Accurate anatomic repair of obstetric anal sphincter damage or rectovaginal fistula aided by prior ultrasonograghy: a cohort study

Anorectal obstetric injuries resulting in anal sphincter damage (ASD) and rectovaginal fistula (RVF) remain a major problem. The resulting flatus or faecal incontinence is devastating. Surgical repair remains a challenge. Postpartum RVF primarily results from ischaemic pressure necrosis following obstructed labour. The fistula tract is surrounded by a fibrous scar. ASD usually results from precipitous labour. The injury heals by fibrous scar leading to varying degrees of anal incontinence. Contraction and retraction of muscles around the injury renders the defect and fibrous scar larger than the primary injury. Anorectal ultrasonography has been used to define RVF and ASD, and the associated fibrous scar.

Patients and methods

A retrospective review of patients who underwent transvaginal surgical repair of RVF and ASD was undertaken. Patients were preoperatively assessed for pathology and incontinence degree. Anorectal ultrasonography was used to define ASD or RVF and the associated scar preoperatively. Repair of RVF or ASD entails total excision of the scar with accurate anatomical layers reconstruction of healthy tissues.

Results

There were 23 patients, 8 RVF with a mean (SD) age 29 (6.78) years and 17 ASD with a mean (SD) age 35.25 (15.90). Twenty followed obstetric trauma (6RVF, 14 ASD), 1 prior rectocoele repair (ASD), 2 rape (1RVF + 1 ASD) and 1 was idiopathic (RVF). All patients had 1 or more prior repairs except for idiopathic RVF. Operative technique entailed transvaginal complete excision of the fibrous scar and accurate anatomical reconstruction of healthy tissue layers. A colostomy was not routinely used. There were three significant postoperative complications: ASD breakdown from an infected haematoma; perianal abscess, later a sinus after drainage; and RVF repair dehiscence during early coitus. All patients had full continence after 8 months minimum follow-up.

Conclusion

Complete excision of the fibrous scar and accurate anatomical tissue layers reconstruction of the obstetric RVF or ASD, aided by prior ultrasonography, yielded good results.

Is there still an indication for episiotomy? Results from a French national database analysis

OBJECTIVE

To assess the link between mediolateral episiotomy and the occurrence of obstetrical anal sphincter injury (OASIS).

METHODS

Data were collected from the national database (PMSI; Programme de Médicalisation des Systèmes d'Information). Women between 18 and 50 years old, undergoing a vaginal delivery in France in 2018 were included. The main outcome was factors associated with a higher adjusted OASIS rate after a vaginal delivery.

RESULTS

Of 623 003 women with a vaginal delivery, 239 949 were primiparous (38.5%), 62 310 experienced mediolateral episiotomy (10.0%) and 7077 had a third- or fourth-degree perineal tear (1.14%). Risk factors for OASIS were primiparity (adjusted odds ratio [OR] 2.97), shoulder dystocia (aOR 2.57), instrumental delivery (aOR 2.81), gestational diabetes (aOR 1.20), and post-term delivery (aOR 1.53). Mediolateral episiotomy increased the occurrence of OASIS for women without an instrumental delivery, either for parous (OR 1.32, 95% confidence interval [CI] 1.07-1.62) or primiparous (OR 1.26, 95% CI 1.13-1.39) women. In contrast, episiotomy among primiparous women with episiotomy and a vacuum or forceps delivery significantly decreased the risk for OASIS (OR 0.62, 95% CI 0.56-0.67).

CONCLUSIONS

The practice of routine episiotomy should be discouraged. Selective mediolateral episiotomy should be considered with extreme caution and mainly for primiparous women during instrumental vaginal delivery. Further randomized trial may confirm such results.

Isolated recto-vaginal septum injury during parturition: Single-center experience

BACKGROUND

Traumatic rectal injuries are uncommon and can originate due to various causes. Rectal injuries have a high mor-bidity, regardless of cause, and detection at the time of occurrence is important to prevent fistula formation and/or stoma. In this article, treatment approaches in patients with isolated rectovaginal septum injury without perineal and sphincter injury during sponta-neous vaginal delivery are presented and the current literature is reviewed.

METHODS

The records of spontaneous vaginal deliveries that resulted in live births between January 2015 and January 2020 were analyzed retrospectively at our center. The records of patients with isolated rectovaginal septum injury were evaluated in terms of demographic and obstetric data, trauma, classification of injury, and early and late results.

RESULTS

Isolated septum injuries were detected 12 women (0.06%). Of the isolated rectovaginal septum injuries, 9 (75%) were clas-sified as Type III, 2 (16.6%) as Type IV, and 1 (8.3%) as a Type V injury according to the Rosenshein classification. Transvaginal repair was performed because all of the injuries underwent early surgical intervention, were limited, and exploration through the vagina was possible.

CONCLUSION

Rectal examination should be performed simultaneously with a detailed perineal examination after vaginal delivery. For birth-related rectal injuries detected early in appropriate patients, a primary repair without diversion stoma may be the best option.

Robot-assisted laparoscopic repair of injuries to bladder and ureter following gynecological surgery and obstetric injury: A single-center experience

Introduction:

The objective of the study is to evaluate the outcome of robot-assisted laparoscopic repair of injuries to urinary tract following gynecological surgery and obstetric injury.

Methods:

This retrospective analysis from prospectively collected data of repair of injuries to bladder and ureter using da Vinci Si robotic platform was carried out. Between April 2014 and May 2019, 27 patients were operated on in a single surgical unit; 25 had hysterectomy and 2 were obstetric cases. Fifteen patients underwent vesicovaginal fistula (VVF) repair, ten underwent ureteral reimplant, with concomitant psoas hitch, and two underwent Boari flap repair following gynecological surgery and obstetric injury.

Results:

Among 15 patients of VVF repair, 3 cases were previously attempted failed repair, 2 underwent concomitant ureteral reimplant, and 1 underwent concomitant ovarian cystectomy. The mean total operative time was 126 (75–206) min, and the mean hospital stay was 4.4 (3–6) days. Among 12 cases of ureteral injury, 5 were on the right side and 7 were on the left side; the mean total operative time was 150.16 (110–215) min, and the mean hospital stay was 4 (3–7) days. No case required conversion to open in this cohort. All cases were successfully cured without any recurrence of fistula or stricture during their mean follow-up period of 35.3 (9–66) months.

Conclusions:

Robot-assisted laparoscopic repair for injuries to bladder and ureter is effective and highly successful even in previously failed cases.

The natural history of recovery of elbow flexion after obstetric brachial plexus injury managed without nerve repair

In this study, we report the outcome for spontaneous recovery of elbow flexion in obstetric brachial plexus injury managed without nerve reconstruction. Excluding those with transient paralysis, our records revealed 152 children with obstetric brachial plexus injury born before our unit routinely offered brachial plexus reconstruction. Five had had nerve repairs. Of the remainder, only one patient had insufficient flexion to reach their mouth. Elbow flexion started to recover clinically at a mean age of 4 months for Narakas Group 1, 6 months for Group 2, 8 months for Group 3 and 12 months for Group 4. The mean active range of elbow flexion, in 44 cases, was 138°. The mean isometric elbow flexion strength, in 39 patients, was 63% (range 23%-100%) of the normal side. It appears to be rare for elbow flexion not to recover spontaneously, although recovery occurs later in more severe injuries. It is doubtful if nerve reconstruction can improve elbow flexion above the likely spontaneous recovery in babies with obstetric brachial plexus injuries.

LEVEL OF EVIDENCE

II.

Women's views on autologous cell-based therapy for post-obstetric incontinence

AIM

Fecal and urinary incontinence are devastating consequences of obstetric-related perineal injury. The aim of the present study is to determine acceptability to parous women of autologous cell-based therapy for fecal and urinary incontinence that arises due to pelvic diaphragm tearing during vaginal childbirth.

MATERIALS & METHODS

A multiple choice questionnaire survey was offered to 76 parous women at the Maternity Unit, University College Hospital, London, UK. Seventy completed questionnaires - response rate: 92%.

RESULTS

In total, 84% of women indicated a willingness to accept autologous cell-based therapy for obstetric injury-induced incontinence rather than surgery.

CONCLUSION

These observational data provide an indication of likely acceptance of autologous cell-based therapies for birth injury incontinence and will help with designing new therapeutic approaches.

Obstetrics and fecal incontinence

Anal incontinence (AI) can be a debilitating condition for women following vaginal delivery. Operative vaginal delivery and anal sphincter laceration are important risk factors for the development of postpartum AI. Obtaining a comprehensive delivery history, along with a thorough physical examination of the perineum, vagina and rectum may aid the clinician in the diagnosis of an anal sphincter defect. Sonographic imaging can also assist in identifying sphincter defects. The treatment of AI may include a combination of dietary modification, medications that promote constipation, pelvic floor physical therapy, biofeedback, anal sphincteroplasty, and/or sacral neuromodulation.

Obstetrics and fecal incontinence

Anal incontinence (AI) can be a debilitating condition for women following vaginal delivery. Operative vaginal delivery and anal sphincter laceration are important risk factors for the development of postpartum AI. Obtaining a comprehensive delivery history, along with a thorough physical examination of the perineum, vagina and rectum may aid the clinician in the diagnosis of an anal sphincter defect. Sonographic imaging can also assist in identifying sphincter defects. The treatment of AI may include a combination of dietary modification, medications that promote constipation, pelvic floor physical therapy, biofeedback, anal sphincteroplasty, and/or sacral neuromodulation.