An update on surgery for vesicovaginal and urethrovaginal fistulae

Management of urinary-tract fistulas using reversible balloon nephrostomy: a single-center retrospective analysis of 56 patients

PURPOSE

To evaluate the effectiveness of balloon nephrostomy (BN) for treating urinary tract fistulas.

MATERIALS AND METHODS

In a single-center retrospective analysis, 56 patients were treated using BN between 2003 and 2014. All causes of urinary tract fistula were included. We assessed the effectiveness of drainage, complications, and the types of reconstruction surgery used. Success was defined as fistula closure without surgery.

RESULTS

The cohort consisted of 25 males (54%) and 31 females (55%) with a median age of 63 years who underwent BN for a urinary fistula secondary to surgery, i.e., urologic (40%; n = 22), gynecologic (34%; n = 19), or digestive (20%; n = 11). Of these patients, 48 (86%) had a history of cancer (49% had a tumor progression). Median drainage time was 90 days (10-583), with an average of three successive readjustments needed per patient. We obtained a 21% success rate (n = 12), morbidity was 6.5% (urinary sepsis, renal abscess, ureteral stricture), and 7% of patients developed ureteral stricture after balloon removal. There was no recurrence of any fistula within a median follow-up time of 15.2 months.

CONCLUSION

This minimally invasive procedure can be used for selected urinary tract fistulas with few complications. It can also be used safely in populations that have several comorbidities.

How and why to take a Martius labial interposition flap in female urology

The Martius modified labial fat pad flap at nearly 90 years old is still very much part of the modern vaginal surgeon’s armamentarium. Here we describe this straightforward and adaptable technique, the avoidance of pitfalls, its advantages and uses in vaginal surgery, and outcomes both short and long term. Specifically patient reported outcomes related to scar perception and sexual function are explored.

Quantifying uncertainty in intervention effectiveness with structured expert judgement: an application to obstetric fistula

OBJECTIVE

To demonstrate a new application of structured expert judgement to assess the effectiveness of surgery to correct obstetric fistula in a low-income setting. Intervention effectiveness is a major input of evidence-informed priority setting in healthcare, but information on intervention effectiveness is generally lacking. This is particularly problematic in the context of poorly resourced healthcare settings where even efficacious interventions fail to translate into improvements in health. The few intervention effectiveness studies related to obstetric fistula treatment focus on the experience of single facilities and do not consider the impact of multiple factors that may affect health outcomes.

DESIGN

We use the classical model of structured expert judgement, a method that has been used to quantify uncertainty in the areas of engineering and environmental risk assessment when data are unavailable. Under this method, experts quantify their uncertainty about rates of long-term disability in patients with fistula following treatment in different contexts, but the information content drawn from their responses is statistically conditioned on the accuracy and informativeness of their responses to a set of calibration questions. Through this method, we develop best estimates and uncertainty bounds for the rate of disability associated with each treatment scenario and setting.

PARTICIPANTS

Eight experts in obstetric fistula repair in low and middle income countries.

RESULTS

Estimates developed using performance weights were statistically superior to those involving a simple averaging of expert responses. The performance-weight decision maker's assessments are narrower for 9 of the 10 calibration questions and 21 of 23 variables of interest.

CONCLUSIONS

We find that structured expert judgement is a viable approach to investigating the effectiveness of medical interventions where randomised controlled trials are not possible. Understanding the effectiveness of surgery performed at different types of facilities can guide programme planning to increase access to fistula treatment.

Genitourinary Fistula: An Indian Perspective

BACKGROUND

In developing countries, obstetric trauma is the most common cause of genitourinary fistulae. But over the last two decades, health care facilities have been improved and the scenario has been changed.

PURPOSE

The aim of the present study is to share our experience with genitourinary fistula in terms of mode of presentation, diagnostic modality, and management with the emphasis on the surgical approach and a parallel review of the available literature.

MATERIALS AND METHOD

During a 6-year period from January 2007 to December 2013, 41 cases of genitourinary fistula, who admitted and treated in the urology department of a tertiary care center, were retrospectively analyzed for etiology, site, size and number of fistulae, clinical presentation, diagnostic modalities, and management. The literature search was done using the Medline database.

RESULT

Mean age of the patient was 27 years (range 16-51). Primary and simple fistulae were common. Obstetric trauma was the most common etiology (56.09 %) followed by iatrogenic (39.03 %). Vesicovaginal fistula was the most common type (78.37 %) and trigone was the most common site involved (51.72 %). 51.35 % of patients were approached successfully by the vaginal route. Ancillary procedures were required in patients for various other associated anomalies at the time of fistula repair. The success rate on follow up was 94.5 %. In the mean follow up of 3 years, 35 patients were sexually active.

CONCLUSION

Genitourinary fistula is a frustrating entity with potentially devastating psychosocial consequence. Its management poses a tricky challenge to the surgeon. Accurate and timely diagnosis, adhering on basic surgical principle, and repair by an experienced surgeon provide the optimum chance of cure.

Congenital vesicovaginal fistula: spontaneous or forced? Two cases and literature review

INTRODUCTION AND HYPOTHESIS

Congenital vesicovaginal fistula is an exceedingly rare entity. There is no consensus regarding the nature and origin of this condition. We report two cases with congenital vesicovaginal fistula and compile previously reported cases in the English literature. Theories behind the genesis of this anomaly will be briefly presented.

METHODS

We describe the presentation, diagnostic workup, and management of two patients with congenital vesicovaginal fistula. Previously reported cases were retrieved through an extensive English literature review using Medline and PubMed. Cases are tabulated based on the presence or absence of vaginal menstrual outflow obstruction.

RESULTS

Two women, aged 23 and 17, had had cyclic hematuria since puberty that was perceived as normal menstruation. One woman presented with an inability to have sexual intercourse, and the other with severe cyclic pelvic pain. Diagnostic workup unveiled congenital vesicovaginal fistula and distal vaginal agenesis in both. One had abnormal ureteric insertion, while the other had a history of anomalies unrelated to the urogenital system. Successful surgical correction of fistula was undertaken in both. An English literature review revealed 23 reported cases of congenital vesicovaginal fistula. While 74 % had concomitant menstrual outflow obstruction, the remaining had normal menstruation per vagina.

CONCLUSION

Congenital vesicovaginal fistula can present as an isolated anomaly, or associated with complex malformations of a wide spectrum. The presenting symptoms as well as the age at diagnosis vary widely. While the term "congenital" implies its genesis before birth, a congenital vesicovaginal fistula can be a manifestation of faulty embryological development, but also the result of outflow obstruction.

Sexual function after vaginal and abdominal fistula repair

OBJECTIVE

The purpose of this study was to compare clinical outcomes and sexual function between transvaginal and transabdominal repairs of vesicovaginal fistulae (VVF).

STUDY DESIGN

Participants (99 women with VVF at a tertiary referral center) were treated with urinary catheterization for 12 weeks and, if the procedure was unsuccessful, underwent repair using either the transvaginal (Latzko) or transabdominal technique. Objective clinical parameters were analyzed; subjective outcomes were recorded prospectively before surgery and at the 6-month follow-up examination with the use of the female sexual function index to evaluate sexual function and the visual analog scale to measure general disturbance by the fistula.

RESULTS

After bladder drainage for 12 weeks, 8 patients had spontaneous fistula closure. Demographic variables were similar in the transvaginal (n = 60) and transabdominal (n = 31) repair groups. The transvaginal procedure showed significantly shorter operation times, less blood loss, and shorter hospital stay. Continence rates 6 months after surgery were 82% (transvaginal) and 90% (transabdominal). Sexual function in the 64 sexually active patients was significantly improved, and overall disturbance by the fistula was reduced with both operative techniques. Neither surgical intervention was superior to the other regarding sexual function or visual analog scale.

CONCLUSION

Fistula repair improves sexual function and quality of life with no difference attributable to surgical route. Given this and that operating time, blood loss and length of stay are less with the transvaginal approach, the transvaginal approach is preferred in VVF repair if fistula and patient characteristics are suitable.

Robotic repair of vesico-vaginal fistula with perisigmoid fat flap interposition: state of the art for a challenging case?

Since its introduction, robotic-assisted operations have established themselves in an increasingly wide range of procedures. We applied this approach as a viable surgical alternative for the management of a complex vesicovaginal fistula. We present the case of a patient with total urinary incontinence due to the formation of a vesicovaginal fistula, following total abdominal hysterectomy. The fistula was located at the vaginal vault and at approximately one cm from the right ureteric orifice. For this specific scenario a robotic approach was chosen over the vaginal-, laparotomic- and laparoscopic repair, as in our view it offered the best possibility to specifically treat the target anatomy with a reduced risk for involvement of the surrounding structures, while maintaining a low morbidity and a quick postoperative recovery.In our video we show how the vesicovaginal fistula can be repaired by interposition of a vascularized flap of perisigmoid fat, in order to reduce the risk of recurrences [Ezzat et al., Repair of giant vesicovaginal fistulas, 181(3):1184-1188, 2009].The postoperative course was uneventful; on postoperative day 1 the patient reported pain of 2/10 on a VAS scale (0 = no pain; 10 = unbearable pain) and was mobilized. She was discharged on postoperative day two with bladder catheter in situ. The successful repair of the fistulous tract was confirmed via retrograde cystogram on postoperative day 10 and the patient was continent immediately after catheter removal. At the six month follow up visit the patient had no complaints.

Urologic disease in a resource-poor country

BACKGROUND

Understanding the role that urologic disease plays within central Haiti could lead to the development of sustainable and regionally appropriate urologic care. We aim to document the prevalence of urologic surgical disease presenting for treatment in central Haiti.

METHODS

The present study is based on a retrospective review of surgical case logs at five Partners in Health and Zanmi Lasante hospitals in central Haiti. Data were collected from June 30, 2009, through July 29, 2010, and included patient demographics, disease processes, interventions required, surgeon name, and surgeon training (urologic trained versus non-urologic trained).

RESULTS

Urologic surgical disease comprised 498/5,539 (9.0 %) of all surgical cases in central Haiti from July 2009-July 2010. A total of 492 diagnoses and 498 urologic procedures on 469 patients were recorded. Most common diagnoses included hydrocele (33.3 %), phimosis (23.0 %), benign prostatic hyperplasia (10.8 %), and cryptorchidism (7.3 %). Hydrocelectomy was the most commonly performed procedure (160/498, 32.1 %), followed by circumcision (117/498, 23.4 %) and open prostatectomy (38/498, 7.6 %). Surgeon training (urologic versus non-urologic) was determined for 360/498 (72.3 %) of surgical cases. Urologic trained surgeons performed 55/360 (15.3 %) of all surgical procedures. Among patients who underwent prostatectomy, urology surgeons performed 14/31 (45.2 %) of open prostatectomies, and non-urology surgeons performed 17/31 (54.8 %). Urologists performed all transurethral resections of the prostate (9 vs. 0; p = 0.0051).

CONCLUSIONS

Urologic surgical diseases comprise a substantial source of morbidity for patients in central Haiti. Understanding the scale and scope of urologic disease is important in developing health systems to adequately address the regional burden of surgical disease in limited-resource settings.

Laparoscopic transabdominal transvesical repair of supratrigonal vesicovaginal fistula

INTRODUCTION AND HYPOTHESIS

We investigated the clinical efficacy of early laparoscopic repair of supratrigonal vesicovaginal fistula.

METHODS

Laparoscopic repair of vesicovaginal fistula was performed and retrospectively studied in 18 consecutive patients who had clear indications for iatrogenic supratrigonal vesicovaginal fistula following hysterectomy or obstetric trauma during delivery. All patients underwent laparoscopic surgery via the transabdominal transvesical route. Wide mobilization of the bladder and vaginal wall, complete excision of devitalized tissue, tension-free closure, omental interposition, and efficient postoperative bladder drainage provides dependable support for definitive closure of the path. Success was defined as the disappearance of the fistula.

RESULTS

Average patient age was 36.7 years; none required open conversion. Mean operative time was 135 (range 75-175) min. Mean duration of bladder catheterization was 15 (range 14-16) days. All patients were cured at the first attempt, with no surgical reintervention or recurrence at a mean follow-up of 22.7 (range 3-45) months.

CONCLUSIONS

We believe that laparoscopic repair of supratrigonal vesicovaginal fistula is an excellent alternative to the traditional abdominal approach and provides excellent results.