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Complex fistula involving both the large and the small bowel in a 59-year-old woman 2½ years after debulking surgery for stage IIC ovarian carcinoma and 1½ years after radiation therapy for a recurrent tumor at the vaginal vault. (a) Sagittal STIR MR image shows an additional recurrent tumor at the vaginal cuff (V), with bullous edema of the bladder (white arrow) and infiltration of the posterior bladder wall (black arrow). (b) Sagittal T2-weighted MR image obtained 3 months later, after the patient reported passing undigested food and feces per vaginum, shows an air-fluid level in the vagina (arrow) and irregular vaginal wall thickening (arrowheads), findings indicative of disease progression. (c) Sagittal T2-weighted MR image shows feces in the vagina (arrowhead) and a high-signal-intensity fistulous tract (arrow) coursing to the vagina from the small bowel above. (d) Axial T2- weighted MR image shows bilateral invasion of the pelvic side walls, a finding that precluded exenterative surgery. A right hydroureter (arrow) also is depicted.
Source publication
A fistula that occurs in association with a malignancy of the female reproductive tract may be caused by a primary or recurrent tumor or may be a complication of surgery or radiation therapy. Identification of the cause, complexity, and location of a fistula is essential for optimal management planning. Radiologic imaging, particularly with compute...
Context in source publication
Context 1
... the fistula is typically seen as a high-signal- intensity, fluid-filled communication. Short inver- sion time inversion-recovery (STIR) images may provide even more elegant depiction of a fistulous tract than conventional T2-weighted images (Fig 2). An air-filled tract produces low signal intensity on MR images, regardless of the pulse sequence used. ...
Citations
... The vascular insult to the ureter caused mucosal breakdown, which weakened the area, making it susceptible to the initial formation of the fistula. 11,12 The fistula resulted from the chronic inflammatory state, concomitant • with a presacral abscess at presentation, and the radiation-induced tissue injury. These issues, in tandem, prevented the fistula from resolving. ...
Ureteral fistulas are a rare occurrence that can arise from iatrogenic trauma, radiation, malignancy, and inflammation. Treatment options of urinary tract fistulas are handled on a case-by-case basis, and can necessitate a surgical approach. The authors present the case of an 85-year-old female patient with a ureterocutaneous fistula, where conservative management with percutaneous nephrostomy is a viable alternative to surgical intervention.
... Malignancy may be first diagnosed by CT and is typically utilized for staging once the diagnosis is confirmed. MRI is widely applied because of its higher soft-tissue resolution and tissue characterization, allowing for a more accurate evaluation of a tumor's size and local invasion and fistula detection [5,6]. ...
... The imaging features of a fistula depend on its composition, which may be gas, fluid, or a mixture of both. In general, a fistula is seen as a high-signal-intensity, fluid-filled tube connecting two adjacent organs on T2weighted imaging and can be better seen on the sagittal plane [6,8]. Also, CT can offer information on the fistula's size and location, and complications, such as abscesses or masses (Figs. 8, 9, 14). ...
Gynecological malignancies, such as ovarian cancers, cervical cancers, and endometrial cancers, have a significant global impact. Women with gynecologic malignancies may receive a single or a combination of treatments, including surgery, chemotherapy, and radiation-based therapies. Radiologists utilize various diagnostic imaging modalities to provide the surgeon with relevant information about the diagnosis, prognosis, optimal surgical strategy, and prospective post-treatment imaging. Computerized Tomography (CT) and magnetic resonance imaging (MRI) may be used initially to evaluate and detect post-treatment complications. Although CT is primarily used for staging, MRI is commonly used for a more accurate evaluation of a tumor’s size and detection of local invasion. Complications such as hematoma, abscess, inclusion cyst, seroma, tumor thrombosis, anorectovaginal fistula, and gossypiboma may occur after the three primary treatments, and systems such as the genitourinary, gastrointestinal, neurological, and musculoskeletal may be affected. In order to distinguish between early-onset and late-onset complications following gynecological treatment, radiological findings of the most common post-treatment complications will be presented in this review.
... The aetiology of these conditions varies greatly from congenital abnormalities to iatrogenic causes. [1][2][3][4][5] Likewise, the management of FRNU conditions ranges from conservative, pharmacological to surgical interventions. Prior to subjecting patients to surgical treatment, a thorough assessment (often including urodynamic studies and radiological imaging) is undertaken. ...
The use of robot-assisted technology has been widely adopted in urological oncological surgery and its benefits have been well established. In recent years, robotic technology has also been used in several functional reconstructive and neuro-urology (FRNU) procedures. The aim of this review was to evaluate the current evidence in the use of robotic technology in the field of FRNU. We performed a PubMed-based literature search between July and August 2022. The keywords we included were ‘robotic assisted’, ‘ureteric reimplantation’, ‘cystoplasty’, ‘ileal conduit’, ‘neobladder’, ‘sacrocolpopexy’, ‘colposuspension’, ‘artificial urinary sphincter’, ‘genitourinary fistula’ and ‘posterior urethral stenoses’. We identified the latest available evidence in the use of robotic technology in specific FRNU procedures such as the reconstruction of the ureters, bladder and urinary sphincter, urinary diversion, and repair of genitourinary prolapse and fistula. We found that there is a lack of prospective studies to assess the robotic-assisted approach in the field of FRNU. Despite this, the advantages that robotic technology can bring to the field of FRNU are evident, including better ergonomics and visual field, less blood loss and shorter hospital stays. There is therefore a need for further prospective studies with larger patient numbers and longer follow-up periods to establish the reproducibility of these results and the long-term efficacy of the procedures, as well as the impact on patient outcomes. Common index procedures and a standardized approach to these procedures should be identified to enhance training.
... Cervical, ovarian and colon cancers are the most common malignancies associated with tumor bowel fistula in the absence of prior treatment [101,102]. The size of the tumor is an important factor in the formation of fistulas [103]. This may happen because large tumors are more likely to cause pressure necrosis of adjacent bowel wall or be the source of direct tumor cell infiltration. ...
With advancements in cancer treatment, the survival rates for many malignancies have increased. However, both the primary tumors and the treatments themselves can give rise to various complications. Acute symptoms in oncology patients require prompt attention. Abdominopelvic oncologic emergencies can be classified into four distinct categories: vascular, bowel, hepatopancreatobiliary, and bone-related complications. Radiologists need to be familiar with these complications to ensure timely diagnosis, which ultimately enhances patient outcomes.
Graphical abstract
... The underlying etiopathogenesis of RIF is progressive chronic ischemia occurring due to endarteritis obliterans resulting in necrosis and fibrosis with loss of tissue planes leading to the development of fistulas [1,6]. Radiation-induced damage to the microvasculature of pelvic and abdominal organs initially present with acute symptoms of cystitis, enteritis, and proctitis and further progress to chronic complications like formation of strictures, abscesses, and fistulas [2,8]. ...
Radiation-induced fistulas (RIF) are uncommon therapeutic complications of radiotherapy in patients treated for carcinoma of the uterine cervix. Synchronous occurrence of enterocervical and enterovesical fistulas secondary to radiation is extremely rare and previously unreported in the literature. We report a case of synchronous enterovesical and enterocervical fistulas in a patient with carcinoma of the cervix treated using chemotherapy and radiation along with a brief overview of etiopathogenesis of RIF.
... Enterovaginal fistulas are rare afflictions possibly leading to severe clinical symptoms with critical impairment of quality of life for affected women. A variety of predisposing conditions and surgical procedures have been described to potentially cause enterovaginal (EV) fistulas [1][2][3][4][9][10][11]. The postpartum development of entero-or rectovaginal fistulas is most common in up to 88% of all EV fistula events [1,2]. ...
... Likewise, surgical interventions using stapler devices for functional pelvic floor disorders have been reported to result in rectovaginal fistulas [2][3][4]6]. Other than obstetric fistulas, gynecologic malignancies or radiation therapy for gynecologic tumors may lead to fistula development [10,11]. ...
Background
Enterovaginal fistulas represent a serious complication of various diseases and therapeutic procedures, often associated with complicated clinical courses and massive impairment of quality of life. As underlying conditions and procedures are multifarious, therapeutic approaches are challenging and have to be tailored individually. As the therapeutic management is complex and individualized, multiple surgical interventions might be necessary.
Methods
The aim of this study was to identify possible predictors for outcome in the treatment enterovaginal fistula patients. The study was realized as a retrospective analysis. Ninety-two patients treated with enterovaginal fistulas between 2004 and 2016 were analyzed. Patient characteristics, therapeutic data, and endoscopic findings were stratified according to etiology, closure rate and time, as well as recurrence of fistula. Main outcome measure was the overall rate of fistula closure.
Results
Overall therapeutic success rate was 67.4%. Postoperatively derived fistulas were most frequent (40.2%), mainly after rectal surgery (59.5%). Postoperative and non-IBD-inflammation associated fistulas had better outcome than IBD-, radiotherapy-, and tumor-related fistulas (p = 0.001). Successful fistula closure was observed more frequently after radical surgical interventions, best results observed after transabdominal surgery (p < 0.001). Fistula recurrence was also less frequently observed after radical surgical therapies (p = 0.029). A temporary stoma was associated with higher incidence of fistula closure (p = 0.013) and lower incidence of fistula recurrence (p = 0.042) in the postoperative subgroup, as well as shortened therapy period in all groups (p = 0.031).
Conclusion
Enterovaginal fistulas are a result of various etiologies, and treatment should be adjusted accordingly. A very sustainable, rapid, and persistent therapeutic success can be expected after radical surgical approaches with temporary diverting stoma. This is especially true for postoperatively derived fistulas.
... Localised pelvic fistulisation in advanced malignancy is not an uncommon finding in patients with gynaecological cancers. Fistulation involving gynaecological malignancies generally occur from either localised progression of disease, radiotherapy, or prior surgical intervention [1]. ...
Introduction:
Targeted radiotherapy, surgery, and localised disease progression can all result in fistulous tract formation in patients with a pelvic malignancy, in particular cervical or endometrial cancer. This report discusses a novel technique for palliative management of ureterovaginal fistulas in end-stage disease.
Presentation of case report:
We report the case of a 37 year old female with metastatic cervical squamous cell carcinoma previously treated with chemoradiation who presented with progressive disease and secondary development of a symptomatic ureterovaginal fistula.
Discussion:
This case report discusses the causes and sequalae of uretero-vaginal fistula formation, the role of the interventional radiology with regards to palliative intervention, and potential patient factors that can affect performance of such procedures.
Conclusion:
Interventional radiology plays an important role in palliative and symptomatic management of end stage malignant disease. Ureteric embolisation via a retrograde transurethral approach by way of an existing stent is a novel approach to access making the procedure easier for both the patient and radiologist.
... This is particularly important in settings where the fistula formed after radical hysterectomy with or without adjuvant radiotherapy for malignancy. Of 20 patients in a study from Narayanan et al., eight had recurrent disease in combination with fistula [8]. It is well known that recurrent malignancy is a common etiology of VVF. ...
Purpose of Review
To summarize recent experience with robotic vesicovaginal fistula repair and describe the contemporary technique.
Recent Findings
Robotic vesicovaginal repair has been tested at multiple centers, with similar outcomes to open surgery. It has benefits including decreased hospital stay, less blood loss, and similar long-term outcomes. As long as the surgeon is experienced in robotic surgery, this technique appears to be promising.
Summary
Robotic vesicovaginal repair results in similar outcomes to open surgery with decreased morbidity.
... This contrasts with rates of 15% for all-grade fistula and 6% for grade ≥ 3 fistula observed in the GOG 240 study [12]. Although fistulas in gynecological malignancy are rare, they are known complications of this type of cancer, and can lead to substantial physical and psychological morbidity [17][18][19]. Vesicovaginal and enterovaginal fistulas are common, but ureterovaginal, enterovesical, rectovaginal, and enterocutaneous fistulas also occur [17,19]. Symptoms include urinary leakage or fecal discharge through the vagina, bleeding, fever and pain [17][18][19], and fistulas can be diagnosed and examined using various imaging methods [19]. ...
... Although fistulas in gynecological malignancy are rare, they are known complications of this type of cancer, and can lead to substantial physical and psychological morbidity [17][18][19]. Vesicovaginal and enterovaginal fistulas are common, but ureterovaginal, enterovesical, rectovaginal, and enterocutaneous fistulas also occur [17,19]. Symptoms include urinary leakage or fecal discharge through the vagina, bleeding, fever and pain [17][18][19], and fistulas can be diagnosed and examined using various imaging methods [19]. ...
... Vesicovaginal and enterovaginal fistulas are common, but ureterovaginal, enterovesical, rectovaginal, and enterocutaneous fistulas also occur [17,19]. Symptoms include urinary leakage or fecal discharge through the vagina, bleeding, fever and pain [17][18][19], and fistulas can be diagnosed and examined using various imaging methods [19]. Fistulas can be managed symptomatically or surgically [19]. ...
Background:
This study aimed to determine the incidence of pelvic fistulas in cervical cancer patients treated with bevacizumab in Japanese clinical practice.
Methods:
A post-marketing surveillance (PMS) study was conducted between June 2016 and February 2018 to survey physicians who treated advanced or recurrent cervical cancer patients with bevacizumab (according to the product label). The clinical/treatment status of patients with pelvic fistulas was assessed in an additional retrospective case series study.
Results:
142 patients were included in the PMS study (median age 51 years; 66.9% squamous cell carcinoma; 66.2% recurrent cervical cancer; 64.1% previous radiotherapy). Patients received a median of seven bevacizumab doses. Six patients, all of whom had a history of pelvic irradiation, developed seven fistulas (4.2%; 95% confidence interval, 1.56-8.96), and five patients had also undergone pelvic surgery. The case series study of the patients who developed fistulas indicated that three patients had high cumulative bladder and rectal doses of radiation, and two of them had undergone salvage re-irradiation for pelvic recurrence. The other three patients underwent both radical hysterectomy and adjuvant radiotherapy, but did not receive an excessive radiation dose to the bladder or rectum.
Conclusions:
This study found that the upper limit of the 95% confidence interval for pelvic fistula incidence did not exceed the incidence reported in the GOG 240 study. To ensure an adequate benefit-risk assessment of bevacizumab in cervical cancer patients, a comprehensive evaluation of prior treatment is essential and the possibility of unexpected fistulas, even after careful evaluation, should be considered.
... In developed countries, chronic inflammatory bowel disease (IBD) is the most common cause of ano-/rectovaginal fistula [30] formation (45.6%; [8]). Other causes include surgical trauma (16.7%; [8]), radiation [9], very rarely cryptoglandular inflammation [10], and malignant diseases. The latter can rarely be successfully treated with surgical interventions. ...
Background
Rectovaginal fistulas represent 5% of all anorectal fistulas. For affected women, this pathology is associated with a reduction in quality of life (QoL) and self-esteem. Most commonly used methods of surgical closure have high recurrence rates or permanent perineal complaints, which in turn lead to negative effects on QoL and self-esteem. A fistula closure, using the “de-epithelialized Singapore flap” (SF), can be a good alternative therapy strategy.
Method
Our retrospective case series processes the long-term results of seven patients who were operated on for ano-/rectovaginal fistula using the SF. All patients underwent surgery at the University Hospital Graz, between May 2012 and July 2015. The data of the surgical follow-up examinations were collected and an additional telephone survey was carried out. The procedure is presented based on a structured description. All procedures were performed jointly by the Department of General Surgery and the Department of Plastic Surgery.
Results
The average age of the seven patients was 46.14 years (23–72 a). Five patients had a total of 12 previous operations with frustrating results. Of the seven patients treated, six had a permanent fistula closure (85.7%). The results of the telephone survey ( n = 6) showed a high level of patient satisfaction (100%), and an improvement in QoL (83.3%), through our surgical method. In our cohort, neither urinary nor fecal incontinence occurred.
Conclusion
The treatment of an ano-/rectovaginal fistula using the “de-epithelialized pudendal thigh flap” (Singapore flap) is a promising treatment alternative. In particular, patients who have had previous proctological interventions show a benefit from this procedure.
