DOI: 10.1148/rg.24si045508
Fistulas of the Lower Urinary Tract: Percutaneous Approaches for the Management of a Difficult Clinical Entity1
Rony Avritscher, MD,
David C. Madoff, MD,
Pedro T. Ramirez, MD,
Michael J. Wallace, MD,
Kamran Ahrar, MD,
Frank A. Morello, Jr, MD,
Sanjay Gupta, MD,
Ravi Murthy, MD,
Kenneth C. Wright, PhD and
Marshall E. Hicks, MD
1 From the Division of Diagnostic Imaging, Interventional Radiology Section (R.A., D.C.M., M.J.W., K.A., F.A.M., S.G., R.M., K.C.W., M.E.H.), and the Department of Gynecologic Oncology (P.T.R.), University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 325, Houston, TX 77030-4009. Recipient of a Cum Laude award for an education exhibit at the 2003 RSNA scientific assembly. Received February 13, 2004; revision requested April 2 and received May 11; accepted May 19. K.C.W. has a royalty agreement with Cook; all other authors have no financial relationships to disclose. Address correspondence to D.C.M. (e-mail: dmadoff@di.mdacc.tmc.edu).
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Figure 1. Drawing illustrates a lateral view of a vesicovaginal fistula resulting from surgery. The fistula is located on the posterior wall of the bladder in the interureteric ridge.
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Figure 2. Drawing illustrates a left ureterovaginal fistula.
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Figure 3a. (a) Drawing illustrates a colovesical fistula. (b) Colovaginal fistula in a 51-year-old woman with ovarian carcinoma. The patient developed peritoneal carcinomatosis with extrinsic compression of the sigmoid colon, resulting in complete obstruction, which ultimately led to a contained rupture and development of a sigmoid-vaginal fistula. Lateral radiograph of the pelvis obtained after rectal instillation of iodinated contrast material demonstrates a fistulous communication (arrows) between the sigmoid colon (c) and vagina (v, arrowheads). Note that the bladder (BL) is filled with contrast material from previously performed cystography.
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Figure 3b. (a) Drawing illustrates a colovesical fistula. (b) Colovaginal fistula in a 51-year-old woman with ovarian carcinoma. The patient developed peritoneal carcinomatosis with extrinsic compression of the sigmoid colon, resulting in complete obstruction, which ultimately led to a contained rupture and development of a sigmoid-vaginal fistula. Lateral radiograph of the pelvis obtained after rectal instillation of iodinated contrast material demonstrates a fistulous communication (arrows) between the sigmoid colon (c) and vagina (v, arrowheads). Note that the bladder (BL) is filled with contrast material from previously performed cystography.
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Figure 4a. Rectourethral fistula that developed after radical pelvic resection in a 60-year-old man with prostate carcinoma. (a) Lateral radiograph of the pelvis obtained after an iodinated contrast material enema reveals a fistulous tract (black arrows) between the rectum and surgical bed with direct communication with the urethra (U). White arrow indicates applicator used for enema. (b) Computed tomographic (CT) scan of the pelvis shows a collection of gas and contrast material (arrows) anterior to the rectum, a finding that is indicative of the communication between the rectum and surgical bed. (c) CT scan of the pelvis obtained at a lower level than b reveals a flow of contrast material into the posterior urethra (arrow).
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Figure 4b. Rectourethral fistula that developed after radical pelvic resection in a 60-year-old man with prostate carcinoma. (a) Lateral radiograph of the pelvis obtained after an iodinated contrast material enema reveals a fistulous tract (black arrows) between the rectum and surgical bed with direct communication with the urethra (U). White arrow indicates applicator used for enema. (b) Computed tomographic (CT) scan of the pelvis shows a collection of gas and contrast material (arrows) anterior to the rectum, a finding that is indicative of the communication between the rectum and surgical bed. (c) CT scan of the pelvis obtained at a lower level than b reveals a flow of contrast material into the posterior urethra (arrow).
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Figure 4c. Rectourethral fistula that developed after radical pelvic resection in a 60-year-old man with prostate carcinoma. (a) Lateral radiograph of the pelvis obtained after an iodinated contrast material enema reveals a fistulous tract (black arrows) between the rectum and surgical bed with direct communication with the urethra (U). White arrow indicates applicator used for enema. (b) Computed tomographic (CT) scan of the pelvis shows a collection of gas and contrast material (arrows) anterior to the rectum, a finding that is indicative of the communication between the rectum and surgical bed. (c) CT scan of the pelvis obtained at a lower level than b reveals a flow of contrast material into the posterior urethra (arrow).
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Figure 5. Drawing illustrates the normal anatomic relationship between the bladder, uterus, and ureters in the female pelvis.
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Figure 6. Drawing illustrates the normal arterial blood supply to the ureter. The arterial supply to the upper part of the ureter approaches from a medial direction, and the arterial branches within the pelvis approach the ureter from a lateral direction.
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Figure 7. Drawing illustrates the location of a standard external radiation port in patients with cervical cancer (black octagon). Note that the bladder, uterus, ureters, and rectosigmoid colon are included within the radiation port.
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Figure 8a. Ureterovaginal fistula in a 44-year-old woman with recurrent intermediate trophoblastic tumor and continuous urine leakage from the vagina. Lateral (a) and anteroposterior (b) pyelograms demonstrate a curvilinear collection of contrast material (black arrows) that extends from the distal right ureter to the vagina (arrowheads in a), a finding that is compatible with a ureterovaginal fistula. White arrows in a indicate the position of the left ureter.
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Figure 8b. Ureterovaginal fistula in a 44-year-old woman with recurrent intermediate trophoblastic tumor and continuous urine leakage from the vagina. Lateral (a) and anteroposterior (b) pyelograms demonstrate a curvilinear collection of contrast material (black arrows) that extends from the distal right ureter to the vagina (arrowheads in a), a finding that is compatible with a ureterovaginal fistula. White arrows in a indicate the position of the left ureter.
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Figure 9. Schematic illustrates an algorithm for establishing the diagnosis of genitourinary fistulas in women. EU = excretory urography.
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Figure 10a. Ureteroenteric fistula in a 69-year-old woman with vaginal cancer who developed right hydronephrosis after extensive pelvic surgery and was treated with nephroureteral stent placement. (a) Intravenous urogram shows contrast material within loops of small bowel (arrows), a finding that indicates a ureteroenteric fistula. However, the actual communication is not visualized. (b) Axial CT scan obtained after the oral administration of contrast material shows air and contrast material around the ureteral stent (arrow), a finding that is consistent with ureteroenteric fistula. (c) Antegrade ureterogram shows a ureteroenteric fistula (arrow) at the junction of the mid- to distal ureter.
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Figure 10b. Ureteroenteric fistula in a 69-year-old woman with vaginal cancer who developed right hydronephrosis after extensive pelvic surgery and was treated with nephroureteral stent placement. (a) Intravenous urogram shows contrast material within loops of small bowel (arrows), a finding that indicates a ureteroenteric fistula. However, the actual communication is not visualized. (b) Axial CT scan obtained after the oral administration of contrast material shows air and contrast material around the ureteral stent (arrow), a finding that is consistent with ureteroenteric fistula. (c) Antegrade ureterogram shows a ureteroenteric fistula (arrow) at the junction of the mid- to distal ureter.
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Figure 10c. Ureteroenteric fistula in a 69-year-old woman with vaginal cancer who developed right hydronephrosis after extensive pelvic surgery and was treated with nephroureteral stent placement. (a) Intravenous urogram shows contrast material within loops of small bowel (arrows), a finding that indicates a ureteroenteric fistula. However, the actual communication is not visualized. (b) Axial CT scan obtained after the oral administration of contrast material shows air and contrast material around the ureteral stent (arrow), a finding that is consistent with ureteroenteric fistula. (c) Antegrade ureterogram shows a ureteroenteric fistula (arrow) at the junction of the mid- to distal ureter.
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Figure 11a. Fistulas in a 79-year-old woman with cervical carcinoma who had undergone surgery and pelvic irradiation, which caused a fistulous communication to develop between the bladder, vagina, and colon. (a) CT scan of the pelvis shows contrast material within the vagina (arrows). (b, c) Left anterior oblique (b) and lateral (c) cystograms show contrast material within the bladder (BL in b). A communication between the vagina (V) and colon (C) (white arrow) and a vesicovaginal fistula (black arrows in c) are visualized. The patient was successfully treated with bilateral ureteral occlusion with coils and gelatin sponge.
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Figure 11b. Fistulas in a 79-year-old woman with cervical carcinoma who had undergone surgery and pelvic irradiation, which caused a fistulous communication to develop between the bladder, vagina, and colon. (a) CT scan of the pelvis shows contrast material within the vagina (arrows). (b, c) Left anterior oblique (b) and lateral (c) cystograms show contrast material within the bladder (BL in b). A communication between the vagina (V) and colon (C) (white arrow) and a vesicovaginal fistula (black arrows in c) are visualized. The patient was successfully treated with bilateral ureteral occlusion with coils and gelatin sponge.
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Figure 11c. Fistulas in a 79-year-old woman with cervical carcinoma who had undergone surgery and pelvic irradiation, which caused a fistulous communication to develop between the bladder, vagina, and colon. (a) CT scan of the pelvis shows contrast material within the vagina (arrows). (b, c) Left anterior oblique (b) and lateral (c) cystograms show contrast material within the bladder (BL in b). A communication between the vagina (V) and colon (C) (white arrow) and a vesicovaginal fistula (black arrows in c) are visualized. The patient was successfully treated with bilateral ureteral occlusion with coils and gelatin sponge.
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Figure 12a. Drawings illustrate the surgical excision of a vesicovaginal fistula (a) with multilayered closure achieved with extramucosal sutures that approximate the vesical mucosa (b) and a transverse vaginal approach (c).
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Figure 12b. Drawings illustrate the surgical excision of a vesicovaginal fistula (a) with multilayered closure achieved with extramucosal sutures that approximate the vesical mucosa (b) and a transverse vaginal approach (c).
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Figure 12c. Drawings illustrate the surgical excision of a vesicovaginal fistula (a) with multilayered closure achieved with extramucosal sutures that approximate the vesical mucosa (b) and a transverse vaginal approach (c).
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Figure 13a. Drawings illustrate a Martius labial fat pad graft. (a) The fat pad graft is mobilized by incising the labia majora. Care is taken to preserve the blood supply entering posteriorly. (b) The graft is rotated through the labial tunnel into the vaginal vault, covering the fistulous tract.
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Figure 13b. Drawings illustrate a Martius labial fat pad graft. (a) The fat pad graft is mobilized by incising the labia majora. Care is taken to preserve the blood supply entering posteriorly. (b) The graft is rotated through the labial tunnel into the vaginal vault, covering the fistulous tract.
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Figure 14. Schematic illustrates an algorithm for treating patients with ureteral fistulas. EU = excretory urography.
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Figure 15. Drawings illustrate ureteral occlusion achieved by administering isobutyl-2-cyanoacrylate in the distal ureter. Arrow indicates the site of the ureteral fistula.
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Figure 16a. Drawings illustrate ureteral occlusion achieved with detachable (a) and nondetachable (b) balloons. Arrow indicates the site of the ureteral fistula.
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Figure 16b. Drawings illustrate ureteral occlusion achieved with detachable (a) and nondetachable (b) balloons. Arrow indicates the site of the ureteral fistula.
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Figure 17. Drawings illustrate ureteral occlusion achieved by placing a nylon plug in the distal ureter. Arrow indicates the site of the ureteral fistula.
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Figure 18. Drawings illustrate ureteral occlusion achieved by applying the fulguration technique to the ureter. Arrow indicates the site of the ureteral fistula.
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Figure 19a. (a) Drawings illustrate ureteral occlusion achieved by placing coils and a gelatin sponge in the proximal ureter. Arrow indicates the site of the ureteral fistula. (b, c) Anteroposterior spot images obtained during an occlusion procedure show a single coil (arrow in b) placed within the distal ureter and additional coils and a gelatin sponge intertwined along the ureter for complete occlusion (c).
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Figure 19b. (a) Drawings illustrate ureteral occlusion achieved by placing coils and a gelatin sponge in the proximal ureter. Arrow indicates the site of the ureteral fistula. (b, c) Anteroposterior spot images obtained during an occlusion procedure show a single coil (arrow in b) placed within the distal ureter and additional coils and a gelatin sponge intertwined along the ureter for complete occlusion (c).
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Figure 19c. (a) Drawings illustrate ureteral occlusion achieved by placing coils and a gelatin sponge in the proximal ureter. Arrow indicates the site of the ureteral fistula. (b, c) Anteroposterior spot images obtained during an occlusion procedure show a single coil (arrow in b) placed within the distal ureter and additional coils and a gelatin sponge intertwined along the ureter for complete occlusion (c).
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Figure 20a. Coil migration. (a) Ureterogram shows numerous coils along the length of the ureter (arrow). (b) Follow-up antegrade nephrostogram demonstrates that several coils have migrated into the renal pelvis (arrow). (Case courtesy of Thomas A. Farrell, MB, Washington University, St Louis, Mo; Fig 20 reprinted, with permission, from reference 11.)
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Figure 20b. Coil migration. (a) Ureterogram shows numerous coils along the length of the ureter (arrow). (b) Follow-up antegrade nephrostogram demonstrates that several coils have migrated into the renal pelvis (arrow). (Case courtesy of Thomas A. Farrell, MB, Washington University, St Louis, Mo; Fig 20 reprinted, with permission, from reference 11.)
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Figure 21a. Vesicovaginal fistula in a 33-year-old woman with cervical carcinoma who had undergone radiation therapy. (a) Anteroposterior spot image shows successful occlusion with bilateral coils and a gelatin sponge. The patient had persistent urine leakage from the vagina, so an ileal conduit was created. (b) Anteroposterior image shows a ureteroenteric anastomotic stricture, which necessitated percutaneous urinary diversion.
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Figure 21b. Vesicovaginal fistula in a 33-year-old woman with cervical carcinoma who had undergone radiation therapy. (a) Anteroposterior spot image shows successful occlusion with bilateral coils and a gelatin sponge. The patient had persistent urine leakage from the vagina, so an ileal conduit was created. (b) Anteroposterior image shows a ureteroenteric anastomotic stricture, which necessitated percutaneous urinary diversion.
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Figure 22a. Ureteral occlusion achieved with a bare metallic stent in a pig model. (a) Photograph shows a double-body Gianturco-Rosch biliary stent before (left) and after (right) modification. (b) Lateral urogram obtained 1 week after stent placement shows complete occlusion of the ureter (arrows) by the constrained stent (arrowhead). (Fig 22 reprinted, with permission, from reference 29.)
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Figure 22b. Ureteral occlusion achieved with a bare metallic stent in a pig model. (a) Photograph shows a double-body Gianturco-Rosch biliary stent before (left) and after (right) modification. (b) Lateral urogram obtained 1 week after stent placement shows complete occlusion of the ureter (arrows) by the constrained stent (arrowhead). (Fig 22 reprinted, with permission, from reference 29.)
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Figure 23a. (a) Drawings illustrate the covered stent technique used to manage unilateral ureterocutaneous fistula. Note that nephrostomy is not necessary because the urine flow is antegrade. Arrow indicates the site of the ureteral fistula. (b, c) Ureterocutaneous fistula in a 74-year-old woman. The fistula developed 5 days after an aortobifemoral bypass procedure was performed. The patient presented 1 year after surgery with increasing fistulous drainage to the left inguinal region. The fistula was treated with placement of a covered stent. Anteroposterior ureterogram (b) shows flow from the left midureter along the limb of the aortobifemoral graft (arrows). Ureterogram (c) obtained immediately after deployment of a 6 x 50-mm Wallgraft stent shows complete occlusion of the ureterocutaneous fistula. (d) Ureterogram obtained 7 months after initial treatment shows a patent covered stent and no fistulous communication. (Case courtesy of Riad Salem, MD, William Beaumont Hospital, Royal Oak, Mich; Fig 23 reprinted, with permission, from reference 33.)
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Figure 23b. (a) Drawings illustrate the covered stent technique used to manage unilateral ureterocutaneous fistula. Note that nephrostomy is not necessary because the urine flow is antegrade. Arrow indicates the site of the ureteral fistula. (b, c) Ureterocutaneous fistula in a 74-year-old woman. The fistula developed 5 days after an aortobifemoral bypass procedure was performed. The patient presented 1 year after surgery with increasing fistulous drainage to the left inguinal region. The fistula was treated with placement of a covered stent. Anteroposterior ureterogram (b) shows flow from the left midureter along the limb of the aortobifemoral graft (arrows). Ureterogram (c) obtained immediately after deployment of a 6 x 50-mm Wallgraft stent shows complete occlusion of the ureterocutaneous fistula. (d) Ureterogram obtained 7 months after initial treatment shows a patent covered stent and no fistulous communication. (Case courtesy of Riad Salem, MD, William Beaumont Hospital, Royal Oak, Mich; Fig 23 reprinted, with permission, from reference 33.)
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Figure 23c. (a) Drawings illustrate the covered stent technique used to manage unilateral ureterocutaneous fistula. Note that nephrostomy is not necessary because the urine flow is antegrade. Arrow indicates the site of the ureteral fistula. (b, c) Ureterocutaneous fistula in a 74-year-old woman. The fistula developed 5 days after an aortobifemoral bypass procedure was performed. The patient presented 1 year after surgery with increasing fistulous drainage to the left inguinal region. The fistula was treated with placement of a covered stent. Anteroposterior ureterogram (b) shows flow from the left midureter along the limb of the aortobifemoral graft (arrows). Ureterogram (c) obtained immediately after deployment of a 6 x 50-mm Wallgraft stent shows complete occlusion of the ureterocutaneous fistula. (d) Ureterogram obtained 7 months after initial treatment shows a patent covered stent and no fistulous communication. (Case courtesy of Riad Salem, MD, William Beaumont Hospital, Royal Oak, Mich; Fig 23 reprinted, with permission, from reference 33.)
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Figure 23d. (a) Drawings illustrate the covered stent technique used to manage unilateral ureterocutaneous fistula. Note that nephrostomy is not necessary because the urine flow is antegrade. Arrow indicates the site of the ureteral fistula. (b, c) Ureterocutaneous fistula in a 74-year-old woman. The fistula developed 5 days after an aortobifemoral bypass procedure was performed. The patient presented 1 year after surgery with increasing fistulous drainage to the left inguinal region. The fistula was treated with placement of a covered stent. Anteroposterior ureterogram (b) shows flow from the left midureter along the limb of the aortobifemoral graft (arrows). Ureterogram (c) obtained immediately after deployment of a 6 x 50-mm Wallgraft stent shows complete occlusion of the ureterocutaneous fistula. (d) Ureterogram obtained 7 months after initial treatment shows a patent covered stent and no fistulous communication. (Case courtesy of Riad Salem, MD, William Beaumont Hospital, Royal Oak, Mich; Fig 23 reprinted, with permission, from reference 33.)
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Figure 24. Drawings illustrate ureteral occlusion achieved with the surgical ureterostomy technique.
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Figure 25. Drawings illustrate ureteral occlusion achieved with a ureteral clip. Curved arrows indicate the direction of clip movement; straight arrow indicates the site of the ureteral fistula.
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Copyright © 2004 by the Radiological Society of North America.
