Urinary diversion in the vesico-vaginal fistula patient: general considerations regarding feasibility, safety, and follow-up.

Some women with vesico-vaginal fistulas (VVF) have injuries so severe that they cannot be repaired in a way that would restore continence. The management of these women has been a source of controversy among the providers of VVF care. It would seem logical that urinary diversion surgery could relieve the suffering endured by women with unrelenting urinary incontinence. However, there is little objective evidence on which to base determinations on the safety and practicality of performing urinary diversion in the desperately poor areas where fistulas occur. As in all other areas of VVF care, more data are required before good treatment choices can be made for patients with inoperable VVFs.

The classification of obstetric vesico-vaginal fistulas: a call for an evidence-based approach.

Classification systems for vesico-vaginal fistulas (VVFs) are as old as fistula surgery itself. Many classification systems have been proposed over the past 150 years, and nearly all have been based on descriptions of the size and anatomic location of the defect. While useful in communicating the appearance of a given fistula, systems based on size and anatomy do not necessarily give information on the difficulty of repair or the prognosis for successful outcome. This article serves as a call for a classification system for VVFs based on outcome rather than anatomy. Developing a reliable system will require data resources that do not yet exist. Based on incomplete data from a Nigerian VVF center, a possible system is proposed for further study. Once available, an outcome-based classification system could be vital in selecting fistula cases appropriate for training surgeons, and in improving communication with patients.

Genitourinary reconstruction in obstetric fistulas.

Although most recent literature concerning female urinary tract fistulas has addressed the problem of postoperative and post-irradiation fistula, obstetrical fistula is more common worldwide. A series of fistula repairs predominantly caused by obstructed labor is presented. During a 30-months interval 139 procedures were performed on 98 patients with fistulas at a variety of anatomical locations or on patients with type III urinary incontinence following fistula repair. The fistulas were caused by obstructed labor in 94.9% of the patients. Repair was done vaginally in 110 cases, abdominally in 25 and by a combined approach in 3. Of the patients 81% were dry after 1 procedure and all but 4% were dry after multiple procedures. The subjective observations of moderate to severe vaginal scarring, or severe damage to the urethra or bladder neck were the best predictors of adverse outcome.