Technical aspects in the management of complex vesicovaginal fistulae

Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: A systematic review and meta-analysis

Background

Vesicovaginal fistulas (VVF) are the most commonly acquired fistulas of the urinary tract, but we lack a standardized algorithm for their management. Surgery is the most commonly preferred approach to treat women with primary VVF following benign gynaecologic surgery.

Objective

To carry out a systematic review and meta-analysis on the effectiveness of operative techniques or conservative treatment for patients with postsurgical VVF. Our secondary objective was to define the surgical time and determine the types of study designs.

Methods

PubMed, Old Medline, Embase and Cochrane Central Register of Controlled Trials were used as data sources. This systematic review was modelled on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, including a registration number (CRD42012002097).

Results

We reviewed 282 full text articles to identify 124 studies for inclusion. In all, 1379/1430 (96.4%) patients were treated surgically. Overall, the transvaginal approach was performed in the majority of patients (39%), followed by a transabdominal/transvesical route (36%), a laparoscopic/robotic approach (15%) and a combined transabdominal-transvaginal approach in 3% of cases. Success rate of conservative treatment was 92.86% (95%CI: 79.54–99.89), 97.98% in surgical cases (95% CI: 96.13–99.29) and 91.63% (95% CI: 87.68–97.03) in patients with prolonged catheter drainage followed by surgery. 79/124 studies (63.7%) provided information for the length of follow-up, but showed a poor reporting standard regarding prognosis. Complications were studied only selectively. Due to the inconsistency of these data it was impossible to analyse them collectively.

Conclusions

Although the literature is imprecise and inconsistent, existing studies indicate that operation, mainly through a transvaginal approach, is the most commonly preferred treatment strategy in females with postsurgical VVF. Our data showed no clear odds-on favorite regarding disease management as well as surgical approach and current evidence on the surgical management of VVF does not allow any accurate estimation of success and complication rates. Standardisation of the terminology is required so that VVF can be managed with a proper surgical treatment algorithm based on characteristics of the fistula.

Obstetric fistula in low-resource countries: an under-valued and under-studied problem--systematic review of its incidence, prevalence, and association with stillbirth

BACKGROUND

Obstetric fistula (OF) is a serious consequence of prolonged, obstructed labor in settings where emergency obstetric care is limited, but there are few reliable, population-based estimates of the rate of OF. Stillbirth (SB) is another serious consequence of prolonged, obstructed labor, yet the frequency of SB in women with OF is poorly described. Here, we review these data.

METHODS

We searched electronic databases and grey literature for articles on OF in low-resource countries published between January 1, 1995, and November 16, 2014, and selected for inclusion 19 articles with original population-based OF incidence or prevalence data and 44 with reports of frequency of SB associated with OF.

RESULTS

OF estimates came from medium- and low-HDI countries in South Asia and Africa, and varied considerably; incidence estimates ranged from 0 to 4.09 OF cases per 1000 deliveries, while prevalence estimates were judged more prone to bias and ranged from 0 to 81.0 OF cases per 1000 women. Reported frequency of SB associated with OF ranged from 32.3 % to 100 %, with estimates from the largest studies around 92 %. Study methods and quality were inconsistent.

CONCLUSIONS

Reliable data on OF and associated SB in low-resource countries are lacking, underscoring the relative invisibility of these issues. Sound numbers are needed to guide policy and funding responses to these neglected conditions of poverty.

Management of female uro-genital fistulas: Framing certain guidelines

BACKGROUND

The study was carried out to discuss the pathogenesis and management protocol of seven different varieties of female uro-genital fistulas (FUGFs).

PATIENTS AND METHODS

During 2000-2007, total of 15 FUGFs were operated, which belonged to seven different varieties requiring different routes and surgical procedures for their repair. Different fistulas with different pathophysiological factors required specific examinations and investigations preoperatively.

RESULTS

The results of the repaired FUGFs, following the general surgical principles, were acceptable with formation of only one residual fistula.

CONCLUSIONS

Successful correction of FUGFs is a surgical challenge. Detailed history, through examination and planning, atraumatic tissue handling, routine use of the interposition or onlay reinforcement flaps and vigilant postoperative care were found the key factors in successful outcome of the repaired fistulas.

Peri-vesical fat interposition flap reinforcement in high vesico-vaginal fistulas

Background and Aim:

The urinary bladder becomes small, contracted and is associated with excess pelvic fat in long standing cases of vesico-vaginal fistulas (VVFs). The aim of this new technique was to use this excess pelvic fat for harvesting an interposition flap.

Materials and Methods:

An interposition flap of peri-vesical fat was raised from the anterior, superior and posterior surfaces of the urinary bladder and was interposed between the right angle closed vaginal vault and the urinary bladder to strengthen the repair. This technique was used in two patients of VVFs.

Results:

Both the patients had successful outcome and were able to retain sufficient quantity of urine at 3 months follow-up.

Conclusions:

Peri-vesical fat flap proved an effective interposition flap in the repairs of VVFs in selected cases.