Vesicocutaneous fistula in complex pelvic pathology: diagnostic keys and individualized surgical strategy — a systematic review with PICO questions

Abstract

Introduction: Vesicocutaneous fistula (VCF) is an abnormal communication between the bladder and the skin, with a heterogeneous and nonspecific presentation. Its association with complex pelvic pathology—uterine tumors, prior radiotherapy, multiple surgeries—poses significant diagnostic and therapeutic challenges. Objective: To synthesize evidence on diagnostic keys and individualized surgical strategies for VCF in complex pelvic pathology, through an exploratory systematic review with PICO questions. Methods: Exploratory systematic review following PRISMA 2020 (Page et al., 2021). Three PICO questions were formulated. Search in PubMed/MEDLINE, Europe PMC, and Scopus (January 2000-October 2026). Reports and series on VCF associated with pelvic pathology were included. Quality was assessed with JBI. Results: Of 38 records, 12 studies were included. Predominant causes were surgical iatrogenic and pelvic radiotherapy (Ridha et al., 2021; Tatar et al., 2016). Diagnosis was established by CT cystography and cystoscopy (Tatar et al., 2016). Initial urinary diversion with Foley catheter had variable success: effective in small, early fistulas (Toufique & Merani, 2011), but insufficient in complex or irradiated cases (Ridha et al., 2021). Multilayer primary closure was the standard in viable tissue (Ocronos, 2026). In irradiated fields, vascularized flap reconstruction showed high closure rates (Ludolph et al., 2014). Conclusions: VCF in complex pelvic pathology requires a high index of suspicion, confirmation with CT cystography and cystoscopy, and an individualized surgical strategy based on tissue viability, underlying cause, and prior radiotherapy. Isolated urinary diversion is rarely sufficient in complex cases. Prospective multicenter studies are required to standardize outcomes.