Herlyn-Werner-Wunderlich Syndrome Complicated with Vesicovaginal Fistula: A Rare Case Report.

Herlyn-Werner-Wunderlich (HWW) syndrome is characterized by obstructed hemivagina and ipsilateral renal anomaly, a rare congenital anomaly of the genitourinary tract, resulting from malformations of the renal tract associated with Müllerian duct anomalies. The initial symptoms of HWW frequently present after menarche and may be nonspecific, leading to a delayed diagnosis. We presented a 19-year-old female with 3-year hematuria and abdominal pain. The final diagnosis of HWW syndrome with a rare vesicovaginal fistula was made. The treatment of HWW syndrome typically involves surgical intervention. The primary treatment is resection or removal of the obstructed vaginal septum. The patient underwent excision of vaginal septum and vaginal reconstruction via hysteroscopy, as well as repair of the vesicovaginal fistula. The patient improved well after surgery and fully recovered without sequelae after 3 months. In addition, unilateral renal agenesis is one of congenital abnormalities of the kidney and urinary tract, which are the most frequent cause of chronic kidney disease (CKD) in children. This report describes a patient of HWW syndrome with rarely combined vesicovaginal fistula, and highlights the importance of early recognition and management to prevent associated complications.

Cystitis glandularis with concomitant Crohn's disease leading to a paroxysm of Crohn's disease with ulcerated external iliac vessels.

•we report the case of a 36-year-old female patient who presented to our hospital with a diagnosis of cystitis glandularis manifesting as a vesicovaginal fistula. She underwent cystoscopic biopsy at a local hospital, but anti-inflammatory treatment was ineffective, and the patient was experiencing low urination frequency and urgency, as well as pain. The patient underwent laparoscopic repair of a cystoscopy-confirmed vesicovaginal fistula. After surgery, the patient experienced a paroxysm of Crohn's disease with multiple small bowel fistulas and erosion of the external iliac vessels that ruptured to form an external iliac vessel small bowel fistula. The fistula was confirmed by surgical exploration, and the patient eventually died.

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.

Follow-up of obstetric fistula repair using Singapore fasciocutaneous flap and/or gracilis muscle flap.

AIMS: To report on the follow-up of obstetric fistula repair using vascularized surgical flaps, namely the Singapore fasciocutaneous flap, the gracilis muscle flap, or a combination of both. METHODS: This cross-sectional study reports on the follow-up of 60 patients after fistula repair with a vascularized surgical flap at the Fistula Care Center in Lilongwe, Malawi. The primary outcome was fistula closure based on patients' self-reported continence grade. Secondary outcomes were urinary incontinence based on a 1-h pad-weight test, quality of life based on the Incontinence Quality of Life (I-QOL) questionnaire, surgical complications, and the indication for additional surgery after repair. RESULTS: Successful closure was achieved in 62% of cases and full continence was achieved in 12% of cases. Incontinence based on a 1-h pad weight test improved between surgery and follow-up. QOL scores based on the I-QOL were low but patients indicated moderate to great improvement in quality of life. Twenty-two (37%) patients experienced surgical complication, mostly minor wound breakdowns. No major complications were reported. Six (10%) patients were indicated for additional surgery during follow-up. CONCLUSION: The relative safety of the surgical procedures is shown in the findings of this study, including no reports on major complications during follow-up. Vascularized flaps should be considered in complex fistula cases, especially in repeat cases and before considering urinary diversion as a last resort.

Total uterine prolapse complicated with vesicovaginal fistula: A case report.

RATIONALE: Vesicovaginal fistula (VVF) most commonly occurs due to iatrogenic injury during surgery or obstructed labor. We report a rare case of a patient with severe pelvic organ prolapse who developed VVF even though pessary had not been used. PATIENT CONCERNS: A 63-year-old postmenopausal woman, para 3 (all spontaneous vaginal deliveries), complained of vaginal bulging sensation and involuntary urinary leakage for 3 years. DIAGNOSIS: Stage IV uterine prolapse with VVF. INTERVENTIONS: She underwent transvaginal VVF repair combined with total vaginal hysterectomy and sacrospinous ligament fixation. The postoperative course was uncomplicated. OUTCOMES: The patient remained free of complications during the 1-year follow-up. LESSONS: This case illustrates the point that patients with pelvic organ prolapse (POP) should be treated promptly and careful follow-up should be conducted. Clinicians should be aware of the symptoms of VVF to ensure its early diagnosis and treatment.

Delayed presentation of postcaesarean section vesicouterine fistula repaired robotically.

A premenopausal patient in her late forties presented with a 15-year history of urinary incontinence starting shortly after a caesarean section performed for her fourth delivery and more recently associated episodic light haematuria and passage of clots per vagina. The haematuria was intermittent over several months and associated with per-vaginal bleeding. She had symptomatic anaemia. Flexible cystoscopy and MRI showed a vesicouterine fistula. She underwent a robotic-assisted hysterectomy and multi-layered repair of the bladder with omental interposition. She remained in the hospital for 4 days, though recovered well and underwent catheter removal at 14 days following a normal cystogram. At 3 months, she was well with no incontinence or urinary symptoms. This case demonstrates the need for vigilance in assessing patients with persistent incontinence, particularly in the context of prior caesarean section. It highlights the feasibility of robotic surgery for correcting these defects in a society where minimally invasive surgery is becoming the norm, and cosmesis is a priority for patients.

[Guiding opioid-free intravenous antinociception with the Analgesia Nociception Index: a case report]. / Antinocicepção intravenosa sem opioides orientada pelo Índice de Analgesia/Nocicepção: relato de caso.

BACKGROUND: Opioid-free anesthesia decreases the incidence of opioid adverse events, but its optimal antinociceptive depth has not been clearly defined. Personalizing intraoperative opioid-free infusions with a nociception monitor may be the solution. CASE REPORT: We describe the feasibility and potential limitations of titrating opioid-free antinociception during major abdominal surgery using the Analgesia Nociception Index (Mdoloris, Lille, France) in an obese patient. After stabilizing the patient's nociception-antinociception balance intraoperatively we quickly reversed anesthesia and the patient did not require postoperative opioids. CONCLUSION: Personalizing opioid-free antinociception with a nociception monitor is feasible. It may optimize intraoperative antinociception and improve postoperative comfort.

Guiding opioid-free intravenous antinociception with the Analgesia Nociception Index: a case report / Antinocicepção intravenosa sem opioides orientada pelo Índice de Analgesia/Nocicepção: relato de caso

Abstract Background: Opioid-free anesthesia decreases the incidence of opioid adverse events, but its optimal antinociceptive depth has not been clearly defined. Personalizing intraoperative opioid-free infusions with a nociception monitor may be the solution. Case report: We describe the feasibility and potential limitations of titrating opioid-free antinociception during major abdominal surgery using the Analgesia Nociception Index (Mdoloris, Lille, France) in an obese patient. After stabilizing the patient's nociception-antinociception balance intraoperatively we quickly reversed anesthesia and the patient did not require postoperative opioids. Conclusion: Personalizing opioid-free antinociception with a nociception monitor is feasible. It may optimize intraoperative antinociception and improve postoperative comfort.

Resumo Introdução A anestesia sem opioides diminui a incidência de eventos adversos associados aos opioides, mas a profundidade antinociceptiva ideal dessa abordagem não está claramente definida. Personalizar a infusão intraoperatória sem opioides com o uso de monitor de nocicepção pode ser a solução. Relato de caso Descrevemos a viabilidade e as eventuais limitações da titulação da antinocicepção sem opioides por meio do uso do Índice de Analgesia/Nocicepção (Mdoloris, Lille, França) durante cirurgia abdominal de grande porte em paciente com obesidade. Depois de estabilizar o equilíbrio nocicepção-antinocicepção da paciente no intraoperatório, revertemos rapidamente a anestesia e a paciente não precisou de opioides no pós-operatório. Conclusão A personalização da antinocicepção sem opioides por meio do emprego de monitor de nocicepção é factível. A abordagem pode otimizar a antinocicepção intraoperatória e melhorar o conforto pós-operatório.

Physical etiology of sexual dysfunction in obstetric fistula patients: A prospective study.

OBJECTIVE: To understand how the physical etiology of sexual dysfunction among women with obstetric fistulas can inform repair. METHODS: A prospective cohort study included women aged 18 years or over presenting at the Fistula Care Center, Bwaila Maternity Hospital, Lilongwe, Malawi, with obstetric vesicovaginal fistula before and after repair. The study took place between January 1, 2018, and December 31, 2018, and involved physical examinations and interviews. The primary outcome was sexual function. RESULTS: 115 were interviewed before and after repair. 44 (40.0%) preoperatively and 14 (12.2%) postoperatively reported sexual dysfunction. 94 women (81.7%) had little or no interest in sexual activity before repair. 55 women (47.8%) had little or no interest in sexual activity after repair. Before surgery, 69 women (60.0%) were not sexually active in the 30 days before coming to the Fistula Care Centre. After surgery, 32 women (27.8%) were not sexually active in the 30 days before returning to the Fistula Care Centre. Of those who were not sexually active in the 30 days before coming to the Fistula Care Centre (n=69), the majority cited their health as a reason before repair (n=45, 65.2%), while the most commonly cited reason after repair was an absent partner (n=23, 35%). CONCLUSION: Given the significant percentage of women with obstetric fistula reporting sexual dysfunction after repair, a more holistic perspective of health outcomes should be considered. Further investment should be made in screening tools and surgical techniques targeting sexual dysfunction.

The mobile surgical outreach program for management of patients with genital fistula in the Democratic Republic of Congo.

OBJECTIVE: To describe components of the mobile surgical outreach (MSO) program as a model of care delivery for women with genital fistula; present program results; and discuss operational strengths and challenges. METHODS: A retrospective observational study of routinely collected health data from women treated via the MSO program (2013-2018). The program was developed at Panzi Hospital in the Democratic Republic of Congo to meet the needs of women with fistula living in remote provinces, where travel is prohibited. It includes healthcare delivery, medico-surgical training, and community sensitization components. RESULTS: The MSO team cared for 1517 women at 41 clinic sites across 18 provinces over the study period. Average age at presentation was 31 years (range, 1-81 years). Most women (n=1359, 89.6%) presented with vesicovaginal fistula. Most surgeries were successful, and few women reported residual incontinence postoperatively. Local teams were receptive and engaged in clinical skills training and public health education efforts. CONCLUSION: The MSO program addresses the backlog of patients awaiting fistula surgery and provides a template for a national strategic plan to treat and ultimately end fistula in DRC. It offers a patient-centered approach that brings medico-surgical care and psychosocial support to women with fistula in their own communities.

Genitourinary Fistula: A Curse to Neglected Pregnancy.

Genitourinary fistula is a psychophysiosocial distress that results in prolonged labour. Gradually, it has become a public health issue globally with advancing of its incidence day by day. A handsome number of mothers are also suffering in Bangladesh from genitourinary fistula. This study was done to observe the patterns of presentations of genitourinary fistula and their fetal outcome. One hundred sixteen (116) consecutive patients were enrolled in the study by purposive sampling as a diagnosed case of genitourinary fistula presented in Department of Obstetrics & Gynecology of Dhaka Medical College Hospital, Dhaka, Bangladesh from January 2017 to September 2017. It was a prospective observational cross-sectional study. A pre-structured, interview and observation based, peer reviewed data collection sheet was prepared. Data regarding sociodemographic, clinical and Obstetrical profile were recorded. Statistical analysis was done with SPSS version 23. Data were presented as mean and standard deviation, frequency and percentage with range. The mean age of the respondents was 27.27±4.21 (age range: 20-35 years). The mean height of the respondents was 150.26±13.28cm (range: 133-172cm). Among 106 mothers 69(65.1%) and 25(23.6%) were primiparous and multiparous respectively. On the contrary, 5(4.7%) each were grand multiparous and experienced fistula due to non obstetrics complications like malignancy, hysterectomy and radiotherapy. Mothers had 1, 2 and 3 fistulas in 98(92.5%), 6(5.7%) and 2(1.9%) respectively. Among 106 mothers, 99(93.4%) experienced only urinary incontinence whereas 5(4.7%) experienced fecal incontinence. Only 2(1.9%) experienced both urinary and fecal incontinence. Maximum vesicovaginal fistula was due to obstructed labour (65.09%) which was subsequently followed by trauma (14.15%). Vesicovaginal fistula was the commonest type which was subsequently followed by vesicocervical fistula. Among 106 mothers, 73(68.9%) and 25(23.6%) gave birth, still birth and alive babies respectively. On the contrary, 4(3.7%) neonate experienced death in neonatal period whereas 1(0.9%) each twin deliveries resulted in 'one dead and one alive' and 'Twin alive' respectively. In case of only 3(2.8%) mothers 'no information' regarding fetal outcome could be recorded. Prolonged labour is the principal culprit to develop genitourinary fistulas among which VVF is the commonest variety. Still birth is the frequently evident fetal outcome in case of this clinical disaster of pregnancy.

Vesicovaginal fistula in Uganda.

Kitovu Hospital in Masaka, Uganda, is a leading obstetric fistula repair centre in the country with the highest rates of fistula in the world. In this retrospective case review, the regional incidence and causative factors were studied in patients with vesicovaginal fistula (VVF) who were admitted at Kitovu Hospital. Fistula history included severity (ICIQ score), causes and outcomes of VVF were measured. Women suffered with symptoms of VVF for an average of 4.97 years with an average ICIQ severity score of 7.21. Patients travelled an average distance of 153 km and the majority travelled by public transport. Rates of prolonged labour were high. 69% of fistula-causing delivery resulted in stillbirth and 12% resulted in early neonatal death. Following surgery, 94% of patients were dry on discharge. Impact statement What is already known on this subject? Vesicovaginal fistula (VVF) is a severe, life-changing injury. Although largely eradicated from the Western world thanks to modern obstetric practice, VVF is still highly prevalent in developing countries where factors such as young childbearing age and poor access to emergency obstetric care increase the incidence (Wall et al. 2005 ). At the current rate of fistula repair, it is estimated that it would take 400 years to treat those already suffering with fistula, providing that no new cases emerged (Browning and Patel 2004 ). What do the results of this study add? The Ugandan women in this study reiterate tales of foetal loss, social isolation and epic journeys in search of fistula repair, as previously described in the literature. The study offers some hope for prompt help-seeking during labour and after fistulas are developed. It demonstrates the success of fistula repairs at Kitovu Hospital but highlights the paucity of service provision across Uganda. What are the implications of these findings for clinical practice and/or further research? Further epidemiological research is required to quantify the true burden of the disease. Only by raising the profile of VVF in both developing and developed countries, can there be a collaborative effort to make universal change. To embark upon the prevention and cure of the disease it is necessary to continue tackling issues of poverty and gender inequality.

The use of Singapore flaps for vaginal reconstruction in women with vaginal stenosis with obstetric fistula: a surgical technique.

Gynecologic and plastic surgeons collaborate to improve vaginal reconstruction for women with vaginal stenosis and obstetric fistula. As these cases occur typically in low-resource settings, the Singapore flap is a useful technique given its reliability, safety, ease of dissection, and minimal need for additional supplies. The fasciocutaneous flap maintains cutaneous innervation and vasculature and does not require stenting. The surgical collaboration has made it possible to provide functional vaginal reconstruction as a part of the overall care of obstetric fistula patients. The technique shows promise for improving sexual function for women with obstetric fistula and may also enhance healing. TWEETABLE ABSTRACT: Gynecologic & plastic surgeons collaborate to improve vaginal reconstruction for women with obstetric fistula.

Bladder stones in vesicovaginal fistula: is concurrent repair an option? Experience with 87 patients.

INTRODUCTION AND HYPOTHESIS: The objective was to assess the outcomes of a one-stage approach to bladder stones in the setting of a vesicovaginal fistula, performing fistula repair concurrently with stone extraction. METHODS: Retrospective review of urogenital fistula surgeries at Evangel VVF Center in Jos, Nigeria, between December 2003 and April 2014, identified 87 women with bladder stones accompanying their fistulas and 2,979 repaired without stones. Concurrent stone extraction and fistula repair were performed in 51 patients. Outcomes were compared with respect to fistula size, classification, and fibrosis. RESULTS: Women presenting with bladder stones were older and had larger fistulas than those without stones (P < 0.001). Additionally, their fistulas were more often classifiable as large and less often as high (P = 0.02), and were more fibrotic (P = 0.003). Twenty-six (51 %) patients with concurrent repair successfully became dry. Comparing results by classification, concurrent repair of high fistulas with stones was very likely to be successful (OR 8.8, 95% CI 1.0-78.2), whereas low fistulas were not (OR 0.2, 95% CI 0.02-0.7). Outcomes were similar to those of patients without stones, except for low fistulas, which were 5 times more likely to fail (P = 0.04). CONCLUSION: Concurrent closure of vesicovaginal fistula at the time of bladder stone extraction is possible and, in many respects, preferable to a staged approach, particularly among high or midvaginal fistulas.

Vesicovaginal fistulas in the developed world: An analysis of disease characteristics, treatments, and complications of surgical repair using the ACS-NSQIP database.

AIMS: To analyze patient characteristics, complications, and surgical trends in vesicovaginal fistulas (VVF) from a national database. METHODS: Current Procedural Terminology was used to identify patients undergoing VVF repair from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database. Characteristics and treatments were identified. Logistic regression was used to identify characteristics associated with complications. RESULTS: From 2006 to 2013, 200 patients underwent VVF repair. Mean age was 50.3 ± 12.3 years. A large proportion of patients were overweight (72%) and recent smokers (30%). Predominant comorbidities were heart disease (29%) and type 2 diabetes (9.5%). Of all VVF repairs, 65% were repaired vaginally. Concomitant procedures included hysterectomy (n = 6), reconstructive flaps (n = 13), and slings (n = 2). Post-operative complications occurred in 15% of patients. The most common complication was urinary tract infection (8%) followed by blood transfusion (3%). Compared to the vaginal approach, abdominal VVF repairs had higher overall morbidity (22% vs 7% P = 0.003), longer length of stay (3.5 ± 2.3 vs 1.6 ± 2 days P = 0.00) and were more likely to be associated with sepsis (4.3% vs 0% P = 0.02), blood transfusion (7.1% vs 0.8% P = 0.017), and readmission (10.1% vs 0.8% P = 0.003). In multivariate analysis, abdominal approach was a significant predictor of complications within 30 days (P = 0.03, P = 0.02). CONCLUSIONS: In the US VVF remains a rare entity. Over half of VVFs were repaired vaginally. The occurrence of serious complications is low. A vaginal approach appears to be associated with fewer complications.

Enterovaginal or Vesicovaginal Fistula Control Using a Silicone Cup.

BACKGROUND: An enterovaginal or vesicovaginal fistula is a complication resulting in vaginal discharge of succus, urine, or stool that can lead to significant complications. For low-volume fistulae, tampons or pads may be used. With high-volume fistulae, frequent product change can be painful and unpredictable in terms of efficacy. The psychologic distress is profound. Surgery may not be an option, making symptom control the priority. INSTRUMENT: We report the use of a reusable menstrual silicone vaginal cup placed to divert and contain drainage. EXPERIENCE: The menstrual cup provided significant symptom relief. Drainage is immediately diverted from tissue, unlike with tampon or pad use, which involves longer contact periods with caustic fluids. A system was created by adapting the end of the cup by adding silastic tubing and an external leg bag to provide long-term drainage control. CONCLUSION: Improvement in quality of life is of primary importance when dealing with fistula drainage. This simple and inexpensive device should be considered in those cases in which the drainage can be diverted as a viable option, especially in those who are symptomatic and awaiting surgical repair or in those for whom surgery cannot be performed.

Vesicosalpingo Fistula: A Case Presentation And Review of The Literature.

OBJECTIVES: To describe a case presentation and perform a review of the literature on vesicosalpingo fistulas. METHODS: An otherwise healthy 32 year-old patient was referred to urology with symptoms of persistent abdominal bloating and urine leakage from the vagina after abdominal conversion of laparoscopic hysterectomy. Two fistula tracts were identified in the bladder during preoperative cystoscopy. The tracts were cannulated with temporary ureteral catheters, and the patient underwent a robotic-assisted laparoscopic repair of a vesicosalpingo and a vesicovaginal fistula. RESULTS: The patient was discharged on the first postoperative day with an indwelling urinary catheter. A follow-up cystogram performed on the 14th postoperative day demonstrated no evidence of extravasation. There was no evidence of recurrence at a 4-month follow-up visit. This is the first reported robot-assisted laparoscopic repair of a vesicosalpingo fistula and the fifth reported case of a vesicosalpingo fistula in the literature. This is the first reported case of separate vesicosalpingo and vesicovaginal fistulas presenting concurrently in a single patient. CONCLUSIONS: This case presentation with 2 separate fistula tracts emanating from the bladder demonstrates the need to meticulously evaluate each individual fistula tract in order to successfully visualize and address all fistula tracts present in order to mitigate failures and the need for reoperation.

Outcomes of Surgical Management in Patients with Stress Urinary Incontinence and/or Neovesicovaginal Fistula after Orthotopic Neobladder Diversion.

PURPOSE: To our knowledge there are no guidelines for the evaluation and management of incontinence in women with an orthotopic neobladder. We propose a treatment algorithm based on our experience with treating this patient population. MATERIALS AND METHODS: We identified women in whom orthotopic neobladder diversion and surgery for incontinence were performed from January 1, 1995 to January 1, 2014. Charts were reviewed for management, outcomes and complications within 30 days of surgery. RESULTS: At this institution 12 women with orthotopic neobladder diversion were treated with surgery for incontinence between 1995 and 2014. Six women (50%) had an undiagnosed neovesicovaginal fistula, of whom 3 (50%) underwent successful fistula repair. A total of 12 bulking agent injections were performed in 6 women (50%). The outcomes were continued dryness after 1 injection (8%), transient improvement after 9 (75%), immediate failure after 1 (8%) and secondary fistula development after 1 (8%). Four transobturator slings and 4 pubovaginal slings were placed in a total of 6 patients (50%), of whom 1 (17%) was dry and 1 (17%) was improved. At a median followup of 22.9 months (IQR 11.1-46.4) 6 women (50%) were dry or improved and 6 (50%) had no improvement in leakage. Of the 6 (50%) women who were dry or improved 2 (17%) achieved planned intermittent catheterization after surgery and 2 (17%) underwent ileal conduit conversion. CONCLUSIONS: Bulking agents have low long-term efficacy and carry the risk of fistula formation. The efficacy of tension-free sling placement is low and continence requires an obstructing sling. Counseling should include acceptance of multiple procedures, which may be necessary to achieve continence, and consideration of conduit diversion.