RESUMO
A high proportion of genitourinary fistulas have an obstetric origin. Obstetric fistulas are caused by prolonged obstructed labor coupled with a lack of medical attention. While successful management with prolonged bladder drainage has occasionally been reported, mature fistulas require formal operative repair, and it is crucial that the first repair is done properly. The literature reports 3 approaches to fistula repair: vaginal, abdominal, and combined vaginal and abdominal. Many authors report high success rates for the surgical closure of obstetric fistulas at the time of hospital discharge, without further evaluation of the repair's effect on urinary continence or subsequent quality of life. Data on obstetric fistulas are scarce, and thus many questions regarding fistula management remain unanswered. A standardized terminology and classification, as well as a data reporting system on the surgical management of obstetric fistulas and its outcomes, are critical steps that need to be taken immediately.
Assuntos
Procedimentos Cirúrgicos em Ginecologia/métodos , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/cirurgia , Procedimentos Cirúrgicos Urogenitais/métodos , Fístula Vesicovaginal/diagnóstico , Fístula Vesicovaginal/cirurgia , Feminino , Ginecologia/métodos , Humanos , Complicações do Trabalho de Parto/epidemiologia , Gravidez , Medicina Reprodutiva/métodos , Resultado do Tratamento , Fístula Vesicovaginal/epidemiologiaRESUMO
Obstetric fistulas are rarely simple. Most patients in sub-Saharan Africa and parts of Asia are carriers of complex fistulas or complicated fistulas requiring expert skills for evaluation and management. A fistula is predictably complex when it is greater than 4 cm and involves the continence mechanism (the urethra is partially absent, the bladder capacity is reduced, or both); is associated with moderately severe scarring of the trigone and urethrovesical junction; and/or has multiple openings. A fistula is even more complicated when it is more than 6 cm in its largest dimension, particularly when it is associated with severe scarring and the absence of the urethra, and/or when it is combined with a recto-vaginal fistula. The present article reviews the evaluation methods and main surgical techniques used in the management of complex fistulas. The severity of the neurovascular alterations associated with these lesions, as well as inescapable limitations in staff, health facilities, and supplies, make their optimal management very challenging.