Female non-obstetric urogenital fistula repair: long-term patient-reported outcomes and a scoping literature review.

OBJECTIVE: To investigate long-term and patient-reported outcomes, including sexual function, in women undergoing urogenital fistula (UGF) repair, addressing the lack of such data in Western countries, where fistulas often result from iatrogenic causes. PATIENTS AND METHODS: We conducted a retrospective analysis at a tertiary referral centre (2010-2023), classifying fistulas based on World Health Organisation criteria and evaluating surgical approaches, aetiology, and characteristics. Both objective (fistula closure, reintervention rates) and subjective outcomes (validated questionnaires) were assessed. A scoping review of patient-reported outcome measures in UGF repair was also performed. RESULTS: The study included 50 patients: 17 (34%) underwent transvaginal and 33 (66%) transabdominal surgery. History of hysterectomy was present in 36 patients (72%). The median (interquartile range [IQR]) operating time was 130 (88-148) min. Fistula closure was achieved in 94% of cases at a median (IQR) follow-up of 50 (16-91) months and reached 100% after three redo fistula repairs. Seven patients (14%) underwent reinterventions for stress urinary incontinence after transvaginal repair (autologous fascial slings). Patient-reported outcomes showed median (IQR) scores on the International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms Modules (ICIQ-FLUTS) of 5 (3-7) for filling symptoms, 1 (0-2) for voiding symptoms and 4.5 (1-9) for incontinence symptoms. The median (IQR) score on the ICIQ Female Sexual Matters Associated with Lower Urinary Tract Symptoms Module (ICIQ-FLUTSsex) was 3 (1-5). The median (IQR) ICIQ Satisfaction (ICIQ-S) outcome score and overall satisfaction with surgery item score was 22 (18.5-23.5) and 10 (8.5-10), respectively. Higher scores indicate higher symptom burden and treatment satisfaction, respectively. Our scoping review included 1784 women, revealing mixed aetiology and methodological and aetiological heterogeneity, thus complicating cross-study comparisons. CONCLUSIONS: Urogenital fistula repair at a specialised centre leads to excellent outcomes and high satisfaction. Patients with urethrovaginal fistulas are at increased risk of stress urinary incontinence, possibly due to the original trauma site of the fistula.

The utility of Martius fat pad in the repair of urogenital fistulae: review of current evidence.

OBJECTIVE: To present the contemporary evidence on transvaginal urogenital fistulae (UGF) repair with Martius fat pad (MFP), compared to direct graftless fistula repair. METHODS: We reviewed all available studies reporting lower UGF repair via the transvaginal approach in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). The primary outcome of interest was the fistula closure rates. When available, patients' baseline characteristics, indications for surgery, and early and late postoperative complications with focus on MFP-related complications are reported. RESULTS AND DISCUSSION: In obstetric fistulae, tissue interposition has been almost completely abandoned, with contemporary large series reporting closure rates of >90% with graftless repair, even for complex fistulae. Similarly, most simple, non-irradiated iatrogenic fistulae can be closed safely without or with tissue interposition with success rates ranging between 86% and 100%. However, MFP is valuable in fistulae with difficulty achieving tension-free and layered closure, with significant tissue loss, urethral involvement and with poorly vascularised tissues after radiotherapy, with reported success rates between 80% and 97% in those challenging situations. CONCLUSION: A UGF repair should be individualised after considering the specific characteristics and complexity of the procedure. MFP interposition is probably unnecessary for the majority of low (obstetric) fistulae within otherwise healthy tissues. However, MFP may still have a place to maximise outcomes in low-income settings, in select cases with higher (iatrogenic) fistulae, and in most cases with radiotherapy.

Novel use of the rectus abdominus muscle flap for vaginal reconstruction in complex obstetric fistula repair: A case series.

OBJECTIVE: Globally, obstetric fistula is a tragic outcome following obstructed labour. Failure of complex repair and post-operative incontinence are common. We describe an innovative surgical technique incorporating the rectus abdominus flap at the time of fistula repair. DESIGN: Retrospective case series. SETTING: Malawi, Fistula Care Centre. METHODS: Patients were followed for 3 months after discharge to determine continence and healing. RESULTS: Five of six patients were continent at 3 months and one was lost to follow-up by dry at a one month post-operative phone call. There were no major complications. CONCLUSIONS: The rectus abdominus flap may be a useful adjunct to repair of complex obstetric fistula.

Early bladder dysfunction after vesicovaginal fistula repair: A prospective comparative analysis of transvaginal, open, and laparoscopic abdominal approaches.

INTRODUCTION: We aim to compare the clinical and urodynamic profile of lower urinary tract symptoms (LUTS) in patients undergoing laparoscopic, open transabdominal, and laparoscopic transabdominal vesicovaginal fistulae (VVF) repair at 3 months of repair, that is, in early postoperative period. MATERIALS AND METHODS: Fifty-one consecutive patients with endoscopically confirmed VVF were enrolled in our study over 2 years. Malignant fistulae, radiation-induced, and complex fistulae were excluded after cross-sectional imaging. All patients underwent a postoperative assessment for the success of the repair. Then at 3 months, they completed the American Urological Association Symptom Score questionnaire and underwent a dual channel pressure-flow urodynamic study. The results of transvaginal, laparoscopic, and open transabdominal repairs were compared. RESULTS: All patients belonged to the Indian Caucasian race. The mean age was 35.43 ± 6.63 years. Thirty-two patients had supratrigonal and 19 had trigonal fistulae. Laparoscopic transabdominal repair was done in 15 patients, open transabdominal repair in 22 patients, and transvaginal repair in 14 patients. Forty-six patients reported some LUTS at a median follow-up of 5.83 ± 2.37 months postoperatively. Only 18 (35.2%) of these patients had moderate to severe symptoms The postoperative bladder dysfunction rates in open transabdominal, transvaginal and laparoscopic transabdominal groups were 36.4%, 28.6%, and 20%, respectively. Twenty-seven patients (52.9%) had some urodynamic abnormality, that is, small capacity (5), high voiding pressures (14), genuine stress incontinence (3), and poor compliance (3). Bladder capacity was a significant predictor of bladder dysfunction in our patients. CONCLUSIONS: In our study, all three surgical approaches were associated with bladder dysfunction, however, it was the least in the laparoscopic transabdominal approach. Postoperative bladder capacity is a significant predictor of bladder dysfunction.

Genitourinary Fistula: 5 Years' Experience of Five Referral Centers in Iran.

INTRODUCTION AND HYPOTHESIS: Genitourinary fistula is a devastating ailment that has an impact on women's physical health, mental health, emotional health, and financial security. The management of genitourinary fistula depends on the type, size, and duration of fistula formation. The purpose of this study is to report the features of genitourinary fistula in Iranian women and our experience in the management of fistula. METHODS: Retrospective chart reviews of 283 patients were performed to determine the cause of the fistula, prior repairs, tissue interposition, and the success rate. The operation was considered successful if the patient did not have any urine leakage during the observation time. RESULTS: The mean (SD) age of women was 49.51 (19.39; range: 21-70) years, Of these, 137 (52.9%) had a history of previous genitourinary fistula surgery. The average fistula was 1.53 (0.041) cm in size. The median (interquartile range) operation lasted 70 (15) min. The success rate after fistula repair was 91.5%. The typical follow-up period lasted 13.26 (range: 1-88) months. Forty-three (15.2%) patients had a big fistula (>2.5 cm) and 4 patients (1.4%) had a history of pelvic radiation therapy, among other reasons for failure. After a second repair, all patients' initial failures were resolved. There were no significant complications, as classified by Clavien-Dindo class 2 or greater. Additionally, there were no bowel, ureteral, or nerve injuries. CONCLUSIONS: Our patients with genitourinary fistula had a successful outcome following repair techniques, without any significant morbidity or mortality.

Urinary incontinence following successful closure of obstetric vesicovaginal fistula repair in Southern Ethiopia.

BACKGROUND: Urinary incontinence (UI) after successful closure of obstetric vesicovaginal fistula (VVF) repair is a widely recognized public health problem. However, there is insufficient research evaluating the factors associated with UI after successful obstetric VVF repair in Ethiopia. OBJECTIVES: The main aim of this study was to assess the magnitude and associated factors of UI following the successful closure of obstetric VVF repair at the Yirgalem Hamlin Fistula Center in the Sidama region of southern Ethiopia. METHODS: A retrospective cross-sectional analytical study was performed on patients who underwent obstetric VVF repair at the Yirgalem Hamlin Fistula Center between 2016 and 2020. The data were collected from September to October 2021. EPI Data Version 3.1 and SPSS Version 25.0 were used for data entry and analysis. A multivariable binary logistic regression model was used for all variables significant in the bivariate binary logistic analysis to determine the association between the independent variables and outcome variables. The data are presented in tables and figures. Variables with a p-value < 0.05 were considered to be statistically associated with the study outcome. RESULTS: In total, 499 study subjects were included. The magnitude of UI after successful closure of obstetric VVF repair was 23.25%. A Goh type 4 fistula (AOR = 4.289; 95% CI 1.431, 12.852), a fistula size > 3 cm (AOR = 8.855; 95% CI 4.786, 16.382), a partially damaged urethra (AOR = 2.810; 95% CI 1.441, 5.479), and a completely destroyed urethra (AOR = 5.829; 95% CI 2.094, 16.228) were found to be significantly associated factors with the outcome variable. CONCLUSIONS: Nearly one in four patients who had successful closure of obstetric VVF repair at the Yirgalem Hamlin fistula center had UI, which is above the WHO recommendations. The presence of a Goh type 4 fistula, large fistula size, and damaged urethral status significantly affect the presence of UI. Therefore, interventions are necessary to prevent and manage UI among patients who underwent obstetric VVF repair and had a closed fistula.

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.

Identifying opportunities for prevention of adverse outcomes following female genital fistula repair: protocol for a mixed-methods study in Uganda.

BACKGROUND: Female genital fistula is a traumatic debilitating injury, frequently caused by prolonged obstructed labor, affecting between 500,000-2 million women in lower-resource settings. Vesicovaginal fistula causes urinary incontinence, and other morbidity may occur during fistula development. Women with fistula are stigmatized, limit social and economic engagement, and experience psychiatric morbidity. Improved surgical access has reduced fistula consequences yet post-repair risks impacting quality of life and well-being include fistula repair breakdown or recurrence and ongoing or changing urine leakage or incontinence. Limited evidence on risk factors contributing to adverse outcomes hinders interventions to mitigate adverse events. This study aims to quantify these adverse risks and inform clinical and counseling interventions to optimize women's health and quality of life following fistula repair through: identifying predictors and characteristics of post-repair fistula breakdown and recurrence (Objective 1) and post-repair incontinence (Objective 2), and to identify feasible and acceptable intervention strategies (Objective 3). METHODS: This mixed-methods study incorporates a prospective cohort of women with successful vesicovaginal fistula repair at approximately 12 fistula repair centers in Uganda (Objectives 1-2) followed by qualitative inquiry among key stakeholders (Objective 3). Cohort participants will have a baseline visit at the time of surgery followed by data collection at 2 weeks, 6 weeks, 3 months and quarterly thereafter for 3 years. Primary predictors to be evaluated include patient-related factors, fistula-related factors, fistula repair-related factors, and post-repair behaviors and exposures, collected via structured questionnaire at all data collection points. Clinical exams will be conducted at baseline, 2 weeks post-surgery, and for outcome confirmation at symptom development. Primary outcomes are fistula repair breakdown or fistula recurrence and post-repair incontinence. In-depth interviews will be conducted with cohort participants (n ~ 40) and other key stakeholders (~ 40 including family, peers, community members and clinical/social service providers) to inform feasibility and acceptability of recommendations. DISCUSSION: Participant recruitment is underway. This study is expected to identify key predictors that can directly improve fistula repair and post-repair programs and women's outcomes, optimizing health and quality of life. Furthermore, our study will create a comprehensive longitudinal dataset capable of supporting broad inquiry into post-fistula repair health. Trial Registration ClinicalTrials.gov Identifier: NCT05437939.

Female genital fistula is a traumatic birth injury which occurs where access to emergency childbirth care is poor. It causes uncontrollable urine leakage and is associated with other physical and psychological symptoms. Due to the urine leakage and its odor, women with fistula are stigmatized which has mental health and economic consequences. Ensuring women's access to fistula surgery and ongoing wellbeing is important for limiting the impact of fistula. After fistula surgery, health risks such as fistula repair breakdown or recurrence or changes to urine leakage can happen, but studies during this time are limited. Our study seeks to measure these health risks and factors influencing these risks quantitatively, and work with patients, community members, and fistula care providers to come up with solutions. We will recruit up to 1000 participants into our study at the time of fistula surgery and follow them for three years. We will collect data on patient sociodemographic characteristics, clinical history, and behavior after fistula repair through patient survey and medical record review. If participants have changes in urine leakage, they will be asked to return to the fistula repair hospital for exam. We will interview about 80 individuals to obtain their ideas for feasible and acceptable intervention options. We expect that this study will help to understand risk factors for poor health following fistula repair and, eventually, improve women's health and quality of life after fistula.

Pneumovesical vesicovaginal fistula repair: Lessons learned from an initial series of 25 patients.

OBJECTIVES: This study aims to share the experiences and outcomes of laparoscopic pneumovesical repair for vesicovaginal fistulas (VVF). MATERIALS AND METHODS: A retrospective review of medical records from a single institution over 10 years was conducted. The focus was on patients who underwent VVF repair using a pneumovesical approach with three 5 mm laparoscopic ports. The study evaluated perioperative parameters, postoperative outcomes, and complication rates to assess the efficacy and safety of this surgical method. Cumulative sum (CUSUM) analysis was used to determine the learning curve based on operative time. RESULTS: Of the 26 patients with VVF, 23 (88.5%) had successful fistula closure after the first surgery. One patient required open surgery conversion due to challenges in maintaining pneumovesicum, and two experienced recurrences, although successful repairs were achieved in subsequent surgeries. The average patient age was 47.4 years, with a mean operative time of 99.9 min. The postoperative hospital stay averaged 9.1 days, and catheterization lasted about 11 days. The CUSUM chart indicated a learning curve, with fluctuations until the 19th case, followed by a consistent upward pattern. CONCLUSION: Laparoscopic pneumovesical VVF repair is an effective and safe technique, especially suitable for fistulas near the ureteral orifice or deep in the vaginal cavity. The method demonstrates favorable outcomes with minimal complications and allows for easy reoperation if necessary.

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.

Clinical application of single-layer annular vaginal flap in transvaginal repair for vesicovaginal fistula.

PURPOSE: To compare the first-time success rate and prognosis of repairing vesicovaginal fistula (VVF) by transvaginal and transvesical approaches, and to highlight a modified transvaginal repair technique which only require single layer closure of an annular vaginal flap. METHODS: Retrospective analysis of 57 consecutive patients who underwent VVF repair between 2007 and 2021. Fistula characteristics, operative factors, post-surgical complications and outcomes were analyzed. RESULTS: A total of 57 women with a median age of 50.4 (27-75) years were included. The history ranged from 7 days to 8 years, with an average of 20 months. 56 cases (98.2%) of VVFs were caused by pelvic surgery, and only one resulted from difficult labour. 11 cases (19.3%) had a history of surgical repair failure. All 57 cases of surgery were smoothly completed. Among them, 17 patients underwent transvaginal repair, whereas 40 (70.2%) women had transvesical repair. Transvaginal approach had a significantly shorter operative time, less intraoperative blood loss, reduced postoperative hospital stay, less hospitalization cost and lower minor complication rates than transvesical group (p < 0.05). No serious complications occurred in the two groups. No cystostomy was performed in the transvaginal group, but 12 cases (30%) in the transvesical group. The average follow-up time was 18.5 (3-48) months. The first-time success rates of transvaginal and transvesical techniques were 82.3 and 75%, respectively. CONCLUSION: VVF repair with single layer closure of an annular vaginal flap is a technically feasible, simple and successful approach with significantly better operative parameters and lower complications rates.

Incidental urinary tract injury and the formation of vesicovaginal fistula at the time of hysterectomy for benign indications.

INTRODUCTION AND HYPOTHESIS: The association between hysterectomy type, laparoscopy use and vesicovaginal fistula (VVF) is currently unclear and would be useful to determine route of surgery and provide adequate patient counseling. The objective of this study was to evaluate the magnitude of association between the use of laparoscopic assistance, recognized intraoperative urinary tract injury and subsequent VVF repair and to quantify any differences in fistula repair and injury detection by hysterectomy type. Lastly, we sought to determine whether the type of hysterectomy is a risk factor for VVF repair independent of injury identification. METHODS: We performed a retrospective cohort study utilizing the Healthcare Cost and Utilization Project database examining benign hysterectomies performed in California, New York and Florida from 2005-2011. Multivariable logistic regression models were used to evaluate associations among hysterectomy type, reported injury and VVF. RESULTS: Of 581,395 eligible hysterectomies, urinary tract injuries occurred in 6702 patients (1.15%) and 640 patients developed VVF (0.11%). Patients with reported injury were 20-fold more likely to develop VVF than those without (OR = 20.6; 1.96% vs. 0.089% respectively). The association between reported injury and VVF development was stronger if laparoscopy was involved (OR = 30) than if it was not (OR = 17). Patients undergoing laparoscopic procedures were less likely to have injury reported (OR = 0.6) but more likely to undergo VVF repair (OR = 1.5). This association with VVF repair was independent of injury identification. Patients developing VVF were more likely to have undergone total abdominal hysterectomy compared to other hysterectomy types. CONCLUSIONS: Laparoscopy is an independent risk factor for the need for subsequent VVF repair, independent of hysterectomy type and presence of intraoperatively recognized urinary tract injury.

Robotic repair of a branching vesicouterine and vesicovaginal fistula.

INTRODUCTION AND HYPOTHESIS: We present technical considerations and tips for repairing a complex branching vesicouterine and vesicovaginal fistula via a robotic approach. METHODS: A 31-year-old female presented with constant urinary leakage following a vaginal birth after prior cesarean section. Evaluation with cystoscopy and cross-sectional imaging demonstrated a branching vesicouterine and vesicovaginal fistula. Repair with robotic-assisted approach was carried out. An intentional cystotomy was made with a tear-drop incision around the fistula tracts. The vesicouterine and vesicovaginal planes were dissected and mobilized. The vaginotomy and cystotomy were closed in a running two-layer fashion with absorbable suture and the uterine defect closed with interrupted absorbable suture. Retrograde bladder filling confirmed a watertight repair. A broad peritoneal flap was created, positioned, and secured with care to ensure it covered past the apex of the fistula closure. RESULTS: Following overnight observation she had an uneventful recovery, including catheter removal at 3 weeks after cystogram confirmed resolution of the fistula. At 6 weeks the fistula and her leakage remained resolved, with no de novo voiding or incontinence symptoms. CONCLUSIONS: A robotic approach to complex branching vesicouterine and vesicovaginal fistula is technically feasible. Careful attention to surgical technique and the use of tissue interposition may improve fistula resolution rates.

Clinical efficacy of flap transfer coverage in the treatment of vesicovaginal fistula.

INTRODUCTION AND HYPOTHESIS: Vesicovaginal fistula (VVF) brings severe psychological, physiological, and social stress to patients, which seriously affects the quality of their sexual life. Traditional transvaginal repair surgery can cause vaginal shortening. Transferring the lateral free flap can maintain vaginal length. This study was carried out to investigate the clinical efficacy of the surgery of flap transfer coverage for treating VVF. METHODS: A retrospective analysis was performed on 37 patients diagnosed with VVF and repaired by flap transfer coverage in the Urogynecology department of the First Affiliated Hospital of Kunming Medical University from January 2018 to June 2021. All patients took a prone split leg position to repair VVF with the flap transfer covering method and a chart review was performed. RESULTS: Among the 37 patients, there were 34 cases of primary complete healing, and the success rate reached 91.89% without recurrence and complications. Three cases recurred with leakage of urine; cystoscopy showed that the fistula was significantly reduced, and all patients were cured after secondary repair by the same surgical method without complications. CONCLUSIONS: Flap transfer coverage is a safe and effective surgical method for repairing VVF. The prone split leg position can better increase exposure. The fistula being away from the incision suture is the key to the success of the operation. Transferring the fistula can effectively improve the cure rate of VVF. Transferring the lateral free flap can maintain vaginal length.

The use of tissue adhesive in management of genitourinary fistulas: a systematic review and case report.

INTRODUCTION AND HYPOTHESIS: Articles are getting published on the use of tissue adhesive for vesicovaginal fistula. The objective is to carry out a systematic review on their effectiveness and complications. METHODS: A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Two reviewers screened abstracts and full-text and extracted data independently. A narrative synthesis was conducted given the heterogeneity of studies. RESULTS: A total of 1032 studies were identified after searching the database, and 14 articles were included in this systematic review. Of the 84 women included, 12 (14.3%) presented failure or recurrence of their fistula tract. The mean time of follow-up was 11.46 months. The average size of the fistula was 1.05 (range 0.1 to 3.9) cm. Most fistulas (81) included were vesicovaginal fistulas. Nine papers reported the usage of fibrin glue in which only three (6.5%) women reported recurrence of the fistula in a delay of 2 weeks to 26 months. The other studies used cyanoacrylate (14 women) and autologous fibrin injection from the patients' blood (31 women). No significant complications were reported. Complications reported were urinary tract infections in 3 women (3.6%), hematuria in 2 women (2.4%), overactive bladder symptoms in 6 women (7.2%) and septic pelvic thrombosis in one woman (1.2%). CONCLUSIONS: Tissue adhesive appears to be a promising alternative for management of urogenital fistulas without reported important complications.

Predictors of outcomes in patients with repeat surgery for obstetric fistula: a retrospective review.

INTRODUCTION AND HYPOTHESIS: Predictors of surgical outcomes in patients with an obstetric fistula who have been operated before should be identified in order to guide surgical strategy and optimize counseling of the patient. METHODS: This retrospective study is aimed at identifying predictors of outcomes for repeat surgery in 346 patients who had been operated on before for an obstetrics fistula at the Fistula Care Center (FCC) in Lilongwe, Malawi. Repeat cases were only undertaken by advanced and expert surgeons. The primary outcome was successful anatomical closure, based on a negative postoperative dye test. The secondary outcomes involved urinary continence, based on a patient-reported questionnaire and an objective 1-h pad weight test. Logistic regression models were used to test the predictors for statistical significance. RESULTS: Successful fistula closure was achieved in 288 (83%) patients and continence was achieved in 185 (64%) patients after the first repeat attempt at the FCC. Lack of urethral involvement (Goh classification: proximity to the urethra) was shown to be a good predictor of the outcomes: fistula closure and subjective and objective continence. CONCLUSIONS: Absence of urethral involvement is an independent predictor for successful outcomes in repeat surgery for obstetric fistulas. Even in the hands of an expert surgeon, the risk of another failure in achieving anatomical closure or subjective or objective continence is between 4 and 5 times higher than when the urethra is not involved.

Robotic-Assisted Surgery-a Highly Effective Modality for Vesicovaginal Fistula Repairs.

PURPOSE OF REVIEW: To summarize recent experience with robotic vesicovaginal fistula repair and describe the contemporary technique. RECENT FINDINGS: Robotic vesicovaginal repair has been tested at multiple centers, with similar outcomes to open surgery. It has benefits including decreased hospital stay, less blood loss, and similar long-term outcomes. As long as the surgeon is experienced in robotic surgery, this technique appears to be promising. Robotic vesicovaginal repair results in similar outcomes to open surgery with decreased morbidity.

The Microcirculation of Vaginal Tissue in Women with Obstetric Vesicovaginal Fistula and Short-Term Effects of Surgical Repair on Microvascular Parameters.

OBJECTIVES: The objective of the study was to better understand the extent of the ischemic trauma and the effects of surgical repair on the vaginal microcirculation in patients with obstetric vesicovaginal fistula (VVF). DESIGN: In this observational study, we evaluated the vaginal microvasculature surrounding VVF using handheld vital microscopy (HVM) before, during, and 2 weeks after surgical VVF repair. PARTICIPANTS: Seventeen women undergoing VVF repair were included in this study. SETTING: The study was conducted in the Fistula Care Centre in Lilongwe, Malawi. METHODS: We used HVM with incident dark-field imaging to non-invasively visualize the microvasculature of the vaginal tissue surrounding fistulas. The primary outcome was the presence of microvascular flow. Secondary outcomes included angioarchitecture, fistula closure (postoperative dye test), and urinary continence (pad weight test). RESULTS: Microvascular flow was present before, during, and after surgical repair in, respectively, 83.8%, 83.9%, and 93.4% of obtained image sequences. The angioarchitecture was normal in 75.8% of the image sequences before surgery, 69.4% at fistula closure, and 89.1% two weeks after VVF repair. Fourteen (82.4%) patients had a closed fistula after surgical repair. LIMITATIONS: The study was limited by the lack of a control group and the relatively small sample size. CONCLUSION: Although the vaginal microcirculation in women with VVF is compromised, extensive ischemic damage is not observed in the tissue surrounding fistulas. This suggests significant regenerative capacity of the vaginal vasculature in young women, or less extensive ischemic damage than presumed. Following surgical repair, we observed improvement of microcirculatory flow and angioarchitecture, suggesting that surgery is a good option for patients with obstetric VVF.

Transvaginal vesicovaginal fistula closure: A retrospective study of 28 cases at a single facility in Japan.

OBJECTIVES: We aimed to report the background of patients with vesicovaginal fistulas (VVFs) at our center, which has treated a relatively large number of such patients in Japan, as well as the ingenuity and outcomes of vesicovaginal fistula closure (VVFC). We also investigated the causes of VVFs. METHODS: A retrospective review was performed for 28 patients with VVFs treated at our center. Age, body mass index, etiology, site of fistula, and postoperative outcomes were investigated. RESULTS: Twenty-one (75%) fistulas occurred following hysterectomy. The overall success rate of VVFC was 85.7%, and the success rate limited to the first attempt was 89.5%. In 68% of cases, no bladder injury suspected as the cause of VVF was noticed during the surgery. Energy devices were used in all 12 patients for whom information on the type of device used for hysterectomy was confirmed. CONCLUSIONS: To our knowledge, this is the first report to evaluate a relatively large number of VVFCs in Japan. Although VVF is thought to be caused by bladder injury during hysterectomy, delayed thermal damage might also result in this pathology, even if there is no apparent intraoperative bladder injury.

[Clinical application effect of pedunculated rectus abdominis muscle combined with bilateral ureters for repairing refractory bladder-vaginal stump fistula through external vesical drainage].

Objective: To investigate the efficacy and safety of pedunculated rectus abdominis combined with bilateral ureteral extravestheter drainage in the treatment of refractory bladder-vaginal stump fistula. Methods: The clinical data of 8 cases of the refractory bladder-vaginal stump fistula were admitted to the Second Hospital of Hebei Medical University and Henan Cancer Hospital and underwent the clinical treatment of bladder-vaginal stump from December 2019 to December 2022 were collected. The reason of refractory bladder-vaginal stump fistula was analyzed, the operation manner of pedunculated rectus abdominis combined with peduncle and bilateral ureter for the treatment of bladder-vaginal stump through extrabladder drainage was explored. The operation time, bleeding volume and clinical effect were record. Results: The median operation time of 8 patients was 150 minutes(120~180 min), and the median blood loss was 400 ml(200~600 ml). During the perioperative period, there were 2 cases of incision infection, delayed healing by debridement and dressing, 2 cases of incision rupture and suture wound healing after reoperation, and 2 cases of urinary tract infection were cured by anti-infection. When followed up for 6 months, 8 cases of vesicovaginal stump fistula were cured. Conclusion: Bilateral ureteral external drainage of the rectus abdominis muscle, has a practical effect in the treatment of refractory bladder-vaginal stump fistula, which can be one of the clinical repairing treatment.