Surgical management of acquired complex urinary fistula: a single-center retrospective analysis

Purpose Acquired urinary fistula is a rare complication. Scientific evidence supporting the right technique of fistula repair is lacking. To predict treatment failure, the aim of this study is to document our experience in management of acquired complex fistula, reporting surgical success of different strategies in relation to fistula type, previous radiotherapy, sex, and patient comorbidities. Methods A retrospective review of all fistula treatments at the University Hospital of Cologne, Germany was performed. Causal interventions and comorbidities were recorded. Only outcomes of complex fistulas, as defined by WHO criteria, were included. Primary outcome was fistula-closure per intervention strategy and fistula type. Secondary outcome was to identify patient characteristics leading to therapy failure and the need for permanent urinary diversion. Results Between November 2014 and February 2021, 45 patients were treated. Patients with vesicosymphyseal (35.6%), vesicovaginal (28.9%), rectovesical (22.2%) and ureterovaginal fistula (13.3%) were observed. A cumulative fistula closure rate of 67.7% was achieved. Conservative management, surgery with primary closure and tissue interposition was successful in 28.6%, 83.3% and 64%. Patients previously treated with radiotherapy scored significantly worse (p=0.013). 12 patients eventually needed permanent urinary diversion. Differences measured in type of interposing tissue, sex and medical comorbidities were not significant. Conclusion Definitive surgical repair is mandatory in most complex urinary fistulas. Treatment should be individualized and tailored to the underlying disease, tissue quality and patients’ comorbidities. Oncological status, previous radiation and previous reconstructive surgery should be critically regarded to determine if permanent urinary diversion is required. A treatment algorithm is proposed. Keywords Urinary - rectourinary – genitourinary - vesicovaginal – ureterovaginal – vesicosymphyseal fistula