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|Year : 2013 | Volume
| Issue : 3 | Page : 220-222
Vesico-cutaneous fistula to the hip: A case report and review of the literature
J Wang, Y Xu
Department of Urology, Affiliated Sixth People's Hospital, Shanghai Jiaotong University, Shanghai, China
|Date of Submission||23-Sep-2012|
|Date of Decision||03-Feb-2013|
|Date of Acceptance||22-Mar-2013|
|Date of Web Publication||12-Sep-2013|
Department of Urology, Affiliated Sixth People's Hospital, Shanghai Jiaotong University, Shanghai
Source of Support: None, Conflict of Interest: None
A 37-year-old woman with a vesico-cutaneous hip fistula was admitted to our department. The bladder fistula had formed after repeated hip infections. The fistula was completely resected and the bladder was repaired using a tension-free closure and indwelling catheter for 2 weeks. Vesico-cutaneous fistulae are very rare, and their causes can be complex.
Keywords: Diagnosis, gluteal abscess, treatment, vesico-cutaneous fistula
|How to cite this article:|
Wang J, Xu Y. Vesico-cutaneous fistula to the hip: A case report and review of the literature. J Postgrad Med 2013;59:220-2
| :: Introduction|| |
A fistula is an abnormal communication between two or more of a body's epithelial-lined organs. In the industrialized world, most fistulae are iatrogenic, but they can also be caused by congenital anomalies, malignant disease, inflammation, infection, radiation therapy, trauma, ischemia, parturition, and a variety of other processes.  Vesico-cutaneous hip fistulae are a type of urinary fistula and are rare. y are rare. ,,,, The current report discusses a case of vesico-cutaneous fistula to the right buttock and examines related literature.
| :: Case Report|| |
A 37-year-old woman with a vesico-cutaneous hip fistula was admitted to our department. She had no history of trauma or tuberculosis. She reported that she had this problem for 20 years, but was not bothered by the mild symptoms. She had a history of repeated right gluteal abscesses, which had been treated with incision and drainage. A serious wound discharge developed at 18 years of age. She suffered from abscesses, which require exploration and drainage on three later occasions. She was left with four chronically discharging sinuses in her right thigh. One month after her last drainage procedure, she observed dribbling from the fistula during the urination. This drainage was not accompanied by any other complaint and she did not seek medical treatment until she was seen for evaluation of a hip contracture two months prior to treatment in our clinic. At this time, the drainage was continuous and did not resolve with local wound care. Urologic evaluation at this time included a voiding cystourethrogram (VCUG), which reveal a contrast-filled fistula connecting the bladder to the right buttock [Figure 1]a. She was treated with release of her right thigh contracture and catheter drainage of the bladder. The patient was instructed to return to our department after 6 months for further evaluation.
|Figure 1: (a) Voiding cystourethrogram shows a right vesico‑cutaneous fistula. (b) Pre‑operative cystoscopy: A 3 mm fistula opening was seen in the right posterolateral portion of the bladder. (c) Post‑operative cystoscopy shows the right lateral bladder mucosa. The fistula was closed and normal bladder mucosa was visible|
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Physical examination showed that the patient has a fistula in the lower right hip. A small amount of leakage was associated with the voiding. There was scar tissue in the area of the fistula. Urinalysis and biochemical parameters were within normal limits. A cystoscopy was performed. A fistulous opening about 3 mm in diameter was observed in the right posterolateral bladder. The surrounding bladder mucosa showed that chronic inflammatory changes and the bladder mucosa showed pus moss secreta and green follicular cystic swell [Figure 1]b. The urethra was normal.
The patient provided consent, and the lesion was explored. A fistula was found originating from the right posterior lateral bladder. The fistula was completely resected and the origin of the fistula was excised using electrocautery. The bladder was closed in layers without tension and drained with a urethral catheter. The patient was placed on intravenous antibiotics. Two weeks later, the catheter was removed and the patient voided normally. The post-operative pathology was cystitis glandularis accompanied with inflammatory cell infiltration. Follow-up cystoscopy 3 months later [Figure 1]c revealed no fistulous tract, mild edema, and healing bladder mucosa. VCUG showed that normal bladder fills without extravasation. Uroflowmetry revealed a maximum urinary flow rate of 35 ml/s and bladder capacity of 305 ml. The patient remained health and experienced no recurrence of cellulitis or fistula in 24 months.
| :: Discussion|| |
There are many causes of a urinary fistula. Surgical treatment of the urinary or reproductive organs can cause injuries that heal in the form of fistulas. Some individuals develop fistulae as a complication of inflammatory bowel disease, bowel cancer, or radiation therapy. , Mintzer et al. reported several common causes of urinary fistulae, such as congenital anal atresia, Crohn's disease, diverticulitis, surgery, childbirth, radiation therapy, trauma, and malignant neoplasms of the colon, bladder, or reproductive system.  Other common causes include, appendicitis, erosion of an embedded stone through the bladder wall, foreign bodies, lymphogranuloma venereum, pelvic inflammatory disease, endometritis, schistosomiasis, tuberculous enterocolitis, and ulcerative colitis. Guan et al. reported a complicated case of chronic hip osteomyelitis with bladder stones and bladder fistula.  Banihani reported a 90-year-old man with a traumatic pelvic fracture after a motor vehicle accident, bladder rupture and  vesico-cutaneous fistula and anterior urethral stricture two years later. A suprapubic cystotomy was performed for urinary diversion. Mechanical injuries during hip replacement can lead to prosthetic infections and fistula formation. ,, Primary and secondary infections can also cause urinary fistulae. The post-operative pathology of the patient in the current case study included cystitis glandularis accompanied with inflammatory cell infiltration likely related to her repeated infections and urinary leakage.  These chronic infections gradually invaded the deep muscle tissue, leading to local muscle contracture, eroded the pelvic cavity, and then invaded the bladder. The patient's incision and drainage procedures were not adequate, leaving a reservoir of deep infection. This contributed to the decline of her body's immunity and eventually allowed the fistula to form. Female patients can develop pelvic soft-tissue necrosis and fibrosis after childbirth, secondary infection, and bladder fistula formation. 
The diagnosis of the urinary fistula is based on clinical symptoms, voiding cystourethrography, and cystoscopic examination. Cystoscopic examination can show the location and size of the fistula and the presence of bladder stones, diverticula, and tumors.
Urinary fistulae should be treated in a timely fashion and urinary extravasation should be controlled to prevent secondary skin damage, reduce the severity of other complications, and alleviate patient stress. However, small bladder fistulae of less than 1 cm often close and heal spontaneously after insertion of a urinary catheter to divert the urine. For more severe cases, such as vesico-cutaneous fistulae, surgery may be necessary. The repair and reconstruction of urinary tract fistulae may involve improvised maneuvers in the operating room, tailored to each patient. The surgeon should be familiar with a variety of approaches and techniques, because not all approaches are optimal for patients with a given type of urinary fistula.  Most fistulae procedures require adequate exposure of the fistulous track with debridement of devitalized and ischemic tissue; removal of any involved foreign bodies or synthetic materials from the region of the fistula; careful dissection or anatomic separation of the involved organ cavities; watertight closure; use of well-vascularized, healthy tissue flaps for repair; multiple-layer closure; tension-free, non-overlapping suture lines; adequate urinary tract drainage or stenting after repair; treatment and prevention of infection; and maintenance of hemostasis. In order to reduce the risk of recurrence, the tract and surrounding scar tissue should be completely excised. The fistulous stump should be cauterized, without excessive electrocoagulation of normal tissue. The bladder should be closed in layers to control bleeding and preserve tissue vascularity. The bladder closure should be covered with the peripheral adipose tissue. An indwelling catheter should be left in place and intravenous antibiotics should be administered. These measures facilitate satisfactory curative effects and reduce the chance that the fistula will recur.
Urinary tract fistulae cause the patient considerable physical and psychological distress. Fistulae are frequently recurrent. This is especially true of fistulae attributable to rare causes, which are often misdiagnosed. Clinicians should follow the basic principles of fistula repair, remain flexible in their choice of suitable repair techniques, and practice meticulous post-operative care.
| :: References|| |
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