Urology

Fistula between the vagina and the bladder

What does this procedure entail?

The surgery consists in closing the abnormal communication (associated with urine leakage) between the vagina and the bladder.

What are the alternatives to this procedure?

• Urinary drainage through bladder catheter / nephrostomy
• Urine excretion via a part of the small intestine (ileal conduit)
• Follow-up

What should I expect before this procedure?

If you regularly use Anopyrin, Clopidogrel, Warfarin, etc., you must tell your doctor. These medications can be associated with increased risk of bleeding during and after the surgery if they are not stopped in time. In some cases, it is necessary to replace these drugs with injection preparations. It is necessary to consult your general practitioner or cardiologist about this approach.

At the request of the referring physician, you will have to schedule preoperative examinations to assess your overall condition, including laboratory and instrumental tests. If the report does not preclude the indicated procedure, you will be admitted to the hospital. If you don’t undergo a preoperative examination or it is incomplete, you will not be able to have the surgery as scheduled. You will be admitted by a nurse and a member of the medical team will complete your examination and assess your fitness for the surgery.

You will be asked not to eat or drink for at least 6 hours before the surgery!

In the evening before the surgery, you will receive medication from an anaesthesiologist to calm you down so that you sleep well.

Remember to inform your physician about the following possible facts before the surgery:

• artificial heart valve
• coronary artery stent
• pacemaker
• artificial joint
• artificial vascular graft
• neurosurgical bypass
• other implanted foreign body
• use of the following prescription drugs: Acylpyrin, Anopyrin, Aspirin, Godasal, Clopidogrel, Plavix, Kardegic, Aspegic, Micristin, Ibustrin,Ticlid, Tagren, Ipaton  Apo-Tic, Plavix, Persantin, Curantyl, Anturan, Aggrenox, Vessel due F.
• drug and other allergies
• any abnormalities or eventualities

It is NECESSARY to inform the physician about your use of drugs affecting blood clotting before your admission for the procedure.

What will happen during the surgery?

You will normally receive an injection or oral antibiotics before the procedure, but any allergies must be checked first.

The procedure is performed exclusively under general anaesthesia. Cystoscopy is performed before the procedure itself – examination of the urethra and bladder using a telescopic instrument to locate the fistula.

The fistula can be closed from the vaginal approach, but access through the abdominal wall is more frequent and usually more advantageous. An incision in the lower abdomen is performed. The fistula is removed after opening the bladder. The bladder and the vaginal wall are then separated and closed separately. Sometimes, a stretched abdominal omentum is inserted between these 2 layers. A catheter and/or epicystostomy is inserted into the bladder before the end of the urine drainage procedure, and a tubular drain is inserted into the bladder wound. The whole surgery usually takes 60-90 minutes.

 What will happen immediately after the procedure?

You will wake up at the intensive care unit equipped for the continued monitoring of patients immediately after the procedure. The surgeon will inform you about the course of the procedure. You will still have high levels of anaesthetics in your blood at that time, so you may not remember this conversation.

Patients usually have an infusion access point into a vein in their arm; if necessary, a monitoring/infusion port (a tube inserted into the vein to monitor blood pressure or administer drugs and nutrition) will be inserted into a vein (jugular vein) in the superclavicular region (the area between the collarbone and neck).

Nutrition is provided in an intravenous manner shortly after the surgery. You will receive a liquid and mushy diet for the next 2 to 3 days. This procedure is necessary for the proper restoration of gastrointestinal function. Non-compliance of the patient is usually associated with severe abdominal pain, vomiting with the risk of suffocation and may require surgical revision (further surgery in case of complications).

Physical rehabilitation is very important to prevent complications in the postoperative period. You will first exercise on the bed. As soon as your medical condition allows, you will be allowed to sit down and then stand up. After that, you will be able to walk slowly and carefully around the room, initially accompanied by medical staff. Pay close attention to eventual dizziness, uncontrollable weakness, and to gait stability. Otherwise immediately inform medical personnel or anyone in the vicinity.

 Once you are fully conscious, you should:

• ask if the planned outcome was achieved
• inform the medical staff about any problems
• ask what you can and cannot do
• ask all the questions you have for the healthcare professionals and members of the medical team.
• remember (and understand) why the surgery was performed, how it turned out, and what will follow

The catheter/epicystostomy is usually left in place for 7 days, but this period can be prolonged to up to 3 week. The wound drain is removed about 3-5 days after the surgery, sutures from the wound before discharge from the hospital, i.e., day 9-10. The average hospitalisation is 10 days.

What are the postoperative risks or complications?

Common (10% of procedures of this type)

• Infection or hernia in the wound requiring further therapy
• Abnormal bladder function for a short time, but sometimes with a longer duration

Occasional (2-10% of procedures of this type)

• Anaesthesiology-related or cardiovascular problems requiring treatment in the intensive care unit (including lung infection, pulmonary embolism, stroke, deep vein thrombosis, myocardial infarction and death)
• Blood loss requiring blood transfusion or repeated surgical revision
• Surgery failure, with vaginal urinary leakage requiring a repeated procedure

Rare (2% of procedures of this type)

• Not known

Hospital infections

• MRSA colonisation (0.9% – 1 of 110)
• Intestinal infection by clostridium difficile (0.01% – 1 of 10,000)
• MRSA blood infection (0.02% – 1 of 5,000)

Hospital infection rates may be higher in high-risk patients, such as in cases requiring long-term drainage, after a previous infection, after prolonged hospitalisation or after multiple hospitalisations.

What should I expect when I return home?

When you are discharged from the hospital, you should:

• get recommendations on recovery at home
• ask when you can return to normal activities such as work, exercise, driving, cycling, housework
• get a contact number for further questions after returning home or in case of trouble
• ask about the date of the following check-ups and the place where you should come (hospital or your attending physician)
• make sure you are aware of the reason, course and outcome of the surgery, the results of examinations or the removal of tissues or organs.

At your departure from the hospital (sometimes several days later), you will receive a hospitalisation report. The document contains important information about your hospital stay, your surgery and recommended follow-up. If you need to call your attending physician or visit the hospital for any reason, take this document with you so that the physician knows the details of your treatment. This is especially important if you need to consult another doctor or longer after discharge.

You may need to take pain medication for 2-3 weeks, and it may take 2-3 weeks for you to reach sufficient mobility.

You may be discharged with 1 or two catheters in your bladder, and you will be re-admitted to the hospital to have them removed. In this case, you will be instructed about the care for the catheters and drainage system.

You should not drive for at least 6 weeks (or even longer).

If you work, you will need at least 6 weeks off. This period can be significantly longer if you have a physically strenuous occupation. Lifting of heavy objects is prohibited for 3 months.

Sexual intercourse is prohibited for 6 weeks.

You can have blood in the urine or vaginal discharge for up to a month after the surgery.

What else should I watch out for?

If you are leaving the hospital with a catheter, you should regularly check for urine drainage. If the catheter is occluded, it can exert pressure on the fistula closure, and it is therefore necessary to have the catheter reopened very quickly

If you leave the hospital without catheters, it is necessary to urinate more often for about 6 weeks (even possibly waking up at night) to avoid overfilling it and the associated excessive pressure on the fistula closure.

Any important information?

A postoperative follow-up visit is usually planned about 6 weeks after the surgery – in case of ambiguity or difficulties, do not hesitate to contact your doctor/urologist.

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