Both-Genders Fistula Repair
Genitourinary fistulas that occur in both sexes — 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
27 of 27 techniques
| Technique | Fistula Type | Best for / indication |
|---|---|---|
| Percutaneous Nephrostomy ± Antegrade Stent (Pyeloenteric) | Pyeloenteric | Post-procedural / small upper-tract fistula; nephron-sparing |
| Endoscopic Clipping / Endoloop Ligation (Pyeloenteric) | Pyeloenteric | Patients unfit for surgery; isolated small tract |
| Percutaneous Fulguration of Fistulous Tract | Pyeloenteric | Mature, narrow tract amenable to ablation |
| Nephrectomy + Bowel Repair (Pyeloenteric) | Pyeloenteric | Non-functioning / chronically infected kidney with duodenal or colonic communication |
| Conservative Drainage (Nephropleural) | Nephropleural | Post-supracostal-PCNL urinothorax; first-line in nearly all cases |
| Small-Bore Pleural Catheter (8–12F) | Nephropleural | Pleural decompression; comparable to chest tube with shorter LOS |
| VATS Decortication | Nephropleural | Refractory / loculated effusion failing tube drainage |
| Intrapleural Fibrinolytic (t-PA) | Nephropleural | Loculated collection resistant to drainage |
| Bowel Resection + Primary Anastomosis (Ureterocolonic) | Ureterocolonic | Diverticular / Crohn's / malignant ureterocolonic fistula; ureter usually preserved |
| Anti-TNF Therapy (Crohn's Ureterocolonic) | Ureterocolonic | Initial therapy in fistulizing Crohn's per ACG 2025; combine with ciprofloxacin × 12 wk |
| One-Stage Sigmoidectomy + Foley Drainage (CVF / EVF) | Colovesical / Enterovesical | Diverticular CVF without abscess; **68% need Foley alone for bladder** (Ferguson 2008) |
| Robotic / Laparoscopic Sigmoidectomy (CVF) | Colovesical / Enterovesical | Fit patients; shorter LOS, equivalent recurrence |
| Staged Resection (Complicated CVF) | Colovesical / Enterovesical | Abscess, obstruction, or emergent presentation |
| OTS Clip (Endoscopic CVF / Colovaginal) | Colovesical / Enterovesical | Poor surgical candidate; ~50% durable closure |
| Crohn's EVF — Bowel Resection + 2-Layer Bladder Closure | Colovesical / Enterovesical | Recurrent UTI / pyelonephritis; ~90% require surgery |
| Foley Drainage (Vesicocutaneous) | Vesicocutaneous | Small fistula; spontaneous closure attempt |
| Vacuum-Assisted Closure (VCF) | Vesicocutaneous | Skin contamination control; bridge to definitive repair or definitive in selected cases |
| Fistulectomy + Partial Cystectomy + Vascularized Flap | Vesicocutaneous | Persistent / large defects; rectus femoris musculocutaneous or omental interposition |
| Endoscopic Transurethral Suture Cystorrhaphy | Vesicocutaneous | Selected small VCF; minimally invasive alternative |
| Antegrade PCN ± JJ Stent (Post-Transplant) | Post-Transplant | Late-presenting (> 72 h) fistulae; definitive in ~62% |
| Re-do Ureteroneocystostomy (Post-Transplant) | Post-Transplant | Adequate distal-ureter length; standard surgical option |
| Native-to-Graft Ureteroureterostomy | Post-Transplant | Distal graft-ureter ischemia; reduces leak rate (1.5% vs 4.1%) |
| Boari Flap + Psoas Hitch (Post-Transplant) | Post-Transplant | Long graft-ureter defects when reimplant insufficient |
| Pedicled Omental Wrap (Recurrent Transplant Fistula) | Post-Transplant | Adjunct for recurrent fistula or hostile field |
| Endovascular Stent-Graft (Ureteroarterial) | Ureteroarterial | Hemodynamically unstable / comorbid; preferred initial treatment |
| Open Bypass / Ligation / Graft Interposition (UAF) | Ureteroarterial | Pre-existing graft, infection, abscess, or failed endovascular |
| Provocative Arteriography (Diagnostic-Therapeutic) | Ureteroarterial | Occult bleeding; CT and standard angiography non-diagnostic |
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