Fistula Repair (All Patients)
Genitourinary fistulas that occur regardless of sex — upper-tract uroenteric, enterovesical, vesicocutaneous, post-transplant ureteral, and vascular-urinary — share a small set of recurring decisions: whether the fistula will close with diversion alone (proximal urinary decompression ± fecal diversion), whether endovascular or endoscopic salvage is feasible, and when definitive segmental resection ± interposition flap is required. The dominant variables are the etiology (iatrogenic, inflammatory, malignant, radiation, post-transplant ischemia), the functionality of the upstream organ (kidney, bladder, bowel), and the patient's fitness for major reconstruction.
Decision Framework
| Fistula | First-Line | Definitive | Salvage / Adjunct |
|---|---|---|---|
| Pyeloenteric | Percutaneous nephrostomy ± stent (70% closure)[1] | Nephrectomy + bowel repair when kidney non-functional | Endoscopic clipping / fulguration |
| Nephropleural (post-PCNL ~3.3%) | Urinary diversion (PCN / JJ) + chest-tube drainage; small-bore 8–12F adequate | Most resolve < 3 mo conservatively | VATS decortication; intrapleural t-PA |
| Ureterocolonic | Resect diseased bowel + primary anastomosis; ureter usually preserved | Same | Anti-TNF first in Crohn's (ACG 2025) |
| Colovesical / Enterovesical | One-stage sigmoidectomy + anastomosis; Foley alone for bladder in 68% (Ferguson 2008) | MIS sigmoidectomy preferred | OTS clip 50% durable when unfit |
| Vesicocutaneous | Foley drainage; VAC for granulation control | Fistulectomy + partial cystectomy + vascularized flap (rectus femoris / omentum) | Endoscopic suture cystorrhaphy |
| Post-transplant | Antegrade PCN ± JJ — definitive in 62% at > 72 h | Re-do UNC, ureteroureterostomy, Boari + psoas hitch; omental wrap | Native-to-graft UU (1.5% vs 4.1% leak) |
| Ureteroarterial | Endovascular stent-graft (preferred) | Open bypass / ligation if infected, failed endo, or pre-existing graft | Provocative arteriography for occult cases |
Treatment Database
| Technique | Fistula Type | Best for / indication |
|---|---|---|
| Pyeloenteric Fistula Repair | Pyeloenteric | PCN ± stent first-line; nephrectomy + bowel repair if kidney non-functional. |
| Nephropleural Fistula Repair | Nephropleural | PCN / JJ + chest-tube drainage first-line; VATS decortication for refractory collections. |
| Ureterocolonic Fistula Repair | Ureterocolonic | Bowel resection + primary anastomosis, ureter usually preserved; medical therapy first in Crohn's. |
| Colovesical / Enterovesical Fistula Repair | Colovesical / Enterovesical | One-stage sigmoidectomy + Foley for bladder; staged resection if abscess / emergent; OTS clip for unfit. |
| Vesicocutaneous Fistula Repair | Vesicocutaneous | Foley ± VAC for small fistulas; fistulectomy + interposition flap for large / persistent defects. |
| Post-Kidney-Transplant Ureteral Fistula Repair | Post-Transplant | PCN ± antegrade stent first-line; re-UNC, native UU, Boari flap, or omental wrap by defect length. |
| Ureteroarterial Fistula Repair | Ureteroarterial | Endovascular stent-graft first-line; open bypass for infection or failed endo. |
| Fecal Diversion | Colovesical / Enterovesical | Loop ileostomy or colostomy as adjunct in complex bowel-urinary fistula; staged Shackley protocol. |
References
1. Maillet PJ, Pelle-Francoz D, Leriche A, Leclercq R, Demiaux C. Fistulas of the upper urinary tract: percutaneous management. J Urol. 1987;138(6):1382–5. doi:10.1016/s0022-5347(17)43648-2