Surgical outcomes of vesicovaginal fistulae in patients with previous pelvic radiotherapy

Robotic female artificial urinary sphincter implantation vs. male artificial urinary sphincter implantation for non-neurogenic stress urinary incontinence

PURPOSE

Previous studies suggested better functional outcomes and longer device survival for female artificial urinary sphincter (AUS) implantation compared to male AUS implantation. We hypothesized that the adoption of robotic approaches for female implantation might have influenced these comparisons. This study aimed to compare the outcomes of robotic female AUS and male AUS implantation for non-neurogenic stress urinary incontinence (SUI).

METHODS

We retrospectively reviewed charts of male patients who had AUS implantation and female patients who underwent robotic AUS implantation for non-neurogenic SUI between 2010 and 2022 at a single center. Prior AUS implantations were exclusion criteria. The primary endpoint was continence status at 3 months, categorized as complete resolution of SUI (0 pad), improved SUI (1pad), or unchanged SUI (>1pad).

RESULTS

After excluding 79 patients, 171 were included: 70 women and 101 men. Operative time was shorter in males (126.9 vs. 165.5 min; p < 0.0001). Postoperative complication rates were similar (17.3% vs. 22.9%; p = 0.38). Continence status at 3 months and last follow-up favored females. The ICIQ-SF decrease at 3 months was greater in females (-7.2 vs. -4.6; p < 0.001). The 5-year estimated explantation-free survival was similar (78.6% vs. 73.7%; p = 0.94) as was the revision-free survival (67.4% vs. 61.7%; p = 0.89). Multivariate analysis showed that female gender was associated with better continence at last follow-up (OR = 4.3; p = 0.03).

CONCLUSION

Robotic female AUS implantation is associated with better functional outcomes than male AUS implantation, with similar morbidity and survival rates.

The utility of Martius fat pad in the repair of urogenital fistulae: review of current evidence

OBJECTIVE

To present the contemporary evidence on transvaginal urogenital fistulae (UGF) repair with Martius fat pad (MFP), compared to direct graftless fistula repair.

METHODS

We reviewed all available studies reporting lower UGF repair via the transvaginal approach in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). The primary outcome of interest was the fistula closure rates. When available, patients' baseline characteristics, indications for surgery, and early and late postoperative complications with focus on MFP-related complications are reported.

RESULTS AND DISCUSSION

In obstetric fistulae, tissue interposition has been almost completely abandoned, with contemporary large series reporting closure rates of >90% with graftless repair, even for complex fistulae. Similarly, most simple, non-irradiated iatrogenic fistulae can be closed safely without or with tissue interposition with success rates ranging between 86% and 100%. However, MFP is valuable in fistulae with difficulty achieving tension-free and layered closure, with significant tissue loss, urethral involvement and with poorly vascularised tissues after radiotherapy, with reported success rates between 80% and 97% in those challenging situations.

CONCLUSION

A UGF repair should be individualised after considering the specific characteristics and complexity of the procedure. MFP interposition is probably unnecessary for the majority of low (obstetric) fistulae within otherwise healthy tissues. However, MFP may still have a place to maximise outcomes in low-income settings, in select cases with higher (iatrogenic) fistulae, and in most cases with radiotherapy.

[Urinary diversion with or without simple cystectomy as a salvage option for benign diseases of the lower urinary tract]

Benign diseases of the lower urinary tract can occur as a result of oncological or neurological diseases or their respective therapies (e.g., surgery or radiation treatment) and can significantly reduce the quality of life for affected patients. Urinary diversion serves as a salvage option when all other therapeutic regimens have been carried out and proven unsuccessful. When selecting the suitable urinary diversion, a comprehensive clinical assessment of the patients is required in order to ensure long-term success. In some cases, a cutaneous, catheterizable pouch offers the last and only option for a long-term and definitive treatment of a patient's condition. Overall, a decreasing trend in the establishment of a continent urinary diversion is observed in Germany. Current data on benign indications for urinary diversion are limited. Therefore, further data collection and research are needed.

[Genitourinary complications after pelvic radiotherapy: Diagnosis and management]

OBJECTIVE

The purpose of this review was to present the different genitourinary complications following pelvic radiotherapy as well as their assessment and treatments.

METHODS

A review of literature was conducted using Medline/Pubmed database without period restriction. In order to write this article, we also use the 2016 AFSOS, SFRO and AFU recommendations.

RESULTS

On the one hand, early side effects are common and mild. The symptomatic treatments available generally provide effective relief to patients. On the other hand, late adverse effects need long and complex care. Its side effects alter the quality of life and can be life-threatening. The effects of radiotherapy are irreversible. Except hyperbaric oxygen therapy and hyaluronic acid/chondroitin sulfate instillations, treatments remain symptomatic. Urethrovesical fibroscopy is essential in cases of gross hematuria, and urodynamic assessment (or videourodynamic) can be used in cases of severe vesicosphincter disorders. Pharmacological treatments are less effective than in non-radiation patients, and the morbidity of surgical treatments is higher in this population.

CONCLUSION

Genitourinary complications after pelvic radiotherapy are frequent and mild in the early phase but rare and severe in the late phase. Their management is based on a vast diagnostic and therapeutic arsenal, but the treatments are only symptomatic, and the sequelae of radiotherapy remains, to date, irreversible.

"Labia majora fasciocutaneous flap reconstruction in complex urogynecological fistulas with vaginal deficit - A versatile approach"

OBJECTIVES

To appraise the pivotal points of different modifications of labia majora fasciocutaneous flap in combating the challenges of complex urogynecological fistula repair in the form of seven cases.

METHODS

Seven patients with complex urogynecological fistulas with vaginal deficit were treated over last three years. The challenges associated with them were non-capacious rigid vagina, irradiated and inflamed surrounding tissues, inelasticity, long-standing fistula with radiation-induced vesicovaginal fistula(VVF), an iatrogenic urethrovaginal fistula with anterior vaginal wall loss with vaginal stenosis, and a case of vesicolabial fistula with a history of forceps delivery and transvaginal VVF repair. Transvaginal repair with labia majora fasciocutaneous flap along with fat pad with relevant technical modifications was contemplated in all.

RESULTS

All radiation-induced VVF patients demonstrated no leak in the postoperative period barring one who became dry after transvaginal colpocleisis later. The patient with urethrovaginal fistula and vaginal stenosis was continent, had capacious vagina, and without any leak with regular menstrual periods. The female with vesicolabial fistula remained dry at the end of six-month follow-up.

CONCLUSION

Transvaginal repair using the labia majora fasciocutaneous flap and the demonstrated technical modifications can be a feasible option in repairing complex urogynaecological fistulas associated with vaginal wall deficit.

Vesicovaginal fistula repair experiences in a single center high volume of 33 years and necessity of cystostomy

OBJECTIVE

The aim of this study was to retrospectively examine the patients who underwent surgical treatment for vesicovaginal fistula (VVF) repair in our clinic, to evaluate our surgical preferences, success, and treatment results, to compare these with the literature, and firstly to reveal the necessity of cystostomy and its effect on treatment success.

MATERIAL AND METHODS

Between 1985 and 2018, a retrospective evaluation was performed on the records of 102 patients who underwent surgical treatment for VVF repair. All cases underwent a detailed physical examination and had their routine laboratory tests and imaging methods. In obese patients, a Foley catheter was moved into the bladder through the fistula tract, then inflated in order to push the vagina and bladder wall upwards. A transurethral catheter was used in all cases, and cystostomy was used in 58 (56.9%).

RESULTS

The most common cause was prior hysterectomy for benign diseases in 35 (34.31%) cases. Among a total of 102 cases with for VVF, 95 (93.1%) were primary, 5 (4.9%) secondary, and 2 (1.9%) tertiary. The transvesical and O'Connor approaches (transabdominal) were performed in 61 (59.8%) and 41 (40.2%) cases, respectively. Transvaginal approach was not used in any of the cases. Cystostomy was applied in 58 (56.9%) of cases and not applied in 44 (43.1%).

CONCLUSION

Complete excision of the fistula tract and sealing of the layers separately using the water-tight technique are extremely crucial factors to increase the success rate of VVF repair. In cases where good transurethral drainage is ensured, cystostomy is unnecessary and may increase the risk of infection.