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Vesicocutaneous Fistula Repair

This is the surgical-technique atlas for vesicocutaneous fistula (VCF). For definitions, classification by cutaneous opening (suprapubic, inguinoscrotal, perineal, thigh), etiology (pelvic-fracture extraperitoneal bladder rupture, iatrogenic, suprapubic-catheter complications, inguinoscrotal hernia, radiation, neurogenic bladder, malignancy), pathogenesis (the four-factor non-closure framework plus radiation-induced ischemia), clinical presentation, and diagnostic evaluation (indigo carmine, CT cystography, fistulography, cystoscopy), see the clinical-conditions page: Vesicocutaneous Fistula. This page focuses on the stepwise repair framework, surgical repair options, and outcomes.

Stepwise Repair Framework​

VCF management is staged in three sequential phases. Most patients pass through Stage 1 (decompression / sepsis control); a subset closes without operation; the rest progress to Stage 2 (minimally invasive bridge or definitive endoscopic closure) and/or Stage 3 (open fistulectomy with multilayer closure and tissue interposition).[1][2][3]

StageGoalModalities
1. Conservative / temporizingSepsis control, urinary diversion, wound preparationLarge-bore (≥ 18 Fr) urethral Foley ± percutaneous nephrostomy, broad-spectrum antibiotics, abscess drainage, nutrition
2. Bridge / minimally invasivePromote spontaneous closure or downsize before definitive repairVAC (negative-pressure wound therapy), transurethral suture cystorrhaphy
3. Definitive surgical repairEradicate the tract and restore bladder integrityFistulectomy + multilayer bladder closure ± partial cystectomy ± tissue interposition (omental, muscle, free flap)

Stage 1 — Conservative Catheter Drainage​

Appropriate for small, uncomplicated fistulae without distal obstruction, foreign body, intracavitary calculus, or malignancy. Continuous bladder decompression diverts urine from the tract and allows epithelialization to reverse.[4]

  • Large-bore (≥ 18 Fr) urethral Foley for a minimum of 7 days, with cystography to confirm healing before removal
  • Addition of percutaneous nephrostomy or ureteric stenting if bladder drainage alone is insufficient
  • Topical wound care with stoma adhesive / barrier paste to prevent skin maceration
  • Treatment of any underlying driver (foreign body, distal obstruction, infection, anti-angiogenic therapy)

Spontaneous closure is achievable when the bladder is fully decompressed and the tract is not epithelialized — a sunitinib-related VCF closed simply with discontinuation of the anti-angiogenic agent.[5]

Stage 2 — VAC and Minimally Invasive Closure​

Vacuum-assisted closure (VAC)​

VAC (negative-pressure wound therapy) controls urine exposure, removes excess fluid, reduces edema, promotes granulation tissue, and approximates wound edges. It has been used in two complementary roles:[1][6]

  • Definitive therapy — a pediatric VCF after augmentation cystoplasty closed with VAC alone without further surgery[1]
  • Preoperative bridge — VAC downsizes the wound and improves tissue quality before definitive flap reconstruction of large complex defects[6]

Bladder must remain continuously decompressed (urethral or suprapubic catheter) while VAC is in place. Dressing changes every 48–72 h; surrounding skin protected with hydrocolloid barrier.

Transurethral (endoscopic) suture cystorrhaphy​

Cystoscopically assisted closure of the intravesical opening with intracorporeal suturing has been reported as a minimally invasive alternative in selected vesicovaginal and vesicocutaneous fistulae, avoiding open surgery.[7] Best suited to small, fresh, non-irradiated tracts with healthy surrounding mucosa.

Percutaneous catheter management​

For VCF arising around a malpositioned or extruded suprapubic catheter, exchange to a properly anchored small-caliber suprapubic tube with simultaneous urethral Foley drainage can allow the parastomal tract to contract and close.[8]

Stage 3 — Definitive Surgical Repair​

Required for complex, chronic, or refractory VCF and for any fistula with distal obstruction, epithelialized tract, foreign body, malignancy, or radiation injury.[2][9]

Fistulectomy with multilayer bladder closure​

  1. Tract excision — circumferential excision of the cutaneous opening and the entire fibrotic tract down to the bladder wall; submit specimen for histology to exclude malignancy
  2. Bladder mobilization — develop perivesical planes to allow tension-free closure
  3. Partial cystectomy — when the bladder wall around the fistula is extensively damaged, irradiated, or carcinomatous, excise involved bladder wall as a wedge[2]
  4. Multilayer closure — two-layer absorbable closure: full-thickness inner layer (running 3-0 absorbable) and seromuscular imbricating outer layer (interrupted 3-0 absorbable), with watertight test
  5. Catheter drainage — large-bore urethral Foley ± suprapubic tube for 10–14 days; cystogram before removal

Tissue interposition​

The central principle for complex or recurrent VCF. Local tissue around a chronic VCF is fibrotic, ischemic, and unsuitable for primary healing; vascularized non-irradiated tissue must be brought in to separate the bladder closure from the skin closure.[2][6][10]

FlapBest for / indication
Omental flapFirst-line for most abdominopelvic VCF; pedicled on right or left gastroepiploic
Rectus abdominis (VRAM / pedicled)Large suprapubic / lower-abdominal defects with skin and fascial loss
Rectus femoris musculocutaneousThigh / inguinal VCF; described for a huge VCF combined with VAC[6]
GracilisPerineal and inguinoscrotal VCF; thin pliable workhorse
Perivesical fat / peritoneal flapSmall suprapubic defects with adequate adjacent tissue
Free tissue transfer (latissimus dorsi + serratus anterior bipedicled)Extensive radiation-induced VCF with combined bladder and abdominal-wall defect; reconstructed both layers with no recurrence at 4 months in the Ludolph case[10]

Layered closure with overlying tissue coverage for extensive trauma​

For extensive suprapubic post-traumatic VCF with loss of skin, fascia, and muscle, simple bladder closure alone fails — successful repair requires muscle and fascial flap coverage to reconstruct each layer of the abdominal wall over the closed bladder, as demonstrated in the Bockrath series.[11]

Special Considerations​

Pelvic-fracture extraperitoneal bladder rupture​

Extraperitoneal rupture occurs in 60–90% of pelvic fractures with bladder injury; complex extraperitoneal injuries can drive urine extravasation along tissue planes to skin, with delayed VCF presentation up to 7 years post-injury and up to 2 years when presenting as a thigh abscess.[12][13] Once a tract is established, spontaneous closure is rare and most patients require fistulectomy with interposition.

Radiation-induced VCF​

The most challenging subset because local irradiated tissue cannot support healing:[14][10][15]

  • Conservative treatment is generally ineffective for established radiation-induced fistulae
  • Non-irradiated, well-vascularized interposition tissue is mandatory — omental flap as a minimum; free-flap reconstruction may be necessary
  • Permanent urinary diversion (ileal conduit or continent diversion) is often the most practical option when tissue quality is poor or life expectancy limited
  • Prior radiotherapy is a strong predictor of surgical failure — 75% failure in irradiated patients vs. 10.8% in non-irradiated patients (p = 0.012) in a 14-year urogenital-fistula series[15]

Neurogenic-bladder VCF​

The chronic high-pressure state must be addressed before or concurrent with fistula repair. In the Raup series of 21 patients with neurogenic-bladder urinary-cutaneous fistulae:[16]

  • 13 underwent surgical repair, but 9 of 13 (69%) ultimately required permanent urinary diversion despite repair
  • 8 underwent primary urinary diversion at presentation
  • 81% (17/21) required permanent urinary diversion overall — suprapubic tube (53%), ileal conduit (23%), condom catheter (18%), or perineal urethrostomy (6%)

In this population, primary urinary diversion ± bladder reconstruction (augmentation, bladder neck closure) is often a more durable answer than fistulectomy alone.

Malignancy-associated VCF​

Bladder, colorectal, or other pelvic tumors with direct invasion require oncologic management as the primary intervention; reconstructive repair is generally deferred until disease control is achieved. The sunitinib-associated VCF that closed on drug withdrawal is a reminder to interrogate anti-angiogenic exposure in any patient with new fistula formation on systemic therapy.[5]

Outcomes​

  • Post-traumatic VCF — outcomes scale with extent of tissue loss; simple defects close with layered repair and overlying tissue coverage, while extensive defects may require staged reconstruction.[11]
  • Post-surgical VCF — generally favorable when diagnosed early and managed with diversion ± VAC; spontaneous closure achievable with adequate decompression.[1]
  • Radiation-induced VCF — worst prognosis among etiologies; 75% surgical failure in irradiated tissue, with permanent diversion often required.[14][10][15]
  • Neurogenic-bladder VCF — 81% require permanent diversion despite repair attempts.[16]
  • Overall specialist-series outcomes — primary success ~80.6%, definitive closure ~92.5%; predictors of failure include prior RT, oncologic etiology, and prolonged delay to repair (12 vs. 6 months, p = 0.027).[15]

Key Takeaways​

  • VCF management follows a three-stage framework — decompression, minimally invasive bridge or definitive endoscopic closure, then open repair
  • Small, fresh, non-epithelialized tracts can close with catheter drainage alone or VAC; an epithelialized tract requires fistulectomy
  • Tissue interposition is the central principle of definitive repair — omental flap is first-line; muscle and free flaps for complex / radiation / large defects
  • Radiation and neurogenic-bladder VCF carry the worst surgical prognoses; permanent urinary diversion is frequently the most durable answer
  • Always investigate for distal obstruction, foreign body, calculus, malignancy, and anti-angiogenic drug exposure as drivers that must be addressed for any repair to succeed

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. Shackley DC, Brew CJ, Bryden AA, et al. "The Staged Management of Complex Entero-Urinary Fistulae." BJU Int. 2000;86(6):624–629. doi:10.1046/j.1464-410x.2000.00871.x

4. Johnsen N, Wessells H, Archer-Arroyo K, et al. "Best Practices Guidelines: Management of Genitourinary Injuries." American College of Surgeons. 2025.

5. 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

6. 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

7. 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

8. 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

9. Gill HS. "Diagnosis and Surgical Management of Uroenteric Fistula." Surg Clin North Am. 2016;96(3):583–592. doi:10.1016/j.suc.2016.02.012

10. 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

11. 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

12. 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.

13. Coccolini F, Moore EE, Kluger Y, et al. "Kidney and Uro-Trauma: WSES-AAST Guidelines." World J Emerg Surg. 2019;14:54. doi:10.1186/s13017-019-0274-x

14. 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.

15. 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

16. 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