Ureterovaginal Fistula
A ureterovaginal fistula (UVF) is an epithelialized communication between the ureter and the vagina. It accounts for 16–31% of urogenital fistulas and is almost always the late expression of an unrecognized iatrogenic ureteral injury at hysterectomy or other pelvic surgery.[1][2] A characteristic presentation is continuous vaginal urinary leakage with preserved normal voiding per urethra, because one ureter leaks while the contralateral kidney drains normally into an intact bladder. Preserved voiding does not exclude a small VVF or a combined fistula. Early endoscopic stent placement, when feasible, is AUA-recommended initial management.[3]
For the operative settings that produce UVF, see Cesarean Section and Intraoperative Consultation. Reimplantation, psoas hitch, and Boari flap technique are covered in detail in Ureteral Stricture — distal reconstruction. For operative selection see the Female Fistula Repair database; the definitive repair pages are Ureteral Reimplantation and Boari Flap & Psoas Hitch.
Epidemiology
- UVF accounts for 16.4–31% of urogenital fistulas in modern series.[1][2]
- Ureteral injury complicates ~1.0% of hysterectomies for benign indications; 18.6% of these injuries are recognized only in delayed fashion, a subset of which evolve into UVF.[4]
- After radical hysterectomy for cervical cancer, UVF occurs in ~2.4% of cases.[5]
- Minimally invasive radical hysterectomy carries a markedly higher UVF risk than open radical hysterectomy (OR 4.44).[6]
Etiology and Anatomy of Injury
| Setting | Notes |
|---|---|
| Hysterectomy (benign or radical) | Dominant cause across all routes — abdominal, vaginal, laparoscopic, robotic[1][2][3] |
| Cesarean section | Increasingly recognized; left-sided predominance with adhesions from prior cesarean[9][10] |
| Pelvic prolapse / incontinence surgery | Concurrent prolapse or sling adds risk[1] |
| Colorectal surgery | LAR, APR, sigmoidectomy near the pelvic brim |
| Obstetric obstructed labor | Rare in HIC; classical setting in low-resource environments |
| Penetrating pelvic trauma | Rare |
Three anatomic danger zones during pelvic surgery
- Pelvic brim — ureter crosses the common iliac artery
- Uterine artery crossing — "water under the bridge," 1–2 cm lateral to the cervix
- Cardinal ligament / vaginal cuff — ureter enters the bladder just lateral to the upper vagina
Mechanisms include ligation, transection, crush, kinking, devascularization, and thermal injury — the last especially during laparoscopic or robotic dissection. The defining feature of injuries that produce UVF is that they are almost never recognized intraoperatively: in one series, none of 19 UVFs were identified at the index operation.[4][6][7]
Risk factors
The hysterectomy associations below concern urinary tract injury in an observational cohort, not UVF-specific causal effects; the radical-hysterectomy comparison concerns UVF.[4][6]
| Risk factor | OR |
|---|---|
| Concurrent prolapse repair[4] | 1.44 |
| Concurrent incontinence procedure[4] | 1.40 |
| Mesh-augmented prolapse repair[4] | 1.55 |
| Endometriosis[4] | 1.46 |
| Low-volume facility[4] | 1.37 |
| Minimally invasive vs open radical hysterectomy[6] | 4.44 |
Clinical Presentation
The hallmark is sudden continuous vaginal urinary leakage 1–4 weeks after pelvic surgery in a patient who continues to void normally per urethra.[7][8][9]
| Feature | UVF | VVF |
|---|---|---|
| Vaginal leakage | Continuous | Continuous |
| Voiding per urethra | Preserved | Often diminished or absent |
| Ipsilateral flank pain | Present in ~63% (obstruction proximal to fistula)[9] | Uncommon |
| Hematuria | May be absent; does not exclude injury | Sometimes present |
Normal voiding with continuous vaginal leakage should prompt evaluation for UVF, including the upper tracts; symptoms alone do not distinguish UVF from a small VVF or combined injury.
Diagnostic Evaluation
The workup answers three questions: Is it UVF or VVF? Where is the injury? Is the upper tract obstructed or infected?
Double-dye test (the bedside discriminator)
The single most useful office maneuver:[2][12][13]
- Methylene blue / indigo carmine instilled into the bladder via Foley
- Oral phenazopyridine given simultaneously (stains urine orange)
- A vaginal tampon is placed for 30–60 minutes
| Tampon staining | Interpretation |
|---|---|
| Blue | Supports a bladder communication; does not exclude an additional UVF |
| Orange without blue | Supports UVF; confirm anatomy with upper-tract imaging |
| Mixed staining | Cannot independently establish a combined fistula: orally colored urine also reaches the bladder |
Imaging and endoscopy
| Modality | Role | Notes |
|---|---|---|
| CT urography | Workhorse — most commonly used (~58% of cases) | Hydronephrosis, contrast extravasation into vagina, fistula tract; delayed images essential[7][12] |
| Renal ultrasound | Rapid screen for hydronephrosis | Drives decision to drain the upper tract[9] |
| Retrograde pyelogram + cystoscopy | Definitive — defines level and length, simultaneous opportunity for retrograde stent | Performed at the time of any planned endoscopic intervention[2][8] |
| Antegrade pyelogram | When retrograde access fails | Pairs naturally with PCN and antegrade stent placement[14][17] |
Management
The AUA Urotrauma Guideline (2020) is unambiguous: initially manage UVF with stent placement when feasible; surgical reconstruction is reserved for stenting failure.[3]
Step 1 — protect the upper tract
If hydronephrosis is significant, the kidney is infected, or there is a coexistent urinoma, percutaneous nephrostomy decompresses the system and serves as the access for antegrade stenting if retrograde fails. An infected obstructed collecting system requires urgent drainage and antibiotics; drainage may require a retrograde stent or PCN, and an infected or persistent urinoma may need separate drainage.[10][18]
Step 2 — endoscopic ureteral stent (first-line)
| Approach | Notes |
|---|---|
| Retrograde JJ stent | Cystoscopic; guidewire passed across the injured segment into the renal pelvis; JJ stent left 6 weeks[9][14] |
| Antegrade JJ stent | Via PCN when retrograde fails[14][17] |
Earlier stenting was associated with higher success in a systematic review of 799 UVFs drawn entirely from retrospective studies. Selection, injury severity and timing were heterogeneous; these pooled proportions do not establish a causal timing threshold:[16]
| Time to stent | Pooled success |
|---|---|
| < 2 weeks | 95% (95% CI 87–100%) |
| 2–6 weeks | 46% (95% CI 0–100%) |
| > 6 weeks | 20% (95% CI 1–49%) |
Individual contemporary series report 64–100% success when stenting is attempted early in selected patients.[3][14][15] The pragmatic rule: attempt retrograde stenting at the first encounter and proceed antegrade through PCN if retrograde fails. Delayed referral compounds the problem — both because tissue inflammation matures and because the injured segment may have completed its sloughing.
Step 3 — surgical reconstruction (when stenting fails or is infeasible)
Indications: inability to traverse the injured segment, persistent fistula despite an adequately placed stent, complete transection on imaging.[3][7][15]
The reconstruction follows the same distal-ureter ladder used for any iatrogenic stricture — see Ureteral Stricture — distal reconstruction:
| Defect | Procedure |
|---|---|
| Short distal | Ureteroneocystostomy (anti-refluxing or refluxing) |
| Distal with insufficient reach | Psoas hitch ± reimplant — adds 3–5 cm |
| Mid-to-distal, 8–12 cm gap | Boari flap ± psoas hitch |
| Mid ureteral, both ends viable | Ureteroureterostomy |
| Long defect, no bladder reach, contralateral ureter healthy | Transureteroureterostomy (rarely chosen today) |
Open, laparoscopic and robotic reconstruction are options selected by anatomy, tissue quality, resources and surgeon experience. In Kidd et al., all 12 UVF patients (10 reimplantations and two ureteroureterostomies) were free of leakage off drains/stents at mean 29.3 months, with no reported complications. These selected observational results do not guarantee success or establish robotic superiority.[11]
Approach selection
| Approach | Role | Evidence |
|---|---|---|
| Robotic | Selected patients at centers with reconstructive expertise | Small series demonstrate feasibility and good reported outcomes[11][19][20] |
| Laparoscopic | Similar reconstructive principles where expertise is available | Case series and technical reports; no established equivalence or superiority over other routes[22][23] |
| Open | Established option, including complex or combined reconstruction | Route individualized rather than reserved solely for failed minimally invasive repair[1][2][3] |
| Transvaginal | Highly selected low fistula with accessible distal ureter | Limited case-series evidence[24] |
Operative principles (any approach)
- Identify healthy ureter and mobilize only as needed, preserving adventitia and periureteral blood supply
- Transection above the injured segment; ligation of the distal stump
- Spatulation of the proximal ureter
- Posterior / posterolateral cystotomy
- Tension-free, mucosa-to-mucosa anastomosis over a JJ stent
- Test integrity with retrograde bladder fill
- Pelvic drain; cystogram before catheter removal in selected cases; stent removed at ~6 weeks
Postoperative care and follow-up
- Foley catheter 7–14 d; cystogram before removal in selected cases[19]
- JJ stent removed at ~6 weeks
- Renal ultrasound ~6 weeks post-stent removal — exclude hydronephrosis
- Additional anatomic or functional imaging if symptoms, renal function or ultrasound suggest persistent leakage or obstruction; routine repeated CT urography is not necessary for every uncomplicated repair
- Long-term surveillance for late stricture is advisable
Outcomes
| Management | Success | Notes |
|---|---|---|
| Stenting < 2 wk | 95% | Retrospective pooled estimate[16] |
| Stenting 2–6 wk | 46% | Very imprecise pooled estimate[16] |
| Stenting > 6 wk | 20% | Lower reported success; assess feasibility individually[16] |
| Surgical reconstruction | High reported closure | Selected series; definitions and follow-up differ[1][2][16] |
| Robotic UVF repair (multi-inst.) | 12/12 at mean 29.3 mo | Selected cohort, including two ureteroureterostomies[11] |
Immediate vs Delayed Recognition
In a retrospective cohort of benign hysterectomies, immediate recognition of ureteral injury was associated with fewer subsequent fistulas.[4]
| Timing of recognition | Subsequent fistula rate | Stent alone without subsequent ureteral repair |
|---|---|---|
| Immediate (intraoperative) | 0.7% | 99.0% |
| Delayed (postoperative) | 3.4% | 39.8% |
The stent endpoint was avoidance of a second ureteral repair after injury, not closure of established UVF. These observational data support prompt recognition but do not establish the effectiveness of universal cystoscopy. Cystoscopy and assessment of ureteral efflux can identify some injuries; a normal examination does not exclude delayed thermal or ischemic injury.
Concurrent Fistulas
UVF coexists with VVF in a non-trivial fraction of complex cases — combined repair typically pairs transvaginal VVF closure with abdominal / robotic ureteroneocystostomy in the same setting.[2][21] Always rule out the contralateral ureter on CT urography before committing to a unilateral plan.
Prevention
- Intraoperative cystoscopy when injury is suspected or indicated by the procedure; interpret ureteral efflux alongside the operative findings[4]
- Prophylactic ureteral stents may help identify the ureter in selected difficult dissections, but have not been shown to prevent injury and are not routinely recommended solely for that purpose[25]
- Anatomic identification of the ureter at the three danger zones during every dissection
- Avoid excessive thermal energy near the ureter on laparoscopic / robotic platforms[6]
- Refer high-complexity cases to higher-volume centers[4]
- Immediate recognition was associated with a subsequent fistula rate of 0.7% versus 3.4% after delayed recognition; this is an observational association[4]
Algorithm summary
- Suspect UVF — vaginal leakage + normal voiding ± flank pain after pelvic surgery
- Confirm — double-dye test, CT urography, cystoscopy with retrograde pyelogram
- Protect the upper tract — PCN if obstructed or infected
- Attempt retrograde JJ stent within 2 weeks — ideally at the diagnostic cystoscopy; antegrade through PCN if retrograde fails
- Stent for 6 weeks → remove → follow-up imaging
- If stenting fails or fistula persists → robotic / open ureteroneocystostomy ± psoas hitch / Boari flap
See Also
- Female Fistula Repair database
- Principles of Fistula Repair
- Ureteral Reimplantation
- Boari Flap & Psoas Hitch
Videos
References
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2. Goodwin WE, Scardino PT. "Vesicovaginal and ureterovaginal fistulas: a summary of 25 years of experience." J Urol. 1980;123(3):370–374. doi:10.1016/s0022-5347(17)55941-8
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4. Dallas KB, Rogo-Gupta L, Elliott CS. "Urologic injury and fistula after hysterectomy for benign indications." Obstet Gynecol. 2019;134(2):241–249. doi:10.1097/AOG.0000000000003353
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