Conservative Laser Therapy for Vesicovaginal Fistula in Twice-Relapsed Endometrial Cancer: A Case Report

Case Report

Vesicovaginal fistulas (VVFs) can potentially complicate surgical intervention in previously irradiated patients with endometrial cancer because of the presence of massive ischemia and fibrosis of pelvic tissue from previous irradiation.

Traditional strategies for the treatment of VVFs include endoscopic treatment (when feasible) or a laparoscopic, robotic, or open abdominal approach in some experiences through a transvesical route. The latter approach can be associated with long inpatient hospital stays, postoperative complications, and failure, especially in obese patients. The multidisciplinary team, led by Alessandro Buda, proposed treating VVFs with the conservative approach of prolonged catheterization and placement of nephrostomy tubes with laser therapy of the fistulas.

The case report, published in Cancer Reports, involved  a woman with a second relapse of endometrial cancer at the vaginal vault level; she received a hysterectomy then radiotherapy after the first relapse. She also underwent partial colpectomy and had an intraoperative bladder lesion, which was repaired with interrupted stitches. However, after the procedure, the patient developed a VVF, which was initially treated with conversative therapy rather than surgical repair.

VVF closure in previously irradiated patients is a challenge, with an initial success rate of 20% and an overall success rate of only 25%. Fistulas that arise spontaneously are less likely to be repaired, and when repair is attempted, a success rate of about 40% is observed compared to 100% of post-surgical fistulas. In addition, 70% required primary or secondary urinary diversion due to associated bladder dysfunction and ureteral strictures.

Considering the patient’s clinical condition and both clinical and radiologic confirmation of the fistula, the multidisciplinary team proposed conservative fistula repair. Bladder catheter Ch 20 and bilateral nephrostomy did not completely resolve the fistula, with a minor residual linkage between the bladder and the vaginal vault eight months after the robotic surgery.

A single/month diode laser application for three months was added to the conservative treatment. Cystography was negative at the end of laser sessions, and both nephrostomies were removed one week later. After six months, clinical and radiologic follow-up was negative, and no further vaginal urine loss was recorded.

Discussion

In gynecology, laser technologies have been recently proposed as an alternative option for the treatment of genitourinary syndrome of menopause (GSM) and vulvovaginal atrophy (VVA). The thermal effect generated by nonablative diode lasers enhances vascularization and collagen production, avoiding most of the adverse effects on the vaginal epithelium by causing direct thermal damage only to the connective tissue, sparing the superficial epithelium.

Data show that three sessions of a diode vaginal laser seem to be an effective and easily tolerated procedure for vaginal functional restoration in the treatment of GSM and VVA. Based on these results, the researchers recommended a three-diode laser vaginal session that enhances and favors the complete closure of residual VVFs.

“Conservative management of complex cases, like the one presented in this report, with the integrative approach of laser treatment, can offer a strategy for successful outcomes, even when the patient’s characteristics and the severity of the local anatomical field pose unique challenges to the managing team,” the multidisciplinary team concluded.