A retrospective case series on transvaginal repair of rectovaginal fistula performed by a urogynaecology operative team in Australia.

BACKGROUND: Rectovaginal fistula (RVF) is an abnormal epithelialised connection between the rectum and vagina. It is a common condition in limited resource settings and is caused almost exclusively by obstetric injury. In contrast, RVF is uncommonly seen in high resource settings. AIMS: This study aims to review the aetiology and effectiveness of RVF management in the high resource setting, identifying predictors for repair success and long-term outcomes. MATERIALS AND METHODS: A retrospective case series study of patients who underwent transvaginal RVF repairs at two secondary healthcare facilities over a 14-year period by one operative group. RESULTS: A total of 41 patients underwent 46 surgical repairs. All patients presented with flatal and/or faecal incontinence and aetiology was identifiable in 78.0% (n = 32). Obstetric cause was implicated in 26.8% (n = 11) and other causes include 26.8% (n = 11) from vaginal and abdominal surgery, 14.6% (n = 6) from perianal abscess, 7.32% (n = 3) as complications of Crohn's disease and 2.44% (n = 1) as a complication of a cube pessary. Fistula was cured in 38 of 41 cases (92.7%) with a primary repair closure rate of 80.5% (n = 33). Post-operative symptoms were limited to flatal incontinence in 4.88% (n = 2), faecal incontinence in 2.44% (n = 1), and persistent perineal pain in 7.32% (n = 3). The success of the surgical repair was not significantly impacted by fistula size, aetiology, presence of a stoma for diversion, history of prior repair, duration since RVF formation or repair technique. CONCLUSIONS: This review identifies aetiology for RVF in the high resource setting and highlights the role of earlier surgical repair to minimise patient morbidity with good success in closure and reduction of post-operative symptoms.

Vesicovaginal fistula following pelvic surgery: Our experiences and recommendations for diagnosis and prompt referral.

BACKGROUND: Vesicovaginal fistula (VVF) is an uncommon but known complication of pelvic surgery. Post-operative urine leakage should generate a high index of clinical suspicion for early diagnosis of VVF. AIMS: This study aims to identify areas for improvement and provide recommendations for timely and accurate diagnosis of VVF to minimise patient morbidity. MATERIALS AND METHODS: A retrospective observational study of all patients who underwent VVF repairs unrelated to malignancies in a ten-year period at two primary referral centres in Brisbane was performed to review the aetiology, performance of investigative tests and management of these cases. RESULTS: A total of 56 patients were studied with the identification of significant delays to diagnosis and referral, the performance of multiple unnecessary tests and low rates of primary surgeon referral. CONCLUSIONS: Early recognition of VVF and assessment by outpatient methylene blue dye test can provide quick same-day diagnosis and minimise patient suffering. We hope this will alert gynaecologists and provide guidelines for diagnosis and improved management to allow for prompt referral and repair of genitourinary fistula.

Echogenic bowel in the second trimester - Where to from here?

Echogenic bowel is a 'soft marker' on prenatal ultrasound, which can be associated with a variety of conditions including chromosomal disorders, intrapartum infections, antepartum events and cystic fibrosis. Identification of this marker should prompt a further search for other soft markers, structural defects and placental abnormalities. We explore three cases of echogenic bowel identified on routine ultrasound scan. The first case highlights the potential for echogenic bowel to be a benign feature. Echogenic bowel was identified at eighteen weeks, which was attributed to intra-amniotic haemorrhage and consequent fetal ingestion of blood products. In contrast, the next two cases highlight the pathological causes of echogenic bowel. In case 2, echogenic bowel was identified at seventeen weeks with associated cystic hygromas. The fetus had positive testing for Turner syndrome, and notably, there was a family history of cystic fibrosis. The third case discusses a case of congenital cytomegalovirus infection, which was diagnosed with amniocentesis and maternal serology testing when echogenic bowel was identified. A review of the literature suggests that the risk of adverse outcomes is increased with the presence of multiple soft markers, associated deformities, poor growth, persistent echogenic bowel in the third trimester and increased echogenic resolution. Despite these factors, it is important to note the poor ultrasonographic sensitivity of less than 50% in neonates with congenital cytomegalovirus infection and the consequent importance of invasive testing. Therefore, we aim to propose an action plan for clinicians who identify echogenic bowel on prenatal scans in order to critically exclude detrimental pathology.

Turner syndrome - The clinical spectrum and management dilemmas.

INTRODUCTION: Turner syndrome (TS) is a common sex chromosome disorder, with a varied clinical spectrum and prognosis. It may range from the complete phenotype of TS characterised by short stature, ovarian failure, cardiac and renal abnormalities, with milder variants often associated with mosaic TS. MATERIALS AND METHODS: We describe five cases of TS. RESULTS: In case 1, complete TS was identified by first-trimester screening with a grossly oedematous fetus at 11 weeks of gestation and underwent medical termination of pregnancy due to the dismal prognosis. In case 2, a hydropic fetus and large cystic hygromas were identified at routine second-trimester morphology scan. Intra-uterine fetal death was identified at 22 weeks of gestation and formal karyotype confirmed complete TS. Case 3 demonstrates the potential for a successful live birth of mosaic TS with mild neurocognitive and renal abnormalities. Case 4 demonstrates the ability for TS to go undetected until adolescence where the patient was diagnosed at 15 years of age during investigations for severe anaemia, identified as secondary to critical aortic stenosis and Heyde's syndrome. Case 5 highlights the potential for patients with TS to reproduce with assisted reproductive technology. DISCUSSION: These cases explore the prognostic spectrum of TS and highlight that they have a potential to lead productive and fulfilling lives. CONCLUSION: Consequently, a multimodal risk stratification approach to prognostic counselling should be under-taken with consideration of pertinent history, major sonographic abnormalities, maternal serum testing and invasive testing.