The utility of Martius fat pad in the repair of urogenital fistulae: review of current evidence.

OBJECTIVE: To present the contemporary evidence on transvaginal urogenital fistulae (UGF) repair with Martius fat pad (MFP), compared to direct graftless fistula repair. METHODS: We reviewed all available studies reporting lower UGF repair via the transvaginal approach in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). The primary outcome of interest was the fistula closure rates. When available, patients' baseline characteristics, indications for surgery, and early and late postoperative complications with focus on MFP-related complications are reported. RESULTS AND DISCUSSION: In obstetric fistulae, tissue interposition has been almost completely abandoned, with contemporary large series reporting closure rates of >90% with graftless repair, even for complex fistulae. Similarly, most simple, non-irradiated iatrogenic fistulae can be closed safely without or with tissue interposition with success rates ranging between 86% and 100%. However, MFP is valuable in fistulae with difficulty achieving tension-free and layered closure, with significant tissue loss, urethral involvement and with poorly vascularised tissues after radiotherapy, with reported success rates between 80% and 97% in those challenging situations. CONCLUSION: A UGF repair should be individualised after considering the specific characteristics and complexity of the procedure. MFP interposition is probably unnecessary for the majority of low (obstetric) fistulae within otherwise healthy tissues. However, MFP may still have a place to maximise outcomes in low-income settings, in select cases with higher (iatrogenic) fistulae, and in most cases with radiotherapy.

Surgical Approach to Urethral Diverticulum and Urethrovaginal Fistula With Mesh Erosion.

INTRODUCTION AND HYPOTHESIS: This video illustrates a rare surgical case involving a urethral diverticulum, urethrovaginal fistula, and mesh erosion. METHODS: We present a 58-year-old patient attending a tertiary care center with a suspected urethrovaginal fistula. Her concerns included stress urinary incontinence (SUI), recurrent urinary tract infection, and vaginal pain. The surgical history was notable for the placement of two different mesh slings during the same procedure to treat SUI. Preoperative evaluation and findings are illustrated in detail. The video uses a high-definition surgical camera to emphasize the initial intraoperative evaluation with localization of the fistula and diverticulum. We then demonstrate the approach to the dissection with the goal of ensuring complete resection of the diverticulum, fistula, and mesh, while preserving healthy tissue for subsequent closure. The utilization of unique and specialized tools for each portion of the procedure is also illustrated. A layered vaginal closure, including a Martius flap, is created to prevent recurrence. RESULTS: The surgery was accomplished without complications. CONCLUSIONS: To our knowledge, concomitant findings of a urethral diverticulum, urethrovaginal fistula, and mesh erosion are unique in the literature. We postulate that this triad could have resulted from the mesh burden in this particular patient.

Development and Pilot Test of a Multi-Component Intervention to Support Women's Recovery from Female Genital Fistula.

INTRODUCTION AND HYPOTHESIS: We evaluated a pilot multi-component reintegration intervention to improve women's physical and psychosocial quality of life after genital fistula surgery. METHODS: Twelve women undergoing fistula repair at Mulago Specialized Women and Neonatal Hospital (Kampala, Uganda) anticipated in a 2-week multi-component intervention including health education, psychosocial therapy, physiotherapy, and economic investment. We assessed feasibility through recruitment, retention, and adherence, acceptability through intervention satisfaction, and preliminary effectiveness through reintegration, mental health, physical health, and economic status. We collected quantitative data at enrollment, 6 weeks, 3 months, and 6 months. We conducted in-depth interviews with six participants. Quantitative data are presented descriptively, and qualitative data analyzed thematically. RESULTS: Participants had a median age of 34.5 years (25.5-38.0), 50% were married/partnered, 42% were separated, 50$ had completed less than primary education, and 67% were unemployed. Mean number of sessions received was 12 for health education (range 5-15), 8 for counseling (range 8-9), and 6 for physiotherapy (range 4-8). Feasibility was demonstrated by study acceptance among all those eligible (100%); comfort with study measures, data collection frequency and approach; and procedural fidelity. Acceptability was high; all participants reported being very satisfied with the intervention and each of the components. Participant narratives echoed quantitative findings and contributed nuanced perspectives to understanding approach and content. CONCLUSIONS: Our results suggest that the intervention and associated research were both feasible and acceptable, and suggested certain modifications to the intervention protocol to reduce participant burden. Further research to determine the effectiveness of the intervention above and beyond surgery alone with regard to the health and well-being of women with fistulas is warranted.

Lived experiences of refugee women with vaginal fistula in Nakivale and Oruchinga refugee settlements, Isingiro District, Uganda.

BACKGROUND: Vaginal fistula (VF) affects 2-3 million women globally, with the majority in Africa. In Uganda, it's 2%, with western Uganda having the highest prevalence. Major predisposing factors for refugee women include health system breakdowns and sexual violence during conflict. VF has severe consequences for women, relatives, and communities. There's limited information on lived experiences among refugee women with VF, and there's a need for quality prevention, treatment, and social reintegration strategies. This study aimed to understand the physical, psychosocial, and economic impacts of VF on refugee women in Nakivale and Oruchinga settlements and their coping mechanisms. METHODS: Ten refugee women with VF were interviewed using qualitative study design, utilizing Social-Ecological and Transactional Models for data collection, analysis, and discussion. RESULTS: Ten refugee women aged 24-50 years with or who had experienced VF participated in the study. They lived with VF for at least 2-15 years and had multiple stillbirths. Obstetric Fistula (OF) was the leading cause, followed by rape and cancer. Post-fistula, they faced social discrimination, emotional disturbances, survival difficulties, poverty, and lack of support. They struggled with stigma, social isolation, and marital sexual challenges. CONCLUSION: Refugee women experience physical, emotional, financial, social, and sexual trauma due to VF. Discrimination and stigmatization from loved ones and society lead to isolation, depression, and suicidal thoughts. Despite successful repair, their social and emotional healing remains a burden for their lives. There is a need to provide a supportive environment for VF survivors.

A systematic review and meta-analysis on the recovery time of obstetric fistula in Ethiopia, 2023.

INTRODUCTION: Obstetric fistula is a birth injury that causes the vagina to open abnormally. As a result, women may experience urinary leakage, which can lead to isolation, depression, and a lower quality of life. Due to the scarcity of evidence regarding the average recovery time for obstetric fistula in Ethiopia, Therefore, this study aimed to assess the recovery time for women with obstetric fistula in Ethiopia. METHODS: Between September and 8 November 2023, published studies were searched using online databases including PubMed, Hinari, Epistemonikos, and Google Scholar. The systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Study quality was assessed using Egger's test and a visual inspection of funnel plot symmetry. Statistical analysis was performed using STATA version 17 software. A random-effects model was employed for analysis, and the Cochrane Q-test and I² statistics were used to assess heterogeneity among studies. RESULT: A total of six studies were included in this analysis. The minimum and maximum median survival times were 2.67 and 5.19 weeks, respectively. The pooled median recovery time was 4.05 weeks (95% CI: 2.92, 5.18) based on the random effects model. Heterogeneity among the included studies assessed by the I² statistic was 97.72% (p = 0.000). The p-value for Egger's regression test (0.017) was significant, indicating evidence of publication bias. CONCLUSION: The findings reveal a pooled median recovery time of 4.05 weeks, with considerable heterogeneity. Although these figures provide valuable insights, the presence of publication bias was evidenced by the asymmetric funnel plot and significant Egger's test. Efforts to address publication bias are essential to improve future meta- the reliability of the surveys has increased. REGISTRATION: The protocol for this systematic review was pre-registered on the International Prospective Register of Systematic Reviews (Registration Number: CRD42023270497).

Transanal circumferential pouch advancement for treatment of pouch vaginal fistulae.

BACKGROUND: Ileal pouch anal anastomosis (IPAA) circumferential pouch advancement (CPA) involves full-thickness transanal 180-360° dissection of the distal pouch, allowing the advancement of healthy bowel to cover the internal opening of a vaginal fistula. We aimed to describe the long-term outcomes of this rare procedure. METHODS: Patients with IPAA who underwent transanal pouch advancement for any indication between 2009 and 2021 were included. Demographics, operative details, and outcomes were reviewed. An early fistula was defined as occurring within 1 year of IPAA construction. Clinical success was defined as resolution of symptoms necessitating CPA, pouch retention, and no stoma at the time of follow-up. Figures represent the median (interquartile range) or frequency (%). RESULTS: Over a 12-year period, nine patients were identified; the median age at CPA was 41 (36-44) years. Four patients developed early fistula after index IPAA, and five developed late fistulae. The median number of fistula repair procedures prior to CPA was 2 (1-2). All patients were diagnosed with ulcerative colitis at the time of IPAA and all late patients were re-diagnosed with Crohn's disease. Four (44.4%) patients had ileostomies present at the time of surgery, three (33.3%) had one constructed during surgery, and two (22.2%) never had a stoma. The median follow-up time was 11 (6-24) months. Clinical success was achieved in four of the nine (44.4%) patients at the time of the last follow-up. CONCLUSIONS: Transanal circumferential pouch advancement was an effective treatment for refractory pouch vaginal fistulas and may be offered to patients who have had previous attempts at repair.

Health seeking behaviour associated with obstetric fistula care in Guinea: An analysis of the 2018 Demographic and Health survey.

This study aimed to analyze factors associated with obstetric fistula care-seeking behavior in Guinea, based on data from the 2018 Demographic and Health Survey. Women aged 15-49 years who reported having obstetric fistula constituted the study population, statistical analysis was using Stata 16.0 software. Multivariate logistic regression was used to identify the factors associated with fistula care-seeking behavior. Among women with obstetric fistula, 78.9% sought care; 21.1% of those who sought care underwent repair. Factors associated with care-seeking behavior were being divorced (AOR =8.08; 95% CI:1.56-41.84), having a job (AOR =3.23; 95% CI: 1.11-9.44), being a member of a poor household (AOR =6.49; 95% CI:1.21-34.82) and whose fistula had appeared 6 days or more after the occurrence of the causal circumstance (AOR =3.63 95% CI: 1.28-10.28). This study suggests that the foundations on which fistula prevention and treatment programs are built should be reviewed, taking into account the factors highlighted by this study.

Cette étude visait à analyser les facteurs associés aux comportements de recherche de soins pour la fistule obstétricale en Guinée, partant des données de l'enquête démographique et de santé de 2018. Les femmes âgées de 15 à 49 ans ayant déclaré avoir une fistule obstétricale ont constitué la population d'étude, l'analyse statistique a été réalisée à l'aide du logiciel Stata 16.0. La régression logistique multivariée a été utilisée pour identifier les facteurs associés aux comportements de recherche de soins pour la fistule. Parmi les femmes atteintes de fistule obstétricale, 78,9 % ont eu recours à des soins ; 21,1 % de celles qui ont recouru ont subi une réparation. Les facteurs associés aux comportements de recherche de soins étaient le fait d'être divorcée (ORA=8.08 ; 95% IC :1.56-41.84), d'avoir un travail (ORA =3.23 ; 95% IC : 1.11-9.44), d'être membre d'un ménage pauvre (ORA =6.49 ; 95% IC :1.21-34.82) et dont la fistule était apparue 6 jours ou plus après la survenue de la circonstance causale (ORA =3.63 95% IC : 1.28-10.28). Cette étude suggère de revoir les bases sur lesquelles les programmes de prévention et de traitement de la fistule sont construits, tout en prenant en compte les facteurs mis en évidence par cette étude.

Transabdominal IPAA Revision: Does Indication Dictate Outcome?

BACKGROUND: Following IPAA failure, select patients are eligible for IPAA revision. Presently, there is limited evidence describing long-term revision outcomes and predictors of revision failure. This represents an important knowledge gap when selecting and counseling patients. OBJECTIVE: This study aimed to define long-term IPAA survival outcomes after transabdominal IPAA revision and identify preoperative clinical factors associated with revision failure. DESIGN: This was a retrospective cohort study. SETTINGS: This study was conducted at a tertiary referral center. PATIENTS: This study included all patients who underwent revisional IPAA surgery between 1982 and 2017 for pouch failure. INTERVENTION: Transabdominal IPAA revision was included. MAIN OUTCOME MEASURES: The primary outcome was pouch failure, defined as pouch excision or permanent pouch diversion, after IPAA revision. RESULTS: A total of 159 patients (64.2% women) were included with a median age of 36 years (interquartile range, 28.5-46.5) at revision. Eighty percent of patients had a primary diagnosis of ulcerative colitis. The most common indication for revision was leak/pelvic sepsis, representing 41% of the cohort, followed by pouch-vaginal fistula (22.2%), mechanical factors (20.4%), and poor pouch function (14.6%). During the study period, 56 patients (35.2%) experienced pouch failure. The 3-year pouch survival probability was 82.3% (95% CI, 75.5%-87.5%), 5-year pouch survival probability was 77.2% (95% CI, 69.8%-83.0%), and 10-year pouch survival probability was 70.6% (95% CI, 62.6%-77.2%). Compared to mechanical factors, pouch failure was significantly associated with pelvic sepsis (HR, 4.25; 95% CI, 1.50-12.0) and pouch-vaginal fistula (HR, 4.37; 95% CI, 1.47-12.99). No significant association was found between revision failure and previous revision, redo ileoanal anastomosis, or new pouch construction. LIMITATIONS: This study is limited by its retrospective design. CONCLUSIONS: Revisional IPAA can be undertaken with favorable long-term outcomes at high-volume centers. Consideration should be given to indication for revision when counseling patients regarding the risk of failure. Further research on risk stratifying patients before revision is required. See Video Abstract at http://links.lww.com/DCR/B966 . REVISIN DE LA ANASTOMOSIS ANAL DE LA BOLSA ILEAL TRANSABDOMINAL LA INDICACIN DICTA EL RESULTADO: ANTECEDENTES:Después de la falla en la anastomosis del reservorio ileoanal, los pacientes seleccionados son elegibles para la revisión de la anastomosis del reservorio ileoanal. Actualmente, hay evidencias limitadas que describen los resultados de la revisión a largo plazo y los predictores del fracaso de la revisión. Esto representa un importante vacío de investigación a la hora de seleccionar y asesorar a los pacientes.OBJETIVO:Definir los resultados de supervivencia a largo plazo de la IPAA después de la revisión de la anastomosis del reservorio ileoanal transabdominal e identificar los factores clínicos preoperatorios asociados con el fracaso de la revisión.DISEÑO:Este fue un estudio de cohorte retrospectivo.ENTORNO CLINICO:Este estudio se realizó en un centro de referencia terciario.PARTICIPANTES:Todos los pacientes que se sometieron a una cirugía de revisión de la anastomosis ileoanal del reservorio entre 1982 y 2017, por falla del reservorio.INTERVENCIÓN:Revisión de la anastomosis de reservorio ileoanal transabdominal.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario es el fracaso del reservorio, definido como escisión del reservorio o derivación permanente del reservorio, después de la revisión de la anastomosis del reservorio ileoanal.RESULTADOS:Se incluyeron un total de 159 pacientes (64,2% mujeres) con una mediana de edad a la revisión de 36 años (RIC: 28,5-46,5). El ochenta por ciento tenía un diagnóstico primario de colitis ulcerosa. La indicación más común para la revisión fue la fuga/sepsis pélvica, que representó el 41 % de la cohorte, seguida de la fístula vaginal del reservorio (22,2 %), factores mecánicos (20,4 %) y mala función del reservorio 14,6 %. Durante el período de estudio, 56 pacientes (35,2 %) experimentaron fallas en la bolsa. Las probabilidades de supervivencia de la bolsa a los 3, 5 y 10 años fueron del 82,3% (IC del 95%: 75,5%-87,5%), del 77,2% (IC del 95%: 69,8%-83,0%) y del 70,6% (IC del 95%: 62,6%- 77,2%), respectivamente. En comparación con los factores mecánicos, la falla de la bolsa se asoció significativamente con sepsis pélvica (HR = 4,25, IC del 95 %: 1,50 a 12,0) y fístula vaginal de la bolsa (HR = 4,37, IC del 95 %: 1,47 a 12,99). No hubo una asociación significativa entre el fracaso de la revisión y la revisión previa, el rehacer la anastomosis ileoanal o la construcción de una nueva bolsa.LIMITACIONES:El estudio está limitado por su diseño retrospectivo.CONCLUSIONES:La revisión de la anastomosis del reservorio ileoanal se puede realizar con resultados favorables a largo plazo en centros de alto volumen. Se debe considerar la indicación de revisión al asesorar a los pacientes sobre el riesgo de fracaso. Se requiere investigación adicional sobre la estratificación del riesgo de los pacientes antes de la revisión. Consulte Video Resumen en http://links.lww.com/DCR/B966 . (Traducción - Dr. Fidel Ruiz Healy ).

Gracilis Flap Repair for Reoperative Rectovaginal Fistula.

BACKGROUND: Surgical treatment of recurrent rectovaginal fistulas is notoriously difficult. Placement of the gracilis muscle between the vagina and anus is an advanced technique used to close persistent fistulas. We have utilized this procedure for recalcitrant fistulas and hypothesized that a gracilis interposition would offer a good treatment option for patients with refractory rectovaginal fistulas, regardless of underlying etiology. OBJECTIVE: The purpose of this study was to investigate healing rates of gracilis interposition in patients with refractory rectovaginal fistulas. DESIGN: Following institutional review board approval, a retrospective review of all adult female patients with a diagnosis of rectovaginal fistula between January 2009 and August 2020 was performed; those who underwent gracilis interposition for definitive fistula closure were included for analysis. SETTINGS: The study was conducted at a colorectal surgery department at a tertiary center in the United States. PATIENTS: All patients were adult females with a diagnosis of a rectovaginal fistula who underwent gracilis interposition for definitive closure. MAIN OUTCOME MEASURES: Patient demographics, etiology of rectovaginal fistula, previous surgical intervention, presence of intestinal diversion, operative details, 30-day morbidity, recurrence of fistula, and time to recurrence. Fistula closure was defined as lack of clinical symptoms following stoma closure, negative fistula detection on gastrograffin enema' and absence of an internal opening at examination under anesthesia. RESULTS: Twenty-two patients were included who had a median age of 43 years (range, 19-64 years) and median body mass index of 31 kg/m 2 (range, 22-51). Median time between prior attempted surgical repair and gracilis surgery was 7 months (range, 3-17). The number of previously attempted repairs were 1-2 (n = 8), 3-4 (n = 9), and > 4 (n = 5). The most recent attempted surgical repair was rectal advancement flap (n = 7), transperineal +/- Martius flap (n = 4), episioproctotomy (n = 3), transvaginal repair (n = 2), and other (n = 6). All patients had fecal diversion at the time of gracilis surgery. Thirty-day postoperative surgical site infection at the graft/donor site was 32% (n = 7). At a median follow-up of 22 months (range 2-62), fistula closure was 59% (n = 13). Gracilis interposition was successful in all inflammatory bowel disease patients. LIMITATIONS: The study was limited by its retrospective nature. CONCLUSIONS: Gracilis interposition is an effective operative technique for reoperative rectovaginal fistula closure. Patients should be counseled regarding the possibility of graft/donor site infection. See Video Abstract at http://links.lww.com/DCR/B763 . REPARACIN CON COLGAJO DE GRACILIS PARA LA FSTULA RECTOVAGINAL REOPERATORIA: ANTECEDENTES:El tratamiento quirúrgico de las fístulas rectovaginales recurrentes es muy difícil. La colocación del músculo gracilis entre la vagina y el ano es una técnica avanzada que se utiliza para cerrar las fístulas persistentes. Hemos utilizado este procedimiento para las fístulas recalcitrantes y planteamos la hipótesis de que una interposición del gracilis ofrecería una buena opción de tratamiento para pacientes con fístulas rectovaginales refractarias, independientemente de la etiología subyacente.OBJETIVO:Investigar las tasas de curación de la interposición del gracilis en pacientes con fístulas rectovaginales refractarias.DISEÑO:Tras la aprobación de la junta de revisión institucional, se realizó una revisión retrospectiva de todas las pacientes adultas con un diagnóstico de fístula rectovaginal entre enero de 2009 y agosto de 2020; los que se sometieron a interposición de gracilis para el cierre definitivo de la fístula se incluyeron para el análisis.AJUSTE:Departamento de cirugía colorrectal de un centro terciario en Estados Unidos.PACIENTES:Todas las pacientes adultas con diagnóstico de fístula rectovaginal que se sometieron a interposición de gracilis para cierre definitivo.PRINCIPALES MEDIDAS DE RESULTADO:datos demográficos del paciente, etiología de la fístula rectovaginal, intervención quirúrgica previa, presencia de derivación intestinal, detalles quirúrgicos, morbilidad a los 30 días, recurrencia de la fístula y tiempo hasta la recurrencia. El cierre de la fístula se definió como la ausencia de síntomas clínicos después del cierre del estoma, la detección negativa de la fístula en el enema de gastrograffin y la ausencia de una abertura interna en el examen bajo anestesia.RESULTADOS:Se incluyeron 22 pacientes que tenían una mediana de edad de 43 años (rango 19-64 años) y una mediana de índice de masa corporal de 31 kg / m2 (rango 22-51). La mediana de tiempo entre el intento previo de reparación quirúrgica y la cirugía del gracilis fue de 7 meses (rango 3-17). El número de reparaciones previamente intentadas fue: 1-2 (n = 8), 3-4 (n = 9), y >4 (n = 5). El intento de reparación quirúrgica más reciente fue el colgajo de avance rectal (n = 7), el colgajo transperineal +/- Martius (n = 4), la episioproctotomía (n = 3), la reparación transvaginal (n = 2) y otros (n = 6). Todos los pacientes tenían derivación fecal en el momento de la cirugía gracilis. La infección del sitio quirúrgico posoperatorio a los 30 días en el sitio del injerto / donante fue del 32% (n = 7). Con una mediana de seguimiento de 22 meses (rango 2-62), el cierre de la fístula fue del 59% (n = 13). La interposición de Gracilis fue exitosa en todos los pacientes con enfermedad inflamatoria intestinal.LIMITACIONES:Carácter retrospectivo de los datos.CONCLUSIONES:La interposición de Gracilis es una técnica quirúrgica eficaz para el cierre reoperatorio de la fístula rectovaginal. Se debe asesorar a los pacientes sobre la posibilidad de infección del sitio del injerto / donante. Consulte Video Resumen en http://links.lww.com/DCR/B763 . (Traducción-Dr. Ingrid Melo ).

Rokitansky Syndrome or Cervicovaginal Atresia?

STUDY OBJECTIVE: To investigate the possibility of conservative management of rudimentary uterine horns associated with vaginal agenesis. DESIGN: Observational study on cohort of consecutive cases treated with the same criteria from 2008 to 2021. SETTING: Two academic institutions and teaching hospitals in Milan, Italy. PATIENTS: Eight patients with vaginal agenesis associated with rudimentary cavitated uterine horns treated by the same team and postoperatively followed. INTERVENTIONS: All the subjects underwent the same standardized surgical procedure: laparoscopy, intraoperative ultrasound, and horn-vestibular direct anastomosis. Postoperatively vaginoscopy was performed every 6 months. MEASUREMENTS AND MAIN RESULTS: The postoperative course was generally uneventful and the mean hospital stay was 4.3 ± 2.5 (SD) days. All the patients began to menstruate a few months after the operation. Menstrual flows were light but regular. All patients had a neovaginal length > 4 cm at 1 year postoperatively, reaching approximately 6 cm at 2 years. During the follow-up period, 5 patients were sexually active without dyspareunia. In all cases, surgery restored the continuity of the neovagina and uterine horn through the creation of a "vaginal-horn fistula tract." CONCLUSION: In patients with vaginal agenesis associated with the presence of a uterine cavitary horn, it is possible to recover not only sexual activity but also menstrual function. The horn-vestibular anastomosis may be considered a valid, safe, and effective therapeutic option but requires accurate preoperative and intraoperative evaluation of rudimentary uterine structures.

Management for Ureterovaginal Fistula: A Retrospective Study Comparing Early and Delayed Ureteral Reimplantation.

INTRODUCTION: The timing of surgical repair for ureterovaginal fistula (UVF) is under debate, here we introduce our experience to compare the safety and efficacy between early and delayed ureteral reimplantation for UVF. METHODS: Between January 2012 and January 2020, 22 patients who were diagnosed with UVF had received ureteral reimplantation. Baseline characteristics, history of previous abdominal surgery, operative profile, and follow-up data were collected and analyzed. RESULTS: Among 22 patients diagnosed with UVF, 12 patients received early ureteral reimplantation and others received delayed ureteral reimplantation. Both groups were comparable in baseline characteristics and detailed history of previous operations. The mean operative time of the early surgery group was 140.83 ± 35.28 min, while that of the delayed surgery group was 181.00 ± 43.83 min (p = 0.027). Patients of the early surgery group (183.33 ± 107.31 mL) had less blood loss compared with that of the delayed surgery group (285.00 ± 94.43 mL) (p = 0.030). After an overall mean follow-up of 34.55 months, the ureteral stricture rate of two groups was not statistically significantly different (16.67% in early repair vs. 40.00% in delayed repair, p = 0.348). CONCLUSION: With similar long-term outcomes, the early ureteral reimplantation had a shorter operative time and less blood loss. Moreover, the stress during the waiting period could be minimized. High-quality clinical studies with larger sample size are needed to confirm the superior nature of early surgery.

Factors associated with obstetric fistula among reproductive age women in Ethiopia: a community based case control study.

BACKGROUND: Obstetric fistula is a major public health concerns in Ethiopia. It is the most devastating cause of all maternal morbidities. METHOD: Data from the 2016 Ethiopian Demographic Health Survey (EDHS) was analyzed. A community-based unmatched case control study was conducted. Seventy cases and 210 non cases were selected using random number table. Data were analyzed by using STATA statistical software version 14. Multivariable logistic regression model was applied to determine the factors associated with fistula. RESULTS: The majority of fistula cases were from rural residences. The multivariable statistical model showed that rural residence (Adjusted OR (AOR) = 5, 95% CI 4.26, 7.52), age at first marriage (AOR = 3.3, 95% CI 2.83, 4.60), poorest wealth index (AOR = 3.3, 95% CI 2.24, 5.01) and decision making for contraceptive use by husband alone (AOR = 1.3, 95% CI 1.124, 1.67) were factors significantly associated with obstetric fistula. CONCLUSION: Age at first marriage, rural residence, poorest wealth index and decision making for contraceptive use by husband alone were significantly associated factors for obstetric fistula. Intervening on these factors will reduce the magnitude of obstetrics fistula. In this context there is in-need to improve on avoiding early marriage through awareness creation to the community and developing legal framework by the policymakers. Furthermore, information about the joint decision making to use contraceptives should be disseminated though mass-media and interpersonal channels.

Globally, 2­3 million women are affected by obstetric fistula. It is common in developing nations, mainly in sub-Saharan Africa and Southeast Asia where suitable, timely care and treatment are hard to find. This devastating condition adversely affects women's physical and mental health. There is little research conducted in relation to the experiences of women living with leakage of urine and/or feces in Ethiopia. Therefore, this study provides a better understanding on obstetric fistula and its associated factors.The present study used the recent Ethiopia Demographic Health Survey (EDHS) 2016, to determine the associated factors of obstetric fistula among reproductive age group women (15­49 years) in Ethiopia.In this study rural residence, poorest wealth index, age at first marriage less than 18 years, and decision making for contraceptive use by husband alone were the associated factors of obstetric fistula. Intervening on these factors will reduce the magnitude of obstetrics fistula. In this context there is in-need to improve on avoiding early marriage through awareness creation to the community and developing legal framework by the policymakers. Furthermore, information about the joint decision making to use contraceptives should be disseminated though mass-media and interpersonal channels. Comprehensive intervention strategies should be customized at different government hierarchies to combat and reduce obstetric fistula.

Gracilis muscle interposition for pouch-vaginal fistulas: a single-centre cohort study and literature review.

BACKGROUND: First described by Parks and Nicholls in 1978, the ileal pouch-anal anastomosis (IPAA) has revolutionized the treatment of mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). IPAA is fraught with complications, one of which is pouch-vaginal fistulas (PVF), a rare but challenging complication noted in 3.9-15% of female patients. Surgical treatment success approximates 50%. Gracilis muscle interposition (GMI) is a promising technique that has shown good results with other types of perineal fistulas. We present the results from our institution and a comprehensive literature review. METHODS: A retrospective observational study including all patients with a PVF treated with GMI at our institution from December 2018-January 2000. Primary outcome was complete healing after ileostomy closure. RESULTS: Nine patients were included. Eight of nine IPAAs (88.9%) were performed for MUC, and one for FAP. A subsequent diagnosis of Crohn's disease was made in five patients. Initial success occurred in two patients (22.2%), one patient was lost to follow-up and seven patients, after further procedures, ultimately achieved healing (77.8%). Four of five patients with Crohn's achieved complete healing (80%). CONCLUSION: Surgical healing rates quoted in the literature for PVFs are approximately 50%. The initial healing rate was 22.2% and increased to 77.8% after subsequent surgeries, while it was 80% in patients with Crohn's disease. Given this, gracilis muscle interposition may have a role in the treatment of pouch-vaginal fistulas.

Vaginal Complications after Cystectomy: Results from a Medicare Sample.

PURPOSE: Cystectomy with a vaginal-sparing approach may be associated with unique complications specific to the female population. The objective of this study was to estimate the incidence of vaginal complications (defined to include vaginal prolapse, vaginal fistula, dyspareunia and vaginal cuff dehiscence/evisceration) after cystectomy and to determine risk factors for these complications. MATERIALS AND METHODS: Women 65 years or older undergoing cystectomy for any indication were identified by procedural codes in the Medicare Limited Data Set 5% sample from January 1, 2011 to December 31, 2017. Patients experiencing a vaginal complication after cystectomy were compared to those who did not. Demographic and biological factors that could increase likelihood of complications were identified and time to development of complications determined. Cumulative incidence was calculated using cumulative incidence function. Multivariable cause-specific Cox proportional hazards model assessed risk factors for vaginal complications. RESULTS: In all, 481 women undergoing cystectomy were identified during the study period, and 37.2% were younger than 70 years old. The majority (378, 79%) had bladder cancer, and 401 (83.4%) underwent an incontinent conduit or catheterizable channel diversion. Within 2 years of cystectomy, 93 patients (19.5%) had 1 or more complications on record. Vaginal cuff dehiscence had the highest cumulative incidence, occurring in 49 patients (10.2%). Over the entire study period (2011-2017), 102 women (21.2%) were diagnosed with a vaginal complication, and 27 (5.6%) received an intervention. CONCLUSIONS: Among women who undergo cystectomy, vaginal complications occur at rates higher than expected with over 20% of women experiencing a complication and over a quarter of those diagnosed undergoing intervention.

Management strategies and outcome of ureterovaginal fistulae: A systematic review and meta-analysis.

BACKGROUND: Genitourinary fistula is a distressful condition involving mental, social, marital, and financial repercussions. OBJECTIVE: The objective of this study is to systematically evaluate etiology, clinical presentation, diagnosis, the timing of repair, and perform a meta-analysis evaluating the success rate of various treatment modalities with respect to time taken to seek treatment. SEARCH STRATEGY: We performed a critical review of PubMed/Medline, Embase, and the Cochrane Library in April 2020 according to the PRISMA statement. Seventeen studies were included in the final analysis and all were retrospective in design. SELECTION CRITERIA: Each article was rated by the evidence-based medicine levels of evidence scale and the Methodological Index for Nonrandomized Studies scale for assessment of bias among nonrandomized studies. MAIN RESULTS: Of the 799 fistulae reported in 17 studies, endoscopic management was done in 35.6% (12 studies), whereas surgical management was preferred in 85.6% fistulae (15 studies). The pooled success of endoscopic stenting was 32% (95% confidence interval [CI]: 7-64) and 100% (95% CI: 98-100) in operated patients. Patients who underwent stenting within 2 weeks (20%), 2-6 weeks (21%), and >6 weeks (40%) had pooled success rates of 95% (95% CI: 87-100), 46% (95% CI: 0-100), and 20% (95% CI: 1-49), respectively. Patients who underwent surgical management <6 weeks (15.9%) and >6 weeks (22%) of diagnosis had pooled success rates of 100% (95% CI: 99-100) and 100% (95% CI: 99-100), respectively. CONCLUSIONS: Stent placement as early as <6 weeks (preferably < 2 weeks) had better outcomes as compared to >6 weeks. Proceeding to surgery regardless of timing in cases of stent failure seems to be a feasible option.

Endoscopic management of colovesical and colovaginal fistulas with over-the-scope clips: A single-institution case series.

AIM: Conventional surgical management of colovesical and colovaginal fistulas can be morbid and is contraindicated in many patients. Our aim in this work is to evaluate our experience in the management of colovesical and colovaginal fistulas with endoscopic over-the-scope (OTS) clips. METHOD: A retrospective review of all patients who underwent attempted endoscopic OTS clip management of colovesical and colovaginal fistulas between 2013 and 2020 was performed. Preoperative risk factors, operative details and postoperative outcomes are reported. RESULTS: Ten patients were identified. Fistula types were: colovesical (five), rectovesical (two), colovaginal (two) and rectovaginal (one). The aetiology of the fistula was diverticular disease in seven (70%) cases and surgical complication of pelvic surgery in three (30%). The mean defect age was 157 ± 98 days, the mean defect diameter was 4.5 mm (range 2-10 mm) and the mean fistula length was 15 mm (range 2-25 mm). In nine (90%) cases, fistula identification and cannulation were performed through the nonenteric lumen of the fistula. Initial management with an OTS clip was technically successful in eight (80%) patients. Of the eight patients who underwent OTS clip placement, long-term success (mean follow-up 218 days, range 25-673 days) was achieved after initial intervention in four (50%) patients. One patient underwent serial OTS clip procedures and achieved long-term success after four interventions; three patients have not undergone a repeat procedure after initial failure. CONCLUSION: Endoscopic management of colovesical and colovaginal fistulas with OTS clips offers a promising therapeutic option for patients with contraindications to conventional surgical management. Immediate technical success and long-term success rates are similar to other gastrointestinal tract applications of OTS clips.

Anatomical and functional outcomes of non-obstetric urogenital fistula repair.

INTRODUCTION AND HYPOTHESIS: Studies on non-obstetric urogenital fistulas (NOUGFs) provide limited information on predictive outcome factors. This study was aimed at specifying and analyzing the risk factors for long-term anatomical and functional results. METHODS: A cross-sectional study of surgical repair for non-obstetric urogenital fistula was performed. From 2012 to 2020, a total of 479 patients with urogenital fistulas were treated in two tertiary centers. Patients with isolated ureteral fistulas and rectal injuries were excluded. For evaluation of the long-term results, patients with vesicovaginal and urethrovaginal fistulas with at least 12 months of follow-up were identified and contacted by phone and/or examined in the clinic. The anatomical outcome was assessed by resolution of symptoms and/or clinical examination. The Urinary Distress Inventory (UDI-6) was used for the functional outcomes. RESULTS: Overall, 425 patients were studied (mean age was 49.8; BMI 27.5; mean fistula size 1.4 cm, mean follow-up was 12 months). Vesicovaginal fistula affected 73% of patients. Hysterectomy without radiation was the most common etiology (66.3%), followed by hysterectomy with subsequent radiation (16%) and pelvic radiotherapy (12.2%). The transvaginal approach was used in 54.4%, abdominal in 12.4%, transvesical in 22.4%, and a combined approach in 10.8%. The successful closure rate was 92.9% for primary cases, 71.6% for secondary cases, and 66.7% for radiation fistulas. A high risk for relapse was found for NOUGFs with ureteral involvement (RR 2.5; 95% CI 1.3-4.5; p = 0.003), radiation fistulas (RR 2.1; 95% CI 1.3-3.5, p = 0.003); and combined radiation and hysterectomy cases (RR 2.9; 95% CI 1.8-4.6; p = 0.0001). In multifactorial analysis, fistula size >3.0 cm, pelvic radiation, and previous vaginal surgeries were associated with a higher risk for failure or lower urinary symptoms. CONCLUSIONS: Factors for successful NOUGF closure are fistula size less than 3.0 cm, absence of pelvic radiation, and previous vaginal surgeries.

A retrospective review of genital fistula occurrence in nine African countries.

BACKGROUND: Female genital fistulas are abnormal communications that lead to urinary and/or fecal incontinence. This analysis compares the characteristics of women with fistulas to understand how countries differ from one another in the circumstances of genital fistula development. METHODS: This retrospective records review evaluated demographics and circumstances of fistula development for 6,787 women who sought fistula treatment between 1994 and 2017 in Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia, and Ethiopia. RESULTS: Most women developed fistula during childbirth, whether vaginal (3,234/6,787, 47.6%) or by cesarean section (3,262/6,787, 48.1%). Others had fistulas attributable to gynecological surgery (215/6,787, 3.2%) or rare causes (76/6,787, 1.1%). Somalia, South Sudan, and Ethiopia had comparatively high proportions following vaginal birth and birth at home, where access to care was extremely difficult. Fistulas with live births were most common in Kenya, Malawi, Rwanda, Uganda, Tanzania, and Zambia, indicating more easily accessible care. CONCLUSIONS: Characteristics of women who develop genital fistula point to geographic differences in obstetric care. Access to care remains a clear challenge in South Sudan, Somalia, and Ethiopia. Higher proportions of fistula after cesarean birth and gynecological surgery in Kenya, Malawi, Rwanda, Uganda, Tanzania, and Zambia signal potential progress in obstetric fistula prevention while compelling attention to surgical safety and quality of care.

Building a country-wide Fistula Treatment Network in Kenya: results from the first six years (2014-2020).

It is estimated that one million women worldwide live with untreated fistula, a devastating injury primarily caused by prolonged obstructed labor when women do not have access to timely emergency obstetric care. Women with fistula are incontinent of urine and/or feces and often suffer severe social and psychological consequences, such as profound stigma and depression. Obstetric fistula affects economically vulnerable women and garners little attention on the global health stage. Exact figures on fistula incidence and prevalence are not known. In Kenya, results from a 2014 population-based survey suggest that 1% of reproductive-aged women have experienced fistula-like symptoms. In collaboration with key stakeholders, Fistula Foundation launched the Fistula Treatment Network (initially known as Action on Fistula) in 2014 to increase access to timely, quality fistula treatment and comprehensive post-operative care for women with fistula in Kenya. The integrated model built linkages between the community and the health system to support women through all parts of their treatment journey and to build capacity of healthcare providers and community leaders who care for these women. Fistula Foundation and its donors provided the program's funding. Seed funding, representing about 30% of the program budget, was provided by Astellas Pharma EMEA.Over the six-year period from 2014 to 2020, the network supported 6,223 surgeries at seven hospitals, established a fistula training center, trained eleven surgeons and 424 Community Health Volunteers, conducted extensive community outreach, and contributed to the National Strategic Framework to End Female Genital Fistula. At 12 months post fistula repair, 96% of women in a community setting reported that they were not experiencing any incontinence and the proportion of women reporting normal functioning increased from 18% at baseline to 85% at twelve-months.The Fistula Treatment Network facilitated collaboration across hospital and community actors to enhance long-term outcomes for women living with fistula. This model improved awareness and reduced stigma, increased access to surgery, strengthened the fistula workforce, and facilitated post-operative follow-up and reintegration support for women. This integrated approach is an effective and replicable model for building capacity to deliver comprehensive fistula care services in other countries where the burden of fistula is high.

Role of fluorescence imaging for intraoperative intestinal assessment in gynecological surgery: a systematic review.

BACKGROUND: Our aim was to review the current knowledge of the role of fluorescence imaging for intraoperative intestinal assessment in gynecological surgery. MATERIAL AND METHODS: A computer-based systematic review was performed from 2000 to 2020. All articles describing the use of indocyanine green (ICG) applied to bowel assessments in gynecology or endometriosis surgery were considered for review. RESULTS: ICG is an effective tool for assessing bowel vascularization, potentially preventing anastomotic leakage and recto-vaginal fistula and can therefore be useful for endometriosis surgery or bowel assessment in gynecological oncology procedures. Real-time characterization of the hypovascular pattern of endometriotic nodules has been associated with a larger nodule size and lower microvessel density, helping surgeons choose the best transecting line and the most appropriate technique. ICG angiography allows for a laparoscopic and intrarectal bowel assessment, which can act as a double check of bowel perfusion, enabling the assessment of mucosa vascularization. ICG fluorescence can guide intraoperative decision-making after intestinal anastomosis, discoid resection, and rectal shaving, preventing anastomotic leakage and postoperative recto-vaginal fistula in low anterior resections. CONCLUSIONS: ICG angiography provides a better intestinal assessment. Larger, prospective, randomized controlled studies are needed to validate the technique and confirm these encouraging results.