• Nephropleural FistulaCommunication between the collecting system and pleural space — most often after PCNL in a supracostal puncture or following thoracoabdominal trauma.
• Ureterocolonic FistulaUreter–colon communication from diverticular disease, Crohn's, radiation, malignancy, or iatrogenic colorectal injury.
• Colovesical & Small Bowel FistulasEnterovesical fistulas from diverticulitis (most common), Crohn's disease, colorectal malignancy, radiation, and surgical injury — pneumaturia and fecaluria are the pathognomonic symptoms.
• Vesicocutaneous FistulaBladder-to-skin communication — post-operative, radiation-associated, chronic catheterization, or malignant erosion.
• Urinary Fistula After Kidney TransplantUreteroneocystostomy leak, ureteral necrosis from distal-ureter ischemia, and graft-to-bladder disruption — the principal early urologic complication of renal transplantation.
• Vascular-Urinary FistulaUretero-arterial and uretero-venous fistulas — rare but life-threatening; classic setting is long-indwelling ureteral stent in a radiated or vascular-grafted pelvis.

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Complex Fistula Principles

Certain principles cut across every fistula type and every compartment. Any repair undertaken in the following setting is considered complex, and the operative plan is different from a primary, uncomplicated fistula:

• Multiplicity — two or more fistulous tracts
• Prior failed repair(s) — at least one previous attempt
• Hostile tissue — radiation, ischemia, infection, or inflammatory bowel disease
• Large defect — significant tissue loss precluding primary closure
• Multi-organ involvement — urinary + enteric + vaginal / cutaneous
• Associated malignancy or recurrent cancer

Staging

Complex fistula repair is almost always staged:

1. Damage control — urinary and/or fecal diversion; drainage of abscess or urinoma; nutritional optimization
2. Tissue preparation — allow 3–6 months (longer in radiation cases); optimize tissue perfusion; hyperbaric oxygen in select radiation cases
3. Definitive reconstruction — single-stage if possible; may require multiple procedures

Tissue Interposition — The Non-Negotiable Step

Vascularized tissue interposition is mandatory in any complex fistula repair:

Tissue	Best Use
Martius flap (labial fat pad)	Vaginal / perineal fistulas; women; reliable, straightforward
Gracilis muscle flap	Perineal / rectourethral; irradiated pelvis; excellent bulk
Omental pedicle	Abdominal approach; radiation; fills dead space
Peritoneal flap	Laparoscopic / robotic VVF repair; limited bulk
Fasciocutaneous flap	Large cutaneous defects; perineal reconstruction

Multi-Compartment Fistulas

• Simultaneous involvement of bladder, vagina, and rectum (cloacal-type) requires coordinated urologic, gynecologic, and colorectal reconstruction.
• Often requires fecal + urinary diversion, staged repair, and gracilis or omental flap.
• Urinary diversion (continent or incontinent) may be the most reliable long-term solution when the bladder is unsalvageable.

Radiation Fistulas

• Tissue quality is the rate-limiting factor.
• Hyperbaric oxygen (HBO) may improve tissue oxygenation pre-operatively (20–40 sessions).
• Never repair without vascularized tissue interposition.
• Recurrence rates are higher; patient counseling about realistic expectations is essential.
• Permanent urinary and/or fecal diversion should be presented as a valid and dignified option.

Key Operative Principles

• Treat obstruction before fistula — no repair will hold against back-pressure.
• Vascularized tissue is the common denominator in all complex repair.
• Diversion is not failure — for radiation or multiply recurrent fistulas, it may be the best quality-of-life decision.
• Multidisciplinary planning (urology, colorectal, plastics, gynecology) is essential for multi-compartment cases.
• Document each prior repair attempt, technique, and tissue used — this drives the next-step strategy.