Vesicocutaneous Fistula Repair
This operative atlas addresses a communication between the bladder and skin. See Vesicocutaneous Fistula for the diagnostic framework. Confirm the urinary origin and anatomy before choosing repair: a thigh or perineal urinary fistula may arise from the urethra rather than the bladder.
Treatment Planning
Management depends on the cause, urinary drainage, infection, bladder function and tissue loss. Available options include drainage and wound care, selected endoscopic treatment, direct repair with appropriate coverage, and urinary diversion. These are not three obligatory sequential stages. Most published VCF-specific evidence consists of individual cases or small series.[1][2][6][9]
| Finding | Implication for planning |
|---|---|
| Abscess, sepsis or infected collections | Drain collections and treat infection; a skin opening alone does not ensure adequate source control. |
| Obstruction, malfunctioning catheter, foreign material or stone | Identify and address the continuing cause of urinary leakage before expecting a local repair to hold. |
| Radiation injury, recurrent tumor or major tissue loss | Assess tissue viability, bladder function, oncologic goals and the feasibility of coverage versus diversion. |
| Neurogenic lower urinary tract dysfunction | Evaluate storage pressure and emptying rather than assuming every neurogenic bladder is high pressure. |
A long-standing tract may need excision, but chronicity or presumed epithelialization alone does not prove that fistulectomy is the only treatment. In Banihani's report titled “vesicocutaneous fistula,” contrast imaging actually showed a posterior urethral communication to the thigh with distal stricture; abscess drainage, suprapubic diversion and subsequent stricture treatment achieved healing without fistulectomy. The anatomical distinction changes management.[10]
Drainage and Wound Preparation
Establish reliable low-pressure urinary drainage appropriate to the actual anatomy, protect the skin, address nutrition and treat infection when present. A urethral catheter may suffice; additional or alternative drainage depends on obstruction, the injury and bladder function. There is no VCF-specific evidence supporting the same catheter size and duration for every chronic fistula.
Acute bladder trauma is a separate evidence context. The ACS 2025 guideline recommends a catheter of at least 18 Fr for at least seven days in uncomplicated extraperitoneal blunt bladder injury. It recommends cystographic follow-up for most repaired injuries at seven days or later, with longer drainage/imaging intervals of three to four weeks for complex injuries. Those recommendations must not be applied automatically to every chronic, irradiated or postoperative VCF.[3] See Cystography for injury-specific follow-up and guideline differences.
For leakage related to an extruded or malpositioned suprapubic catheter, verify balloon location and correct drainage and fixation. Vaidyanathan's case supports proper positioning and secure anchoring; it does not establish a universal requirement for a smaller tube plus simultaneous urethral catheterization.[7]
Negative-pressure wound therapy
Negative-pressure wound therapy has been described after augmentation cystoplasty and as part of preparation for extensive reconstruction. One adolescent's fistula closed without further surgery; another report combined wound therapy with a rectus femoris musculocutaneous flap. These reports support a selected wound-management adjunct, not a standard second treatment stage or a proven substitute for urinary drainage and source control.[1][5] Dressing selection, protection of exposed structures and change frequency require a wound/reconstructive plan; the cited cases do not establish a universal 48–72-hour protocol.
Endoscopic closure
McKay described transurethral suture cystorrhaphy in two patients with vesical fistulas, with successful closure. This is preliminary experience with a selected technique; it does not establish comparative effectiveness or validated size, age-of-tract or radiation eligibility thresholds.[6]
Operative Reconstruction
Plan exposure and repair around the bladder defect and the overlying tissue deficit. Important decisions are:
- Define and remove the continuing cause. Identify obstruction, retained material, infection and suspicious tissue; obtain histology when malignancy is a concern.
- Preserve viable tissue. Debride nonviable tissue and excise the tract or involved bladder wall when required; routine radical removal of all tissue around every chronic fistula is not established.
- Create a tension-free, watertight bladder closure. Mobilization, suture technique and the number of layers depend on the defect and tissue available. ACS favors a two-layer absorbable repair for bladder trauma; that is not a VCF-specific mandate for identical suture size and bites in every case.[3]
- Reconstruct deficient coverage. Interpose or transfer vascularized tissue when local tissue is compromised or when skin, fascia and muscle also need restoration.
- Maintain drainage and verify healing as appropriate. Catheter duration and imaging should reflect repair complexity, tissue quality and the original cause.
Partial cystectomy and tract excision were successful in Kosaka's single delayed post-traumatic case; this does not make wedge resection obligatory for every irradiated defect or an adequate oncologic operation for every malignant fistula.[2]
Tissue coverage
| Reconstructive problem | Reported option and evidence limit |
|---|---|
| Accessible pelvic defect with suitable omentum | Omental interposition supported a successful radiation-related repair in Lau's case; it is one option, not a mandatory minimum for all VCF.[11] |
| Large combined bladder and abdominal-wall deficit | Bockrath's two traumatic cases required restoration of deficient overlying tissue after prior simple closures had failed; this experience does not mean every small VCF needs a muscle flap.[9] |
| Extensive wound requiring regional coverage | Rectus femoris musculocutaneous transfer with wound therapy has been reported in a complex case.[5] |
| Major radiation-related bladder and abdominal-wall loss | A bipedicled latissimus dorsi/serratus anterior free flap reconstructed both components in one report, with no recurrence at four months; long-term or comparative efficacy is unknown.[8] |
Regional and free-flap selection should be based on the dimensions, tissue requirements, donor options and vascular supply, with reconstructive input where appropriate.
Special Situations
Radiation-associated fistula
Radiation can compromise healing, but repairability depends on the actual tissue and bladder function. In Lau's case, a patient with a reasonable-capacity bladder, no evident recurrent tumor and a strong preference against a stoma underwent debridement, bladder closure and omental coverage, with short-term healing. Extensive defects may instead require complex coverage or diversion.[11][8]
A dependable VCF-specific failure estimate is unavailable from these small reports; counsel about tissue quality and reconstructive options without assigning a universal radiation-associated failure rate.
Neurogenic lower urinary tract dysfunction
Raup studied 21 patients with neurogenic bladder and urinary-cutaneous fistulas, a broader population than bladder-to-skin fistula alone. Thirteen underwent repair, nine of whom subsequently required diversion; eight had diversion initially. Overall, 17/21 ultimately required a surgical or suprapubic drainage/diversion strategy. This demonstrates the difficulty of a selected complex cohort, not an 81% diversion requirement for every neurogenic VCF.[12]
Assess pressure, emptying, outlet damage, skin/wound burden, renal safety and the patient's ability to manage the proposed system. Local closure, reconstruction, long-term drainage and diversion require individualized consideration.
Malignancy and systemic therapy
Assess active cancer, prior treatment and the aims of care before reconstructing a malignant or treatment-associated fistula. Watanabe reported closure after sunitinib withdrawal in one patient with an unresectable gastrointestinal stromal tumor invading the bladder. The association warrants review with oncology; it is neither proof that stopping the drug will close other fistulas nor an instruction to interrupt cancer treatment independently.[4]
Counseling and Follow-up
Counsel using the patient's etiology and reconstructive problem. Published case successes and mixed urinary-cutaneous cohorts do not provide a reliable pooled VCF closure rate. Follow-up should assess recurrent leakage, infection, wound integrity, bladder drainage/function and the burden of any diversion. Persistent leakage should prompt reassessment of anatomy and the underlying cause before repeating the same local closure.
References
1. Elizondo RA, Au JK, Gargollo PC, Tu DT. "Vacuum-Assisted Closure of a Vesicocutaneous Fistula in a Pediatric Patient After Bladder Cystoplasty." Urology. 2016;95:190–191. doi:10.1016/j.urology.2016.04.001
2. Kosaka T, Asano T, Azuma R, et al. "A Case of Vesicocutaneous Fistula to the Thigh." Urology. 2009;73(4):929.e7–8. doi:10.1016/j.urology.2008.04.063
3. Johnsen N, Wessells H, Archer-Arroyo K, et al. "Best Practices Guidelines: Management of Genitourinary Injuries." American College of Surgeons. 2025. Official guideline.
4. Watanabe K, Otsu S, Morinaga R, et al. "Vesicocutaneous Fistula Formation During Treatment With Sunitinib Malate: Case Report." BMC Gastroenterol. 2010;10:128. doi:10.1186/1471-230X-10-128
5. Katsuragi Y, Ueda K, Kajikawa A, Tateshita T, Okochi H. "Repair of a Huge Vesicocutaneous Fistula With the Rectus Femoris Musculocutaneous Flap and VAC." J Wound Care. 2010;19(4):157–159. doi:10.12968/jowc.2010.19.4.157
6. McKay HA. "Vesicovaginal and Vesicocutaneous Fistulas: Transurethral Suture Cystorrhaphy as a New Closure Technique." J Urol. 1997;158(4):1513–1516. doi:10.1016/s0022-5347(01)64256-3
7. Vaidyanathan S, Hughes PL, Soni BM. "Unusual Complication of Suprapubic Cystostomy in a Male Patient With Tetraplegia." ScientificWorldJournal. 2007;7:1575–1578. doi:10.1100/tsw.2007.253
8. Ludolph I, Apel H, Horch RE, Beier JP. "Treatment of a Chronic Vesicocutaneous Fistula and Abdominal Wall Defect After Resection of a Soft Tissue Sarcoma Using a Bipedicled Latissimus Dorsi and Serratus Anterior Free Flap." Int J Urol. 2014;21(11):1178–1180. doi:10.1111/iju.12545
9. Bockrath JM, Nanninga JB, Lewis VL, Grayhack JT. "Extensive Suprapubic Vesicocutaneous Fistula Following Trauma." J Urol. 1981;125(2):246–248. doi:10.1016/s0022-5347(17)54989-7
10. Banihani MN, Al-Azab RS, Waqfi NR, Kharashgah MN, Al Manasra AR. "Vesicocutaneous Fistula Presenting as a Thigh Abscess." Singapore Med J. 2009;50(9):e336–e337. Full report.
11. Lau KO, Cheng C. "A Case Report — Delayed Vesicocutaneous Fistula After Radiation Therapy for Advanced Vulvar Cancer." Ann Acad Med Singap. 1998;27(5):705–706. Full report.
12. Raup VT, Eswara JR, Weese JR, Potretzke AM, Brandes SB. "Urinary-Cutaneous Fistulae in Patients With Neurogenic Bladder." Urology. 2015;86(6):1222–1226. doi:10.1016/j.urology.2015.07.057