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] The clinical signature distinguishes UVF cleanly from VVF: continuous vaginal urinary leakage with preserved normal voiding per urethra, because one ureter leaks while the contralateral kidney drains normally into an intact bladder. The single most important management point — and the one that dictates whether the patient avoids open reconstruction — is that UVF is uniquely amenable to early endoscopic stent placement, the AUA-recommended first-line therapy.[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.
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
| 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 | Absent | Sometimes present |
A patient who voids normally and leaks continuously per vagina has a UVF until proven otherwise — the contralateral kidney is filling the bladder normally while the injured ureter empties into the vagina.
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 | Diagnosis |
|---|---|
| Blue only | Vesicovaginal fistula |
| Orange only | Ureterovaginal fistula |
| Both | Combined VVF + UVF |
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. Renal salvage approaches 100% when PCN is deployed early.[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] |
Stenting success is dramatically time-dependent. A systematic review and meta-analysis of 799 UVFs by Bahuguna et al.:[16]
| Time to stent | Pooled success |
|---|---|
| < 2 weeks | 95% |
| 2–6 weeks | 46% |
| > 6 weeks | 20% |
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) |
Robotic ureteroneocystostomy is the contemporary standard at experienced centers. The Kidd et al. multi-institutional series of robotic vesicovaginal and ureterovaginal fistula repair after iatrogenic injury reported 100% success at mean 29.3 months with no complications, median console time 160 min, EBL 50 mL, and median LOS 1 day.[11][19][20]
Operative principles (any approach)
- Ureteral identification at the iliac vessels and circumferential dissection distally to the fistula
- 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
Outcomes
| Management | Success | Notes |
|---|---|---|
| Stenting < 2 wk | 95% | Optimal window[16] |
| Stenting 2–6 wk | 46% | Intermediate[16] |
| Stenting > 6 wk | 20% | Poor — proceed to reconstruction[16] |
| Surgical reimplant (any approach) | ~100% | Regardless of timing[1][2][3] |
| Robotic reimplant (multi-inst.) | 100% at 29.3 mo | LOS 1 day; minimal morbidity[11] |
Immediate vs Delayed Recognition
The strongest preventable variable is whether the original ureteral injury is identified at the index operation.[4]
| Timing of recognition | Subsequent fistula rate | Stent success |
|---|---|---|
| Immediate (intraoperative) | 0.7% | 99.0% |
| Delayed (postoperative) | 3.4% | 39.8% |
This makes the case for routine intraoperative cystoscopy after hysterectomy — particularly in radical hysterectomy, cesarean with adhesions, prolapse / sling combinations, and any case complicated by bleeding or distorted anatomy.
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 after hysterectomy — single highest-yield maneuver for early detection[4]
- Prophylactic ureteral stenting in high-risk pelvic surgery (endometriosis, prior pelvic surgery, distorted anatomy, mesh-augmented prolapse repair)
- 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 intraoperative repair of recognized injury collapses the subsequent fistula rate from 3.4% to 0.7%[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
References
1. Zhang C, Saussine C, Tricard T. "Urogenital fistulas: surgical management, outcomes, and prognostic factors — a 14-year monocentric experience." Int Urogynecol J. 2026. doi:10.1007/s00192-026-06580-0
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
3. Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L. "Urotrauma guideline 2020: AUA guideline." J Urol. 2021;205(1):30–35. doi:10.1097/JU.0000000000001408
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
5. Likic IS, Kadija S, Ladjevic NG, et al. "Analysis of urologic complications after radical hysterectomy." Am J Obstet Gynecol. 2008;199(6):644.e1–644.e3. doi:10.1016/j.ajog.2008.06.034
6. Hwang JH, Kim B. "Postoperative urinary complications in minimally invasive versus abdominal radical hysterectomy: a meta-analysis with a focus on ureterovaginal fistula." J Minim Invasive Gynecol. 2025;32(6):502–511. doi:10.1016/j.jmig.2024.12.009
7. Shaw J, Tunitsky-Bitton E, Barber MD, Jelovsek JE. "Ureterovaginal fistula: a case series." Int Urogynecol J. 2014;25(5):615–621. doi:10.1007/s00192-013-2272-y
8. Murphy DM, Grace PA, O'Flynn JD. "Ureterovaginal fistula: a report of 12 cases and review of the literature." J Urol. 1982;128(5):924–925. doi:10.1016/s0022-5347(17)53279-6
9. Rabani SM, Rabani S. "Early detection and endoscopic management of post cesarean section ureterovaginal fistula: a case series study." Int Urogynecol J. 2021;32(9):2537–2541. doi:10.1007/s00192-020-04589-7
10. Meirow D, Moriel EZ, Zilberman M, Farkas A. "Evaluation and treatment of iatrogenic ureteral injuries during obstetric and gynecologic operations for nonmalignant conditions." J Am Coll Surg. 1994;178(2):144–148.
11. Kidd LC, Lee M, Lee Z, et al. "A multi-institutional experience with robotic vesicovaginal and ureterovaginal fistula repair after iatrogenic injury." J Endourol. 2021;35(11):1659–1664. doi:10.1089/end.2020.0993
12. Rogers RG, Jeppson PC. "Current diagnosis and management of pelvic fistulae in women." Obstet Gynecol. 2016;128(3):635–650. doi:10.1097/AOG.0000000000001519
13. Hanash KA, Al Zahrani H, Mokhtar AA, Aslam M. "Retrograde vaginal methylene blue injection for localization of complex urinary fistulas." J Endourol. 2003;17(10):941–943. doi:10.1089/089277903772036334
14. Selzman AA, Spirnak JP, Kursh ED. "The changing management of ureterovaginal fistulas." J Urol. 1995;153(3 Pt 1):626–628. doi:10.1097/00005392-199503000-00020
15. Rajamaheswari N, Chhikara AB, Seethalakshmi K. "Management of ureterovaginal fistulae: an audit." Int Urogynecol J. 2013;24(6):959–962. doi:10.1007/s00192-012-1959-9
16. Bahuguna G, Panwar VK, Mittal A, et al. "Management strategies and outcome of ureterovaginal fistulae: a systematic review and meta-analysis." Neurourol Urodyn. 2022;41(2):562–572. doi:10.1002/nau.24874
17. Lang EK. "Diagnosis and management of ureteral fistulas by percutaneous nephrostomy and antegrade stent catheter." Radiology. 1981;138(2):311–317. doi:10.1148/radiology.138.2.7455109
18. Mueller PR, vanSonnenberg E. "Interventional radiology in the chest and abdomen." N Engl J Med. 1990;322(19):1364–1374. doi:10.1056/NEJM199005103221906
19. Linder BJ, Frank I, Occhino JA. "Extravesical robotic ureteral reimplantation for ureterovaginal fistula." Int Urogynecol J. 2018;29(4):595–597. doi:10.1007/s00192-017-3459-4
20. Laungani R, Patil N, Krane LS, et al. "Robotic-assisted ureterovaginal fistula repair: report of efficacy and feasibility." J Laparoendosc Adv Surg Tech A. 2008;18(5):731–734. doi:10.1089/lap.2008.0037
21. Binstock MA, Semrad N, Dubow L, Watring W. "Combined vesicovaginal-ureterovaginal fistulas associated with a vaginal foreign body." Obstet Gynecol. 1990;76(5 Pt 2):918–921.