Neobladder-vaginal fistula after cystectomy and orthotopic neobladder construction

To determine the potential surgical and clinical factors that contribute to the development of neobladder-vaginal fistula (NVF) after cystectomy and orthotopic neobladder (ONB) construction in women.

Of 37 patients who had vaginal-sparing cystectomy, the records of four who developed a NVF after radical cystectomy and ONB construction were reviewed. Retrospective clinical and surgical information was collected, including patient demographics, tumour pathology, surgical technique, presenting symptoms, and method and efficacy of surgical repair.

In two of the four patients who developed a NVF a small injury to the anterior vaginal wall was noted during surgery and closed primarily. All patients presented with severe urinary incontinence. The NVF was diagnosed after cystoscopy and/or speculum examination. Three of the four patients had an attempted surgical repair, including one obturator flap interposition, one rectus flap interposition, and one primary two-layer closure. To date, one patient is fistula-free and two were subsequently converted to an ileal conduit or continent cutaneous diversion because the fistula recurred. The fourth patient developed a NVF in association with local tumour recurrence and underwent conversion to an ileal conduit.

The development of a NVF is a significant complication after cystectomy. Inadvertent injury to the vaginal wall is an important predisposing factor to subsequent NVF development. The repair of a NVF is often difficult; upon diagnosis, conversion to a continent cutaneous urinary diversion may be considered.