Interposing layer of fibrin glue: A new horizon in vesico-vaginal fistula repair

Repair of Vesicovaginal Fistulae: A Systematic Review

OBJECTIVE

To assess and compile the current level of evidence regarding successful surgical treatment of vesicovaginal fistulae and how these perioperative interventions affect anatomic, patient-centered, and adverse outcomes.

DATA SOURCES

PubMed and EMBASE were searched from inception through September 9, 2022.

METHODS OF STUDY SELECTION

This review included comparative studies (of any sample size) and single-group studies (1,000 or more participants) of primary or recurrent vesicovaginal fistula (ie, vesicovaginal fistula, urethrovaginal fistula, and bladder neck-vaginal fistula). We evaluated preintervention assessment or management, various techniques for intraoperative management, and postoperative management. Outcomes of interest included anatomic and objective outcomes (such as successful repair, fistula closure, urinary incontinence, recurrent fistula, perioperative complications) and subjective outcomes (such as voiding symptoms and quality of life). Abstracts and full-text articles were screened in duplicate, and study descriptions and findings were extracted into standardized extraction forms. Risk of bias was assessed independently by two investigators and adjudicated by a third. Study quality was summarized with standardized tools. We conducted random-effects model and restricted maximum-likelihood meta-analyses of relative risks when at least three studies compared similar interventions and reported similar outcome measures.

TABULATION, INTEGRATION, AND RESULTS

Forty-six studies met the inclusion criteria. Studies were categorized into 11 domains: 1) preoperative assessment, 2) preoperative and postoperative physical therapy, 3) route of surgery, 4) incorporation of a flap, 5) trimming, 6) layered closure, 7) intraoperative antibiotics, 8) fibrin glue, 9) fascial sling, 10) postoperative Foley catheter duration, and 11) quality of life. Although the strength of the data is insufficient, preoperative phenazopyridine, physical therapy, layered closure, and intraoperative antibiotics seemed to improve the rate of successful fistula repair. Route of surgery (vaginal vs abdominal laparotomy) was determined primarily by surgeon preference and showed no difference in successful fistula repair. In addition, use of interpositional flaps, trimming fistula edges, fibrin glue, and fascial sling did not show significant improvement in rates of fistula cure. Overall, quality-of-life scores improved postoperatively regardless of route of repair and use of interpositional flaps.

CONCLUSION

Our findings highlight the limited information available to guide evidence-based treatment of vesicovaginal fistula repair. Overall, high-quality evidence is lacking to provide guidelines; therefore, expert opinion remains the primary influence for fistula repair recommendations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021214948.

Vesicovaginal Fistulas: Prevalence, Impact, and Management Challenges

Background and Objectives: Vesicovaginal fistulas (VVFs) are an abnormal communication between the vagina and bladder and the most common type of acquired genital fistulas. This review will address the prevalence, impact, and management challenges of VVFs. Materials and Methods: Epidemiologic studies examining VVFs are considered. In addition, publications addressing the treatment of VVFs are reviewed. Results: VVFs in developing countries are often caused by obstructed labor, while most VVFs in developed countries have iatrogenic causes, such as hysterectomy, radiation therapy, and infection. The reported prevalence of VVFs is approximately 1 in 1000 post-hysterectomy patients and 1 in 1000 deliveries. VVFs affect every aspect of quality of life, including physical, mental, social, and sexual aspects. Prevention of VVFs is essential. Early diagnosis is necessary to reduce morbidity. Nutrition, infection control, and malignancy detection are important considerations during evaluation and treatment. Conservative and surgical treatment options are available; however, these approaches should be customized to the individual patient. The success rate of combined conservative and surgical treatments exceeds 90%. Conclusions: VVFs are considered debilitating and devastating. However, they are preventable and treatable; key factors include the avoidance of prolonged labor, careful performance of gynecologic surgery, and early detection.

The Microcirculation of Vaginal Tissue in Women with Obstetric Vesicovaginal Fistula and Short-Term Effects of Surgical Repair on Microvascular Parameters

OBJECTIVES

The objective of the study was to better understand the extent of the ischemic trauma and the effects of surgical repair on the vaginal microcirculation in patients with obstetric vesicovaginal fistula (VVF).

DESIGN

In this observational study, we evaluated the vaginal microvasculature surrounding VVF using handheld vital microscopy (HVM) before, during, and 2 weeks after surgical VVF repair.

PARTICIPANTS

Seventeen women undergoing VVF repair were included in this study.

SETTING

The study was conducted in the Fistula Care Centre in Lilongwe, Malawi.

METHODS

We used HVM with incident dark-field imaging to non-invasively visualize the microvasculature of the vaginal tissue surrounding fistulas. The primary outcome was the presence of microvascular flow. Secondary outcomes included angioarchitecture, fistula closure (postoperative dye test), and urinary continence (pad weight test).

RESULTS

Microvascular flow was present before, during, and after surgical repair in, respectively, 83.8%, 83.9%, and 93.4% of obtained image sequences. The angioarchitecture was normal in 75.8% of the image sequences before surgery, 69.4% at fistula closure, and 89.1% two weeks after VVF repair. Fourteen (82.4%) patients had a closed fistula after surgical repair.

LIMITATIONS

The study was limited by the lack of a control group and the relatively small sample size.

CONCLUSION

Although the vaginal microcirculation in women with VVF is compromised, extensive ischemic damage is not observed in the tissue surrounding fistulas. This suggests significant regenerative capacity of the vaginal vasculature in young women, or less extensive ischemic damage than presumed. Following surgical repair, we observed improvement of microcirculatory flow and angioarchitecture, suggesting that surgery is a good option for patients with obstetric VVF.

The use of tissue adhesive in management of genitourinary fistulas: a systematic review and case report

INTRODUCTION AND HYPOTHESIS

Articles are getting published on the use of tissue adhesive for vesicovaginal fistula. The objective is to carry out a systematic review on their effectiveness and complications.

METHODS

A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Two reviewers screened abstracts and full-text and extracted data independently. A narrative synthesis was conducted given the heterogeneity of studies.

RESULTS

A total of 1032 studies were identified after searching the database, and 14 articles were included in this systematic review. Of the 84 women included, 12 (14.3%) presented failure or recurrence of their fistula tract. The mean time of follow-up was 11.46 months. The average size of the fistula was 1.05 (range 0.1 to 3.9) cm. Most fistulas (81) included were vesicovaginal fistulas. Nine papers reported the usage of fibrin glue in which only three (6.5%) women reported recurrence of the fistula in a delay of 2 weeks to 26 months. The other studies used cyanoacrylate (14 women) and autologous fibrin injection from the patients' blood (31 women). No significant complications were reported. Complications reported were urinary tract infections in 3 women (3.6%), hematuria in 2 women (2.4%), overactive bladder symptoms in 6 women (7.2%) and septic pelvic thrombosis in one woman (1.2%).

CONCLUSIONS

Tissue adhesive appears to be a promising alternative for management of urogenital fistulas without reported important complications.

A scoping review of tissue interposition flaps used in vesicovaginal fistulae repair

Background

Research on the use of tissue interposition flaps (TIFs) in vesicovaginal fistulae (VVF) repair is a broad area where a very wide range of natural and synthetic materials have been used. The occurrence of VVF is also diverse in the social and clinical settings, resulting in a parallel heterogeneity in the published literature on its treatment. The use of synthetic and autologous TIFs in VVF repair is not yet standardized with a lack of the most efficacious type and technique of the TIF.

Objectives

The aim of this study was to systematically review all synthetic and autologous TIFs used in the surgical repair of VVFs.

Data sources and methods

In this scoping review, the surgical outcomes of autologous and synthetic interposition flaps used in VVF treatment meeting the inclusion criteria were determined. We searched the literature using Ovid MEDLINE and PubMed databases between 1974 and 2022. Study characteristics were recorded, and data on the change in fistulae size and location, surgical approach, success rate, preoperative patient evaluation and outcome evaluation were extracted from each study independently by two authors.

Results

A total of 25 articles that met the inclusion criteria were included in the final analysis. A total of 943 and 127 patients who had received autologous and synthetic flaps, respectively, were included in this scoping review. The fistulae characteristics were highly variable with regard to their size, complexity, aetiology, location and radiation. Outcome assessments of fistulae repair in included studies were mostly based on symptom evaluation. Physical examination, cystogram and methylene blue test were the methods in order of preference. Postoperative complications, such as infection, bleeding, donor site, pain, voiding dysfunction and other complications, were reported in patients after fistulae repair in all included studies.

Conclusion

The use of TIFs in VVF repair was common especially in complex and large fistulae. Autologous TIFs appear to be the standard of care at the moment, and synthetic TIFs were investigated in prospective clinical trials in a limited number of selected cases. Evidence levels of clinical studies evaluating the effectiveness of interposition flaps were overall low.