Management of genital fistulas in patients with cervical cancer

Among 2096 patients treated for cervical cancer between 1985–1995, genital fistulas developed in 38 cases (1.8%). 16 patients were affected by rectovaginal, 13 patients had rectovesicovaginal and 9 patients had vesicovaginal fistulas. Median age at time of first presentation of the fistulas was 54.8 years. Fistula size ranged from 0.1 to 2.0 cm in diameter. Faecal or urinary leakage through the vagina (44.7%), bleeding (31.5%) and local pain (5.3%) were major clinical symptoms. 10 patients had surgery for the fistula, the remaining patients were managed conservatively. Accepted: 14 June 1996     

Prevention of vesicovaginal fistulas after laparoscopic hysterectomy with electrosurgical cystotomy in female mongrel dogs

OBJECTIVE: Using a previously described animal model, we sought to compare 3 methods of double-layer cystotomy repair to each other and to single-layer repair in the prevention of vesicovaginal fistula formation. STUDY DESIGN: Twenty-four female mongrels, which were divided into 3 groups, underwent laparoscopic hysterectomy followed by monopolar electrosurgical cystotomy. Group 1 had simple 2-layer cystotomy repair with interrupted 2-0 polyglactin sutures; group 2 had resection of tissue 5 mm beyond the visible electrosurgical burn margin followed by 2-layer closure, and group 3 had interposition of an omental flap after 2-layer closure. Animals were killed at least 27 days after the operation, and a careful evaluation for vesicovaginal fistulas was undertaken by retrograde bladder filling. Group results were compared with one another and to a historic control group of 8 dogs that had undergone cystotomy repair with single-layer closure. RESULTS: All groups were similar in preoperative and necropsy weight. Bladder perforation occurred in 1 dog in group 1 on postoperative day 3; necropsy revealed perforation in the area of electrosurgical thermal spread with intact sutures. No vesicovaginal fistulas were noted in any of the study dogs (0/23 dogs; 95% CI, 0-12.7%) compared with 2 of 8 dogs (25%) that underwent single-layer closure (95% CI, 0-55%; P=.06). CONCLUSION: Double-layer repair appears to be superior to single-layer repair for the prevention of vesicovaginal fistulas after monopolar cystotomy. The benefit of electrosurgical burn margin excision or omental flap interposition remains unclear, but both are accomplished easily with little risk and may play a role in fistula prevention.     

Predictors of Obstetric Fistula Repair Outcomes in Lubango,Angola

ObjectiveObstetric fistulas have a significant physical and social impact on many women in Angola. The majority of the population of this sub-Saharan African nation does not have access to high-quality obstetric care, and this is associated with a risk of prolonged labour and formation of obstetric fistulas. Fistulas are challenging to correct surgically and may require repeated operations. The objective of the study was to determine predictors of successful obstetric fistula repair.MethodsIn this retrospective study, data from all recorded cases of fistula repair performed between July 2011 and December 2016 at the Centro Evangélico de Medicina do Lubango (CEML) hospital located in Lubango, Angola, were reviewed. Analysis of the data was carried out to determine factors affecting the success of fistula repair; parametric and non-parametric tests were used for group comparisons and logistic regression for outcome prediction (Canadian Task Force classification II-2).ResultsA total of 407 operations were performed on 243 women. Of these, 224 women were diagnosed with a vesicovaginal fistula and 19 with a combined vesicovaginal and rectovaginal fistula. The success rate for the attempted repairs was 42%. On multivariate analysis, the success of first surgery was negatively affected by the difficulty of repair (odds ratio 0.28; P < 0.01). For patients requiring repeat surgery, the odds of success were increased with each subsequent operation (odds ratio 5.32; P < 0.01).ConclusionAlthough fistulas rated as difficult to repair had a higher likelihood of initial failure, successive attempts at repair increased the likelihood of a successful outcome.     

A modified Mainz II pouch technique for management of refractory vesicovaginal fistulas: patient focused outcomes.

OBJECTIVE: To follow-up the quality of life outcomes in 2 women who underwent a modified Mainz II pouch procedure for refractory vesicovaginal fistulas. METHOD: Two Nigerian patients were located after undergoing a modified Mainz II pouch procedure. They were interviewed 1-2 years postprocedure regarding subsequent sexual function, pregnancy outcomes, and daily life. RESULT: After undergoing the procedure the patients had resumed sexual function, had become pregnant, and had delivered viable neonates. They were also able to provide for their families. CONCLUSION: A urinary diversion procedure for management of refractory vesicovaginal fistula can restore quality of life.     

Pregnancy and delivery after successful repair of vesicovaginal fistula

Pregnant women (110) with successfully repaired vesicovaginal fistula, supervised at the Ahmadu Bello University Teaching Hospital in Zaria, Nigeria, formed the study population. The obstetric complications, mode of delivery and fetal outcome are reviewed. The obstetric complications and fetal outcome were compared with a matched hospital control group. There was a higher complication rate among the women with vesicovaginal fistulae, and the commonest complication was urinary tract infection. Perinatal mortality rate was 17.2% in the cases compared to 10.2% in the controls.     

Vesicovaginal fistula formation in patients with Stage IVA cervical carcinoma

OBJECTIVES: To evaluate the rate of vesicovaginal fistula formation and mortality in women with Stage IVA cervical carcinoma. METHODS: Data were abstracted from the clinical records of women diagnosed with Stage IVA cervical cancer at the time of examination under anesthesia, cystoscopy, and proctoscopy (EUA/C/P) at a single institution from 1994 to 2004. Demographic and treatment characteristics were compared using either Fisher's exact test or Student's t-test, as appropriate. Survival was calculated using the Kaplan-Meier method. RESULTS: Twenty-three patients were diagnosed with Stage IVA cervical cancer. All were diagnosed with extension of disease into the bladder; one patient had rectal involvement as well. Concurrent chemotherapy and radiation was used in 60.8%, while 30.4% received radiation alone and 8.7% elected no treatment. Fifty-six percent of the patients were smokers. Eleven patients (47.8%) developed a fistula at a median time of 2.9 months from cancer diagnosis. Fistula formation was significantly increased among smokers as compared to non-smokers (73 vs 27%; p=0.03). Two patients (8.7%) are alive without evidence of disease at a median follow-up of 19 months. The disease-specific survival is 23.1 months. Patients who developed a vesicovaginal fistula had a median survival of 11.2 months after fistula formation. CONCLUSIONS: High rates of vesicovaginal fistula formation can be expected when treating women with extension of cervical cancer into the bladder, particularly among women who smoke. The routine use of EUA/C/P at the time of initial diagnosis aids in counseling women about the likelihood of this complication. Novel strategies for managing vesicovaginal fistulae after chemoradiation are needed.     

Preventing obstetric fistulas in low-resource countries: insights from a Haddon matrix

An obstetric fistula is classically regarded as an "accident of childbirth" in which prolonged obstructed labor leads to destruction of the vesicovaginal/rectovaginal septum with consequent loss of urinary and/or fecal control. Obstetric fistula is highly stigmatizing and afflicted women often become social outcasts. Although obstetric fistula has been eliminated from advanced industrialized nations, it remains a major public health problem in the world's poorest countries. Several million cases of obstetric fistula are currently thought to exist in sub-Saharan Africa and south Asia. Although techniques for the surgical repair of such injuries are well known, it is less clear which strategies effectively prevent fistulas, largely because of the complex interactions among medical, social, economic, and environmental factors present in those countries where fistulas are prevalent. This article uses the Haddon matrix, a standard tool for injury analysis, to examine the factors influencing obstetric fistula formation in low-resource countries. Construction of a Haddon matrix provides a "wide angle" overview of this tragic clinical problem. The resulting analysis suggests that the most effective short-term strategies for obstetric fistula prevention will involve enhanced surveillance of labor, improved access to emergency obstetric services (particularly cesarean delivery), competent medical care for women both during and after obstructed labor, and the development of specialist fistula centers to treat injured women where fistula prevalence is high. The long-term strategies to eradicate obstetric fistula must include universal access to emergency obstetric care, improved access to family planning services, increased education for girls and women, community economic development, and enhanced gender equity. Successful eradication of the obstetric fistula will require the mobilization of sufficient political will at both the international and individual country levels to ensure that adequate resources are devoted to this problem and that maternal health becomes a high priority on national political agendas. TARGET AUDIENCE: Obstetricians & Gynecologists and Family Physicians. LEARNING OBJECTIVES: After participating in this CME activity, physicians should be better able to apply the Haddon matrix, a tool commonly used for injury analysis, to the field of obstetrics and gynecology; analyze the problem of obstructed labor and obstetric fistula formation in low-resource countries using the Haddon matrix, and implement possible strategies for the prevention of obstetric fistulas and the mitigation of harm in cases of obstructed labor that arise from the use of the Haddon matrix.     

Minimally Invasive Management of Concomitant Vesicovaginal and Ureterovaginal Fistulas After Transabdominal Hysterectomy: Laparoscopic Vesicovaginal Fistula Repair With Ureteroneocystostomy Using a Boari Flap

Study Objective

To demonstrate a laparoscopic approach for repair of concomitant vesicovaginal and ureterovaginal fistulas as a troublesome complication of transabdominal hysterectomy (TAH).

Social Implications of Obstetric Fistula: An Integrative Review

Obstetric fistula is a devastating complication of obstructed labor that affects more than two million women in developing countries, with at least 75,000 new cases every year. Prolonged pressure of the infant's skull against the tissues of the birth canal leads to ischemia and tissue death. The woman is left with a hole between her vagina and bladder (vesicovaginal) or vagina and rectum (rectovaginal) or both, and has uncontrollable leakage of urine or feces or both. It is widely reported in scientific publications and the media that women with obstetric fistula suffer devastating social consequences, but these claims are rarely supported with evidence. Therefore, the true prevalence and nature of the social implications of obstetric fistula are unknown. An integrative review was undertaken to determine the current state of the science on social implications of obstetric fistula in sub‐Saharan Africa.     

Sexual violence-related fistulas in the Democratic Republic of Congo

OBJECTIVE: To determine the magnitude of traumatic gynecologic fistulas caused by sexual violence in the Democratic Republic of Congo. METHODS: A retrospective analysis of hospital records from 604 consecutive patients who received treatment for gynecologic fistulas at Panzi Hospital between November 2005 and November 2007. RESULTS: Of the 604 patients, 24 (4%) reported that their fistulas had been caused by sexual violence; of these, 5 (0.8%) had developed fistulas as a direct result of forced penetration with foreign objects and/or gang rapes. Of the remaining patients, 6 had a fistula before they were raped, 9 developed iatrogenic fistulas following inappropriate instrumentation to manage rape-induced spontaneous abortion or stillbirth, or after abdominal hysterectomy, and 4 developed fistulas after prolonged and obstructed labor. CONCLUSION: Traumatic fistulas are rare compared to obstetric fistulas. Fistulas indirectly related to sexual violence are likely to be more common than those directly related. All fistulas resulting from sexual violence, whether direct or indirect, should be considered traumatic and special care should be given to these women.     

Latzko operation for vault vesicovaginal fistula

BACKGROUND: Various surgical procedures are currently performed for the treatment of posthysterectomy vesicovaginal fistula. Most of them are carried out via an abdominal incision. OBJECTIVE: Report of our experience with Latzko's operation, a simple purely transvaginal procedure. METHODS: Retrospective study of vesicovaginal fistulas treated by a Latzko procedure between June 1991 and June 2005. RESULTS: Eleven patients were operated on. Two (18%) had a prior failed attempt of vesicovaginal fistula repair. Mean size of the fistulas was 12+/-11 mm (range: 2-40 mm). Mean operative duration was 62+/-33 min (range: 20-110 min). All fistulas healed. No intraoperative complications were observed. There was only one postoperative complication, a lower urinary tract infection in one patient. Mean hospital stay was 6+/-4 days (range: 2-12 days). CONCLUSIONS: The Latzko procedure is an efficient, safe, and simple technique for the management of vault vesicovaginal fistulas, and can therefore be proposed as the first-line surgical treatment.     

The use of magnetic resonance imaging in the assessment of malignant vaginal fistulas

The objective of this study was to determine whether magnetic resonance imaging (MRI) could reliably demonstrate fistulas and any associated mass and to see whether these findings were beneficial in the management of the fistula. Twelve consecutive patients presenting with suspected vaginal fistulas were examined prospectively with MRI, using a combination of sequences, for the presence, extent and configuration of fistulas and any associated mass. Comparison was made with CT when available. All patients underwent examination under anesthesia (EUA) and the findings compared. Of the 12 women presenting, seven had vesico-vaginal fistulas (VVF) and seven had recto-vaginal fistulas (RVF). Four women had both types of fistulas. The underlying pathology was cervical cancer (seven cases), colonic cancer (three cases), breast cancer (one case) and ovarian cancer (one case). Vaginal fistulas were unequivocally seen on MRI in eight of 10 cases with fistulas. In the two cases with a difference between the MRI and EUA findings, the MRI was interpreted as showing more than was found at EUA. In the seven women with VVF, MRI detected five of the cases. In the seven women with RVF, MRI detected all seven cases. Magnetic resonance imaging was correct in determining the presence of recurrent disease in the pelvis when an associated mass was seen (seven cases). Computer-assisted tomography was compared in 10 cases and in six cases, the results were comparable and in four cases, more information was obtained from the MRI. Magnetic resonance imaging appears to be accurate in detecting and defining complex gynecologic fistulas and should be considered the investigation of choice to aid the planning of restorative, salvage or palliative surgery.     

Results of treatment of vesicovaginal fistulas

OBJECTIVES: The results of treatment of 74 patients with vesicovaginal fistulas are presented. MATERIALS AND METHODS: The clinical analysis have been performed in 74 women aged from 24 to 70 years (on average 53.4), who had to be treated for vesicovaginal fistulas in the Department of Urology of Lublin University School of Medicine between 1966-1999. RESULTS: The most common cause of vesicovaginal fistulas was gynaecological surgery. Patients who-underwent the operation 96, 9% were cured (after 1st operation 84, 8%). 8 cases were cured by using conservative therapy.     

Prevention of the development of a vesicovaginal fistula

The cause of vesicovaginal fistulas after hysterectomy is not clearly understood. In an attempt to determine its cause, the records of 12 patients who had vesicovaginal fistula develop (after total abdominal hysterectomy) were compared with 12 consecutive patients who underwent total abdominal hysterectomy without fistula formation. Most of the patients who had vesicovaginal fistulas develop had excessive postoperative abdominal pain, distension or paralytic ileus, or both. Hematuria and symptoms of irritability of the bladder were also noted in the fistula group and prolonged postoperative fever and increased white blood cell count occurred more often. In contrast, the postoperative course was uncomplicated in the nonfistula group. The clinical course observed in many of the patients with vesicovaginal fistulas suggests that the patients had an unrecognized injury to the bladder resulting in urinary extravasation. It is postulated that the fistula develops when the urinoma drains into the vaginal cuff which is dependent and usually not closed. It may be possible to abort the development of many vesicovaginal fistulas by early recognition and treatment of an unsuspected bladder injury. It is suggested that patients with severe abdominal pain, distension, paralytic ileus, hematuria or symptoms of severe irritability of the bladder after abdominal hysterectomy be investigated early for a possible bladder injury.     

膀胱阴道瘘47例手术治疗临床分析

目的探讨妇科手术并发膀胱阴道瘘的病因、治疗及预防措施。方法回顾分析中国人民解放军总医院2000年1月至2009年12月间收治的47例妇科手术、放疗后等并发膀胱阴道瘘患者的临床资料,经美兰试验和膀胱镜检查确诊。妇科手术引起膀胱阴道瘘42例,4例行双侧输尿管经皮造瘘术,43例行修补术,其中25例(58.1%)经膀胱修补,18例(41.9%)经阴道修补。结果本文43例修补术患者中,37例1次修补成功,3例2次修补后成功。术后随访1～6个月无复发。结论妇科子宫切除手术所致膀胱阴道瘘为最多见,术前充分准备及术后严格管理大大提高手术成功率。     

Urinary tract fistulas following gynaecological surgery.

Urinary tract fistulas are a relatively uncommon but important complication of gynaecological surgery. Between 1980 and 1995 we identified 17 patients who developed a urinary tract fistula after gynaecological surgery. Seven of the patients had surgery performed for neoplastic disease but none of these patients received adjuvant radiotherapy before the formation of the fistula. There were 12 vesicovaginal fistulas and five ureteric fistulas. Four of the vesicovaginal fistulas were repaired by the vaginal approach and five vesicovaginal fistulas were repaired by the abdominal route. Three vesicovaginal fistulas were treated by catheterisation alone. Two of the 17 patients took medicolegal action. Early recognition and repair of urinary tract fistulas is recommended. Repair of vesicovaginal fistulas by the vaginal approach is advised. The litigious nature of this distressing condition is lessened when early primary closure is successful.     

Juxtacervical vesicovaginal fistulae: outcome by route of repair.

Vesicovaginal fistula is a major public health problem in Nigeria with diverse medical, psychological and social consequences for the patient. This study compared the outcome of vaginal vs abdominal repair of juxtacervical vesicovaginal fistulae. It was a retrospective review undertaken at the University of Nigeria Teaching Hospital, Aghaeze Hospital and Mbanefo Hospital, all in Enugu, Nigeria, from 1 January 1992 to 31 December 2004. The outcome measures were primary repair success rate, blood transfusion, postoperative urinary tract infection rate and duration of hospital stay. Abdominal repair of juxtacervical vesicovaginal fistula was associated with a significantly higher need for blood transfusion when compared with vaginal repair. Both routes of repair had similar primary repair success rates, postoperative urinary tract infection rates and duration of hospital stay. It was concluded that the route of repair of juxtacervical vesicovaginal fistula should be determined by accessibility of the fistula and whenever possible, the vaginal route should be preferred.     

Tratamiento de las fístulas vesicovaginales no complicadas posthisterectomía

AimTo describe our experience with uncomplicated vesicovaginal fistulasMaterial and methodsWe retrospectively reviewed seven consecutive women who presented with uncomplicated vesicovaginal fistulas after hysterectomy, repaired at our institution between 1995 and 2000. Most of the patients presented with continuous discharge of urine from the vagina. Three patients presented with gross hematuria in the immediate postoperative periodResultsIn all patients conservative management was unsuccessful and vesicovaginal fistula was successfully corrected by surgical treatment. The median postoperative follow-up was 21 months (range: 5–35 months)ConclusionsVesicovaginal fistula after gynecological surgery should be suspected in patients with continuous discharge of urine, hematuria or increased vaginal discharge. Early diagnosis and treatment prevent prolonged stress to the patient an the success rate is high