Suprapubic Fistula Closure

Suprapubic fistula closure

A suprapubic fistula is an abnormal connection between the urinary bladder and the skin over the lower abdomen (at or near the prior suprapubic catheter site). This fistula should be closed if it cannot heal spontaneously and leads to incessant urine leakage, skin inflammation, infection or difficulties with hygiene.

The closure of the suprapubic fistula can be conservative or surgical depending on the diameter of the fistula, its duration and the quality of surrounding tissues. 

Suprapubic fistula treatment

A suprapubic fistula is a connection between the urinary bladder and the skin of the lower abdomen that typically arises at or near a previous suprapubic catheter site. It results in continuous or recurrent urine leakage from the abdomen, leading to skin irritation, infection, and difficulty with hygiene. 

The management of the fistula is based on the size, duration, symptoms and the cause.

Types of treatment for Suprapubic Fistula:

Non-Surgical Management 

Bladder Drainage

• A urethral Foley catheter can be placed between 2-4 weeks.
• Constant drainage will aid in decreasing the pressure in the bladder giving small and early fistulas a chance to heal.
• Apposite in case of a small fistula (<5 mm), recent (<23 weeks) and nondisseminated fistula.

Antibiotics

• To detect the presence of infection, cellulitis, or infection of the urinary tract.

Skin Protection

• Protective barrier creams of the leakage area to avoid skin breakdown.
• Tormento dressings to keep it clean.

Management of the Underlying Disorder

• Management of bladder outlet blockage
• Treatment of neurogenic bladder or chronic retention. 
• Removal or replacement of an old suprapubic catheter

Minimally Surgical Therapy

Cauterization of the Fistula Tract

• Endoscopic ablation of the internal fistula hole.
• Goes too little, early pieces.

Fibrin Glue Injection

• An injection of glue is done within the tract to close the tract.
• Success is variable.

Endoscopic Closure Devices

• In some cases, special closure systems or the use of clips can be used.

Surgical Management (Definitive Management)

• Supra pubic fistulas need surgical repair in the majority of cases.

Simple Fistula Excision and Closure

• Removal of the fistula tract.
• Bladder wall closure that is layered.
• Abdominal wall and skin ablation.
• Urethral Foley catheter 10-21 days.

Complex Fistula Repair

Needed for:

• Chronic fistulas
• Large opening
• Recurrent fistulas
• Poor tissue quality

Procedures may include:

• Tissue flap (omental, rectus muscle) reinforcement.
• Reconstruction of the bladder.
• Scar tissue removal
• Deep layered suturing

Robotic Repair or Laparoscopic Repair

• Applied in complicated fistulas, or in cases of minimal invasivity.
• Gives more visualization and healing.

Suprapubic fistula repair

A suprapubic fistula is an abnormal passage between bladder and lower abdomen skin usually in the former site of a suprapubic catheter. Suprapubic fistula is used in case of failure of conservative management, to seal the tract, reinstate integrity of bladder and prevent unremitting leakage of urine.

Pre-operative Evaluation

The assessment of the patient prior to repair is through:

• Clinical observation of fistula size, duration and state of skin around it.
• To examine the internal opening of the bladder, cystoscopy is carried out.
• Ultrasound/CT scan to assess the bladder and the tract.
• Fistulogram when necessary, to localize the tract.
• Infection, bladder outlet obstruction or neurogenic bladder checking.

Types of Suprapubic Fistula Repair

Simple Fistula Repair

• Procedural on minor, new, or uncomplicated fistulas.

Steps:

• Curvilinear cutting around the fistula.
• Total resection of the fistulous tract.
• Strata bladder closure (mucosa, detrusor muscle).
• Peritoneal peritoneal.
• Skin closure.
• Introduction of urethral catheter 10 -21 days.

Complex Fistula Repair

Required when:

• Fistula is large
• Chronic or recurrent
• Surrounded by scar tissue
• Connected with infection or deficient tissue quality.

Techniques may include:

• Omental flap reinforcement
• Peritoneal flap or rectus muscle flap.
• Reconstruction of the wall of the bladder.
• Broad resection of non-healthy tissue.
• Multi-layered water tight closure.
• They stimulate healing and stop recurrences.

Minimally Invasive Repair 

• Cauterization of internal opening endoscopically.
• Fibrin glue sealing of the tract.
• Very small tracts Endoscopic clips.
• The success is lower and less than open repair.

Suprapubic fistula recovery

Post-surgery intervention of suprapubic fistula repair aims at maintaining bladder rest, wound healing, prevention of infection, and surveillance of leakage recurrence. The recovery is normally easy when the care taken after the surgery is in order.

First 24-48 Hours Post-surgical Recovery

• Patient is observed in terms of urine output and bleeding.
• Analgesics are used to treat pain.
• Bladder spasms can be experienced; antispasmodic medications can be administered.
• The suprapubic wound dressing is made clean and dry.
• Continuous drainage of the bladder is done with a Foley catheter.

Hospital Stay

• The majority of patients spend 1-3 days in case of surgery complexity.
• Treatment is discharged when pain is contained, and the wound is healed.

Recovery at Home

Catheter Care

• The Foley catheter is a urinary catheter that remains in the urethra anywhere between 10 to 21 days to empty the bladder and permit fistula repair to cure.
• Assure that there is no catheter bag that is over bladder.
• Do not draw or pull the catheter.
• Always ensure that you are well hydrated to keep the urine crystal clear.

Wound Care

• Suprapubic dressing on a daily basis.
• Keep the area dry and clean, and do not get it wet.
• Redness, bad smell, pus or warmth around the wound are signs of infection. 

Medications

• Antibiotics that prevent Infection.
• Pain relievers.
• Bladder spasm antipsychotics.
• To prevent straining, stool softeners can be ordered.

Diet

• Normal diet is normally permitted.
• Drink plenty of water to reduce urine irritation.
• Cut back on the caffeine and sodas, this can irritate your bladder. 

Activity Restrictions

First 2 Weeks

• Avoid strenuous work.
• No heavy lifting (>5 kg).
• The lower abdomen should not be bent or put pressured.

After 2–4 Weeks

• The slow rise in activity.
• Avoid any strenuous activity until the surgeon clears you.
• Driving
• Typically 1 week later, at any rate of comfort.
• Sexual Activity
• Usually after 4-6 weeks or as recommended by the physician.

Follow-up and Catheter Removal

Follow-up Visits

• Typically after 1 week and 2-3 weeks of operation.
• The surgeon will examine wound healing and catheter drainage.

Removal of catheter 

• To ensure that the bladder has completely healed, a cystogram (bladder X-ray) or ultrasound may be done in 10-21 days. 
• In case no leakage is observed, the catheter is taken out.

Best hospital for suprapubic fistula closure India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Suprapubic fistula treatment is aimed at closing the abnormal communication between the urinary bladder and skin to stop urinary stream through the fistula, to avoid urinary tract infections and to reestablish normal urinary function. Although some small, early fistulas may heal through conservative management with catheter drainage and control of infection, most chronic or large fistulas require surgical repair with multilayered bladder closure and adequate tissue support. To recover sufficiently after surgery requires bladder rest with a Foley catheter, wound care (dressing changes), and monitoring for infection or recurrence. With proper evaluation, surgical technique and timely follow-up, the success rate for repair of the suprapubic fistula is high and most patients can return to their normal routine in 4 to 6 weeks.

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FAQ

1. Can a suprapubic fistula heal on its own?

• Small, early fistulas may close with bladder rest by using a Foley catheter. Most chronic or large fistula still require surgical repair.

2. What is the best treatment for a suprapubic fistula?

• Surgery remains the most definitive treatment, particularly in cases of chronic or recurrent fistulas. Conservative treatment can be performed in limited cases of small and early lesions.

3. What does surgeon do for suprapubic fistula?

• The operation itself involves removal of the fistula tract, a multilayer bladder closure, tissue flaps to reinforce the bladder if necessary, and closure of the wound. A Foley catheter is inserted for 10 to 21 days.

4. Is hospitalization required?

• 1–3 days are required for most patients with uncomplicated repairs though this may vary if the repair is complex and the patient is still recovering.