Predictors of Recurrence and Successful Treatment Following Obstetric Fistula Surgery.

OBJECTIVE: To determine factors contributing to recurrence and successful treatment of obstetric fistula (OF). MATERIALS AND METHODS: Data were collected from OF patients in Saint Luc Hospital Kisantu (DR of Congo) between 2007 and 2013. Patients underwent surgical treatment and were evaluated after a follow-up period of 3 months. Successful treatment was defined as no or dry pads whereas recurrence was defined as the persisting need for wearing incontinence pads immediately after the surgery or after a period of dryness. Fistula classification was done according to Waaldijk. Univariate and multivariate analyses were performed using logistic regression, corrected for preoperative and intraoperative OF characteristics. RESULTS: Median age of 166 OF patients was 29.11 ± 9. 6 years (range 5-61). The majority of OF was type I (57.2%) followed by type III (20.5 %). There were 20.5% who showed vaginal fibrosis during surgical treatment. The most common location of fistula was pericervical (39.8%). The global recurrence rate at 3 months was 28.3%, with type IIBb (100%) as most the common recurring, followed by IIAb (66.67%) and IIAa (41.18%). There were 71.7%, 15.7%, 12%, and 0.6% patients who were considered completely cured, partially cured (downstaged), persistent, and upstaged, respectively. OF patients with fibrosis were 68% less likely (odds ratio 0.32, 95% confidence interval 0.14-0.73; P = .0065) to be dry in comparison to those without fibrosis. Patients with urethral fistula were 73% less likely (odds ratio 0.27, 95% confidence interval 0.11-0.63; P = .0024) to be dry compared to other locations. CONCLUSION: This study showed that fibrosis and urethral location are independent risk factors for fistula recurrence or persistence following surgical fistula repair.

Development of VVF following double J stent placement.

Double J stent (DJ stent) is commonly used in various urological conditions. Theoretically stent-induced tissue erosion can be a possibility, but fistula formation is rarely reported. The present case was a case of genitourinary tuberculosis diagnosed 4 years ago and had received complete treatment. Two months ago she presented with recurrent urinary tract infection and diagnosed to have vesicoureteric reflux with secondary obstruction for which DJ stent was placed, after 15 days of which the patient reported leakage of urine per vagina. She was diagnosed to have vesicovaginal fistula (VVF) with in situ stent eroding through the bladder wall. Stent was removed and fistula was corrected surgically. This is the first reported case of stent-induced VVF, a rare complication of ureteral stent placement.

Continent vesicovaginal fistula.

Vesicovaginal fistula is an abnormal communication between the bladder and vagina and represents the most frequent type of fistula in the urinary tract. The most common cause in Brazil is iatrogenic fistula, secondary to histerectomia. Classically these women present continuous urinary leakage from the vagina and absence of micturition, with strong negative impact on their quality of life. We present a case of totally continent vesicovaginal fistula, with a follow-up of 11 years with no complications.

A novel method for iatrogenic vesicovaginal fistula treatment: autologous platelet rich plasma injection and platelet rich fibrin glue interposition.

PURPOSE: Vesicovaginal fistula remains a challenge in surgical therapy. In this study autologous platelet rich plasma and platelet rich fibrin glue were used as a minimally invasive approach for vesicovaginal fistula closure. MATERIALS AND METHODS: Data including age, parity, ICIQ-UI (International Consultation on Incontinence Questionnaire-urinary incontinence), ICIQ-QOL (International Consultation on Incontinence Questionnaire-quality of life), duration of leakage, fistula diameter and complications were collected before and after the intervention. Platelet rich plasma and platelet rich fibrin glue were prepared from 12 patients' own blood. De-epithelialization was performed around the fistula until a small hemorrhage occurred. Platelet rich plasma was injected around the fistula into the tissue and platelet rich fibrin glue was interpositioned in the tract. RESULTS: No complications were observed during and after the injection. Mean ± SD patient age was 39.75 ± 8.45 years. At 6-month followup 11 patients considered themselves clinically cured, and transvaginal physical examination and cystography were normal. ICIQ-UI and ICIQ-QOL showed remarkable improvement in 11 patients. One patient had significant improvement but did not consent to the second injection. None of the patients had voiding dysfunction, urinary incontinence, retention or urinary tract infection. CONCLUSIONS: Autologous platelet rich plasma injection and platelet rich fibrin glue interposition offer a safe, effective and novel minimally invasive approach for the treatment of vesicovaginal fistula which obviate the need for open surgery. We propose calling this technique the Hamidi-Shirvan method.

Pelvic floor structure and function in women with vesicovaginal fistula.

PURPOSE: Vesicovaginal fistula is a catastrophic event, especially in areas with poor peripartum care, where most occur. It is usually due to severely obstructed and protracted labor. We assumed that such patients would show evidence of abnormal levator function, eg due to denervation. MATERIALS AND METHODS: In an external audit at Hamlin Fistula Hospital in Addis Ababa, Ethiopia, 95 women were seen for clinical examination and 4-dimensional translabial ultrasound. Patients were examined supine and after voiding. Volume data sets were obtained upon coughing, Valsalva maneuver and pelvic floor muscle contraction. RESULTS: Women were seen before (22) or after (73) vesicovaginal fistula repair. Mean age was 29.5 years (range 16 to 65) and mean parity was 2.7 (range 1 to 11). Only 2 patients had a significant cystocele (stage 2), 3 had stage 2 uterine prolapse and 13 had a stage 2 rectocele. Levator biometry was done in 92 of 95 women, which showed no evidence of muscle atrophy. Mean hiatal area on Valsalva was 18.8 cm(2) (range 7.7 to 45.9) and only 6 of the 92 women (7%) fulfilled the criteria for ballooning (hiatal distention 25 cm(2) or greater). Levator avulsion was diagnosed in 27 cases (28%), of which 11 were bilateral. Reflex contraction of the levator ani was observed upon coughing in all except 2 patients. Levator contraction upon request could be performed by all except 6 women. CONCLUSIONS: Abnormal levator function and anatomy in patients with vesicovaginal fistula is not uncommon but no more than in unselected urogynecologic patients in the developed world. There was no evidence of permanent denervation of the levator ani.

Congenital vesicovaginal fistula with menouria: an anomaly of the urogenital sinus.

OBJECTIVE: To describe the diagnostic and therapeutic process for a congenital exceptional anomaly. To analyze the pathogenesis of the embryologic anomalies associated with menouria and congenital vesicovaginal fistula (VVF). STUDY DESIGN: The case of a 28-year-old female with menouria and impossibility of consummating coitus is described. The diagnostic method is analyzed. The type of treatment is described and finally we conclude with a hypothesis about embryology of congenital anomalies with VVF and menouria. RESULTS: For management of anomalies as congenital VVF, imaging tests including cystography and urography could not correctly visualize the fistulous tract. It was identified by cystoscopy, performed during the time of menouria. Surgical treatment consisted in repairing the VVF and vaginoplasty according to the McIndoe technique. CONCLUSIONS: All women with menouria need complete investigation with exhaustive exploration, analytic evaluation, ultrasound, imaging tests (principally magnetic resonance) and, very importantly, cystoscopy on the days of menouria. Surgical treatment must be careful and individualized. This case allows us to hypothesise that the blind vagina encountered reflects an anomaly of correct urogenital sinus development.

Surgical outcome of obstetric fistula: a retrospective analysis of 595 patients.

OBJECTIVE: The aim of the study was to investigate obstetric fistula in terms of patient demographics, fistula characteristics and predictors of surgical outcome. DESIGN: Retrospective cross-sectional study. SETTING: Fistula referral hospital in eastern Democratic Republic of Congo. Population. Five hundred and ninety-five women receiving fistula repair from November 2005 to November 2007. METHODS: Review of patient records for information on patient demographics, obstetric history, clinical data for index pregnancy, fistula characteristics and surgical information. Cross-tabulations and multivariate logistic regression models were used to predict surgical outcome. MAIN OUTCOME MEASURES: Fistula closure and incontinence despite fistula closure. Results. 82.9% had developed fistula following obstructed labor, 17.1% after medical interventions of which 71.1% involved cesarean section or peripartum hysterectomy. Median age at fistula development was 23 years; 40.8% were primiparous and 43.2% were parity three or more. Women took a median of two years to seek treatment. Closure rate was 87.1%, with 15.6% remaining incontinent. Failure to close the fistula was significantly associated with previous repairs, amount of fibrosis and fistula size. Compared with primary repairs, the odds ratio of failure was almost five times greater for three or more repairs (odds ratio 4.7, 95% confidence interval 2.2-10.0). Incontinence was significantly associated with previous repairs, amount of fibrosis and fistula location. Compared with fistulas with a high location, the odds ratio of incontinence for low, circumferential fistulas was 6.3 (95% confidence interval 2.5-16.4). CONCLUSIONS: Fistula in Democratic Republic of Congo was found in both primiparous and multiparous women, indicating a need for increased access to obstetric care for all pregnant women. Fistulas repaired for the first time, with no fibrosis and size <2 cm, had the best surgical outcome.

Duration of bladder catheterization after surgery for obstetric fistula.

OBJECTIVE: To compare the surgical outcome at discharge and at 6-months follow up in patients who underwent repair of obstetric fistulae with postoperative bladder catheterization for 10, 12, or 14 days. METHODS: A retrospective study of 212 obstetric fistula patients who underwent repair with postoperative bladder catheterization for 10 days (group 1), 12 days (group 2), and 14 days (group 3) at the Bahir Dar Hamlin Fistula Center in Ethiopia. Fistulas were classified according to Goh's system. RESULTS: There were 68 women (32%) in group 1, 62 women (29%) in group 2, and 82 women (39%) in group 3. There was a significant difference in the extent of urethral involvement, fistula size, and degree of vaginal scarring among the 3 groups, with the more extensively damaged patients catheterized for longer. Breakdown of repair was seen in 1.5% of patients in group 1, none in group 2, and 2% in group 3 (P=0.47). CONCLUSION: Postoperative catheterization for 10 days may be sufficient for management of less complicated obstetric vesicovaginal fistulae.

[High colpocleisis in the treatment of postradiation vesicovaginal fistulas]. / Vysokii (kosoi) kol'pokleizis v lechenii postradiatsionnykh puzyrno-vlagalishchnykh svishchei.

Surgical treatment with application of the modified technique of high colpocleisis according to Latsko was performed in 174 patients aged 26-72 with postradiation vesicovaginal fistulas. The latter developed 6 months to 26 years after radiotherapy. The operation resulted in restoration of the urinary bladder capacity and spontaneous urination.

Urodynamic findings in patients with urogenital fistulae.

OBJECTIVE: To assess the feasibility of carrying out a urodynamic investigation in patients with a urogenital fistula and to establish the incidence of abnormal lower urinary tract function in such patients. PATIENTS AND METHODS: Of 38 patients referred within the last 3 years with a diagnosis of lower urinary tract genital fistula, 30 were investigated by dual-channel subtracted cystometry before surgical treatment of their fistula; in addition, urethral pressure profilometry was carried out in 19 patients. Fourteen of the patients had fistulae into the vaginal vault; the urodynamic findings in this subgroup were compared with those of 12 patients with bladder neck and urethrovaginal fistulae. Twenty-six of the 30 patients underwent surgical treatment and 24 (92%) were cured anatomically by their first procedure. Ten patients complained of residual lower urinary tract symptoms and were re-investigated. RESULTS: Of the 38 patients, 47% had genuine stress incontinence, 40% showed systolic detrusor instability and 17% impaired bladder compliance. Half had evidence of voiding dysfunction; most appeared to be of a hypotonic detrusor type, although four cases showed an obstructive pattern. Fifteen patients had more than one abnormality and only five (17%) had entirely normal urodynamic findings. The overall incidence of functional abnormality was highest in the patients with urethral or bladder neck fistulae, with only one showing entirely normal urodynamic findings. Genuine stress incontinence was found more than twice as often associated with urethral or bladder neck fistulae and detrusor instability was also more common in this group. Voiding dysfunction of both hypotonic and obstructive types was found equally in the two groups. After surgical treatment, most patients became continent and free from lower urinary tract symptoms, although one complained of residual stress incontinence and nine of urgency or urge incontinence. Of the latter, six were found to have detrusor instability, one after repair of vault fistula, three after urethral or bladder neck fistulae and the other two after mid-vaginal fistulae. CONCLUSION: There is a high incidence of abnormal lower urinary tract function in patients with urogenital fistulae. Patients with urethral or bladder neck fistulae had a higher incidence of both detrusor instability and genuine stress incontinence than those with fistulae into the vaginal vault. Many of these abnormalities appear to resolve after successful repair of the fistula, although detrusor instability may persist and require further treatment in some women. These findings are relevant to the counselling of patients before repair and may be of medico-legal significance.

Pituitary and ovarian function in women with vesicovaginal fistuale after obstructed and prolonged labour.

This study concerns 11 patients with menstrual disorders dating back to an obstructed and prolonged labour, and 5 women with similar histories but without menstrual disorders. All patients were able to secrete gonadotrophins. According to the gonadotrophin pattern, the patients could be divided into three groups: in the amenorrhoeic and in 2 normally menstruating women various degrees of suppression of basal and peak levels of luteinising hormone (LH) could be observed; patients with infrequent menstrual periods showed temporarily arrested secretion of gonadotrophins and ovarian steroids; and in polymerrhoea a non-cyclic but high secretion was seen. The gonadotrophin response to oestrogen levels was temporarily or permanently disordered in all but 3 patients in this series, whereas an ovarian refractoriness to gonadotrophins was only infrequently observed. There were 2 cases of 'ovulatory amenorrhoea' as judged by the normal profiles of ovarian steroids. Biopsies indicated inadequate endometrial transformation in many cases of amenorrhoea. Abnormal responses to the stimulatory tests of pituitary secretion of human growth hormone (HGH) and/or LH were seen in 6 patients. The study suggests that menstrual disorders after obstructed labour are associated with derangement of different hypophyseotrophic areas of the hypothalamus.