Post-TLH Vault Urinary Leakage — Investigation & Management

Step 1 — Confirm & Classify the Fistula

Double-Dye (Three-Swab) Test

1. Insert a vaginal tampon/pad into the vagina
2. Fill the bladder with methylene blue dye via transurethral catheter, then clamp the Foley
3. Give oral pyridium (phenazopyridine) simultaneously — orange colour appears in urine within 20 minutes via the ureter

Patients with VVF develop watery vaginal discharge typically 10–14 days post-surgery (some as early as 48–72 hours). At 2 months, either VVF or UVF is possible. — Berek & Novak's Gynecology

Additional Tests

• IV Methylene Blue test for UVF: Inject IV methylene blue + clamp Foley → blue pad confirms ureteral fistula — Campbell-Walsh-Wein Urology
• Urine analysis — confirm urinary nature of the fluid (creatinine of vaginal fluid >> serum creatinine confirms urinary fistula)
• Cystoscopy — visualize VVF location relative to trigone and ureteric orifices
• CT Urogram (CT abdomen & pelvis with IV contrast + delayed images) — preferred imaging to:
  • Delineate full length of ureter
  • Localize the fistula
  • Evaluate ureteral integrity
  • Rule out ureteric obstruction or urinoma
  • Assess if VVF and UVF coexist

  "The preferred imaging modality to show the leak and delineate the extent of injury is CT of the abdomen and pelvis with intravenous contrast and delayed images to visualize the full length of the ureter." — Campbell-Walsh-Wein Urology

• Retrograde pyelography — if UVF suspected and CT inconclusive
• MRI pelvis — useful for complex fistulae, post-radiation, or when surgical planning is needed

Step 2 — Localization of VVF

"After hysterectomy, the fistula site is above the bladder trigone and away from the ureters. Vaginal repair can be anticipated in most patients." — Berek & Novak's Gynecology

Management

A. VVF Management

• Insert Foley catheter for continuous bladder drainage (prolonged drainage)
• Up to 15% of fistulas close spontaneously within 4–6 weeks of continuous drainage
• If the patient presents at 2 months and no catheter has been placed, a trial is still reasonable if fistula is small

• Wait 3–4 months from diagnosis before operative repair — allows:
  • Reduction of inflammation
  • Improved vascular supply
  • Better tissue quality for repair
• Route: Vaginal repair is preferred for post-hysterectomy supratrigonal VVF
• Technique — Four-layered closure:
  1. Bladder mucosa
  2. Seromuscular layer
  3. Endopelvic fascia
  4. Vaginal epithelium
• Abdominal/laparoscopic/robotic approach for large, complex, or recurrent fistulas; or those near trigone/ureters

B. UVF Management

• Attempt retrograde ureteric stenting under cystoscopy — leave stent for 4–8 weeks to allow healing
• If retrograde fails: percutaneous nephrostomy (PCN) + antegrade stenting to bridge the defect

• Wait 6 weeks after injury for inflammation to subside before open/robotic repair
• Options: Ureteroneocystostomy (reimplantation) ± psoas hitch or Boari flap for distal UVF
• Laparoscopic/robotic approaches are well-described

Summary Algorithm

Post-TLH watery vault leak
         ↓
  Double-dye pad test + CT Urogram
         ↓
   ┌─────┴──────┐
  VVF          UVF
   ↓             ↓
Foley catheter  Retrograde stent / PCN
(6 weeks trial)  (4–8 weeks)
   ↓             ↓
Spontaneous    Healed? → Observe
closure 15%
   ↓
No closure at 6wks
   ↓
Wait 3–4 months total
   ↓
Surgical repair
(vaginal 4-layer / abdominal / robotic)

Key Points

• At 2 months post-TLH, spontaneous closure is unlikely — surgical planning should begin, with repair ideally after 3–4 months from diagnosis
• Always rule out coexisting VVF + UVF (double-dye test, CT urogram)
• Post-hysterectomy VVF incidence is low (~0.2%), but is the most common cause of VVF in developed countries
• Cystoscopy is mandatory before repair to assess trigone proximity and ureteric orifice involvement