Enhanced Proliferation and Adhesion Marker Gene Expression in Fibroblast Cells: Evaluating the Efficacy of a Non-Surgical Treatment for Urogenital Fistula.

BACKGROUND Vesicovaginal fistula (VVF) due to posterior bladder wall and/or anterior vaginal wall necrosis is a condition that leads to urinary incontinence. Both microscopic and macroscopic VVFs severely impact quality of life. They are also associated with frequent recurrence after surgery. A non-surgical intervention for VVF is urgently required. A membrane bilayer could act as a mechanical tamponade and stimulate defect closure. MATERIAL AND METHODS This is an experimental study that explored the characteristics of mucoadhesive bilayer membrane complexes for non-operative treatment of VVF in vitro. We synthesized a mucoadhesive bilayer membrane, and inoculated it with cultured fibroblast cells. The mucoadhesive bilayer membrane was prepared with 3 different treatments: (1) estrogen; (2) lyophilized radiation-sterilized amnion (ALSR), a prepared amniotic membrane; and (3) arginine and glutamine (arginine+glutamine), 2 amino acids associated with wound repair. Expression levels of 3 genes, namely tumor growth factor beta (TGF-ß), lysil oxidase (LOX), and junctional adhesion molecules (JAMs), were measured using the Livak method and polymerase chain reaction (PCR). RESULTS On the fifth day after inoculation, there was no statistically significant difference in expression of the genes in the 3 conditions. However, on the tenth day, gene expression of the LOX and JAMs genes in the fibroblast cells inoculated onto the mucoadhesive bilayer membrane with arginine+glutamine was significantly higher than the expression in the fibroblast cells inoculated onto the mucoadhesive bilayer membrane with estrogen or with ALSR. CONCLUSIONS The mucoadhesive bilayer membrane complex with arginine+glutamine gave rise to the highest expression of the LOX and JAMs genes, indicating that the highest proliferation and cell adhesion were found in cells inoculated with the mucoadhesive bilayer membrane complex with arginine+glutamine.

Cumulative inflammatory burden causing multiple complications after a successful pelvic surgery for advanced ovarian cancer.

Vesicovaginal and rectovaginal fistulas may develop after pelvic metastasis of ovarian carcinoma. Purulent discharge from the vagina results in frequent vaginal or urinary tract infections, and triggers chronic inflammation. These incapacitating symptoms create serious medical and psychosocial problems, and result in low self-esteem and QoL. In this study, we present a metastatic ovarian cancer case admitted with bilateral nephrostomies, nonfunctioning colostomy, and high-volume recto- and vesicovaginal fistulas after debulking. She had frequent urinary tract infections and systemic inflammatory response syndrome. Surgery was performed successfully. However, we had to deal with complications, such as electrolyte imbalance, wound infection and continuing SIRS. Cumulative inflammatory burden caused by advanced carcinoma itself and its complications creates serious medical and psychosocial problems and should be managed with patience.

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.

Migration of a fractured ring IUD resulting in vesicovaginal fistula and vaginal calculus.

CASE: Although many complications have been reported with intrauterine contraceptive devices (IUDs), vesicovaginal fistula with secondary vaginal stones is rare. We report the case of a 46-year-old woman who presented with a vaginal discharge lasting 2 months. Two years previously, she had undergone cystoscopic lithotripsy and surgery to remove an IUD, after pelvic radiography had revealed a fractured Chinese stainless steel ring IUD with secondary vesical stones that had been the cause of her urinary tract symptoms. When she again complained of vaginal discharge, vaginal stones and a vesicovaginal fistula were found on physical examination and CT urography. The patient underwent stone removal and concurrent vesicovaginal fistula repair. IUD fragments were found in the vesicovaginal and rectovaginal spaces. No abnormalities were found at follow-up 6 months after surgery. CONCLUSION: In any woman undergoing surgery to remove a migrated IUD, complete exposure and removal of the IUD are necessary to avoid fracturing of the IUD, secondary breakage and residue.

Presentation and management of vesicovaginal fistulae after delivery at a German women's hospital.

Vesicovaginal fistulae are rarely seen after childbirth in developed countries. This article deals with the causes, presentation, and management of obstetric vesicovaginal fistulae in patients treated at a German women's hospital.

Transperitoneal laparoscopic repair of vesicovaginal fistula for patients with supratrigonal fistula: comparison with open transperitoneal technique.

INTRODUCTION AND HYPOTHESIS: We investigated the treatment outcomes of laparoscopic vesicovaginal fistula repair (LVVFR) in patients with supratrigonal vesicovaginal fistula (VVF) in contrast with open transperitoneal vesicovaginal fistula repair (OVVFR). METHODS: We analyzed 58 VVF repairs from June 2005 to July 2014, with 22 patients in the LVVFR group and 36 in the OVVFR group. Demographic parameters, operative variables, and perioperative outcomes were retrospectively collected and analyzed. The chi-square test, Fisher's exact test, Student's t test and the Mann-Whitney U test were used for statistical analysis. RESULTS: Patients in both groups had comparable preoperative characteristics. Significantly shorter hospital stay (5.6 vs. 13.2 days, p < 0.05) and less blood loss (52 vs. 103 ml, p < 0.05) were observed in LVVFR group. Patients in the LVVFR group achieved a higher overall VVF success rate (95.5 % vs. 83.3 %, p > 0.05) and recurrent VVF success rate (90.0 % vs. 75.0 %, p > 0.05) than OVVFR group, but it was not statistically significant. Patients who underwent OVVFR experienced more postoperative symptomatic bladder spasms (8.3 % vs. 4.5 %, p > 0.05), urinary tract infections (UTIs) (5.6 % vs. 0.0 %, p > 0.05), and stress urinary incontinence (SUI) (5.6 % vs. 4.5 %, p > 0.05), but fewer incidents of postoperative ileus (0.0 % vs. 4.5 %, p > 0.05) than the LVVFR group; differences were not significant. CONCLUSIONS: Judging from this initial trial, LVVFR should be recommended as the primary intervention to treat supratrigonal VVF patients in view of its reduced blood loss and hospital stay.

[Great vesicovaginal fistula after normal vaginal delivery in a developed country]. / Gran fístula vesicovaginal después de un parto eutócico. Reporte de un caso.

BACKGROUND: Obstetric fistulas in developed countries are infrequent and have been associated with instrumental vaginal delivery, manual removal of placenta and surgical complications during caesarean section. We present the diagnosis and treatment of an obstetric fistula of patient without clear risk factors in a developed country. CASE REPORT: The case presented is of a 37 weeks pregnant with history of previous cesarean section. A male of 2,600 g was born after a not prolonged vaginal delivery. In the immediate postpartum period, appeared evident hematuria and in the exploration a defect was detected in the vaginal anterior face at 3 cm from the urethral meatus. Cystoscopy showed a torn in bladder of 8 cm at the bottom. Reparation of vesicovaginal fistula was carried out with omentoplasty. Postoperative course was uneventful. CONCLUSION: A vesicovaginal fistula must be considered in any patient with hematuria. Early repair is essential for a favorable outcome.

[Anterior pelvic exenteration. Report of a case]. / Exenteración pelvica anterior. Reporte de un caso.

Anterior pelvic exenteration is the last opportunity to control disease in a patient with cervical cancer in an advanced stage with a vesico-vaginal fistula, or in a patient with persistence of the disease and the need of improving the quality of life. In this case we present the cause of a 62 year old patient, with IVa stage cervical cancer, with bladder spread and a vesico-vaginal fistula treated with an anterior pelvic exenteration with Bricker technique and adjuvant treatment with radiotherapy.

[Evolution aspect of anatomy clinical lesions of urogenital fistula (UGF) in Cocody Teaching Hospital urological unity from 1990 to 2011]. / Aspect évolutif des lésions anatomo-cliniques des fistules urogénitales (FUG) dans le service d'urologie du CHU de Cocody de 1990 à 2011.

PURPOSE: The aim of this study is to compare anatomy pathological lesions seeing in urogenital fistula in Cocody Teaching Hospital between two decades, 1990 to 2000 and 2000 to 2010. MATERIEL AND METHOD: This survey is retrospective and carries on 20 years (January 1990 to December 2011) 190 urogenital fistulas (140 cases between 1990 and 1999; 50 from 2000 to 2011) hospitalized in our unity. Anatomy clinical characteristics of these fistulas were determined by clinical or paraclinical examination. RESULTS: Between 1990 and 1999, fistulas were classified in 20 bladder-uterine fistulas (14.29%), 16 uretro-vaginal fistulas (11.43%) and 104 bladder-vaginal fistulas (74.29%) of whom 80 isolated UGFs and 24 UGFs associated with recto-vaginal fistula. These 104 UGFs were located at: bladder neck 22 cases (21.15%), bladder trigonal 46 cases (44.23%), urethra 14 cases (13.46%). Twenty-two bladder sphincter were destroyed and represented 21.15% of fistula's bladder-vaginal fistula and 15.71% of all UGFs. The average fistula diameter was 3 cm [extremes: 1 and 12 cm]. In 22 cases (15.71%), fistula diameter was more than 10 cm. It was bladder neck and sphincter destruction. Hundred and twenty-six fistulas were isolated (90%). Only 10% (14 cases) were associated. Fistulas were primitive in 85.71% of cases (120/140), recurrent in 7 cases (7.86%) and multi-recurrent (>3 reinterventions) in 9 cases (6.43%). From 2001 to 2011, no bladder-uterine fistulas were seen, but: 6 (13.95%) isolated uretero-vaginal fistulas and 6 (13.95%) uretero-vaginal fistulas associated with bladder-vaginal fistula, 31 (62%) bladder-vaginal fistulas of whom 20 (64.52%) bladder trigonal fistulas, 6 (19.34%) retro-trigonal fistulas and 2 (6.45%) urethral fistulas. Only three (9,68%) recto-vaginal fistulas were associated. The average fistula diameter was 2 cm. The fistulas were isolated in 40 cases (80%) and associated (VVF+uretero vaginal F) in 10 cases (20%). Thirty-five cases (70%) were primitive and 10 cases (20%) recurrent of whom 5 (10%) many recurrent. Fistulas were classified in simple fistula in 7 cases (14%) and complex fistula in 43 cases (86%) CONCLUSION: UGF remained relatively frequent in Cocody Teaching Hospital, but the lesions have favorably evolved in the last decade. Simple type of fistula became more frequent than complex ones. LEVEL OF EVIDENCE: 4.

Evaluation of the extent of ketamine-induced uropathy: the role of CT urography.

BACKGROUND: With growing ketamine abuse, ketamine-induced uropathy (KIU) has become more prevalent in recent years. This research evaluates the presence, distribution and extent of KIU in the upper and lower urinary tracts by retrospectively reviewing CT urography (CTU) images. METHODS: Patients diagnosed with KIU who underwent CT scanning from 1 January 2006 to 31 December 2011 were recruited. The CT protocols included three-phase CTU in six patients, split-bolus CTU in 17, two-phase CT in one and unenhanced CT in three. The CT images were retrospectively reviewed by two radiologists. RESULTS: A total of 27 patients participated in this study. The common CT findings included diffuse bladder wall thickening (88.9%), small bladder volume (66.7%) and perivesical inflammation (44.4%). Twelve patients (44.4%) were diagnosed with hydronephrosis, including three patients with unilateral hydronephrosis and nine with bilateral hydronephrosis. Of these patients, nine had ureteral wall thickening (33.3%) and two (7.4%) had ureterovesical junction involvement (ie, they had hydronephrosis but no ureteral wall thickening). One patient had a ureteral obstruction because of a ureter stone. The correlation between upper urinary tract involvement and grading of the interstitial cystitis was statistically non-significant (p=0.33). Four patients (14.8%) had a vesicovaginal fistula which could be detected in the excretory phase only. CONCLUSIONS: Upper urinary tract involvement is common in patients with KIU. CTU might aid evaluation of the extent of KIU and prompt adequate management.

Radiological diagnosis of vesicouterine fistula: role of magnetic resonance imaging.

PURPOSE: To retrospectively assess the value of magnetic resonance imaging (MRI) in the diagnosis of vesicouterine fistula (VUF). MATERIALS AND METHODS: Between January 2003 and January 2011, 12 patients with a diagnosis of VUF were surgically managed at our center; among them, eight patients had MRI among their preoperative radiological investigations and those were included in our study. The clinical presentation, radiological investigations, and surgical findings of the patients were reviewed. RESULTS: The mean age of the patients was 31 years. Seven of the eight patients had complaints of cyclic hematuria and the remaining patient complained of urinary leakage through the vagina. The etiology of VUF was cesarean section in all patients. The preoperative radiological investigations included conventional cystography in five patients, intravenous urography in two, computed tomography (CT) urography in two, and MRI in eight. The sensitivities of diagnosis for these investigations were 40%, 0%, 50%, and 100%, respectively. CONCLUSION: In our small retrospective series, pelvic MRI was reliable and sensitive for diagnosis of VUF. It should be considered in the work-up of patients with suspected VUF.

Successful conservative management of a large iatrogenic vesicovaginal fistula after loop electrosurgical excision procedure.

A 40-year-old G3P3 woman with grade 3 cervical intraepithelial neoplasia underwent loop electrosurgical excision procedure complicated by a large vesicovaginal fistula. She was initially managed with an indwelling Foley catheter to allow for fistula maturation. During planned surgical repair it was discovered that the fistula had closed spontaneously.

Urogenital fistula in the UK: a personal case series managed over 25 years.

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Whilst several very large series of obstetric fistulae from the developing world have been published, data on fistulae as seen in the developed world are relatively few. Most fistulae in the UK are known to follow hysterectomy, and several risk factors are recognised. We have confirmed the common association with pelvic surgery, and in particular hysterectomy, but also show the broad range of other associated operations, including so called 'minimally invasive' procedures. High rates of both anatomical fistula closure and continence are shown, when a consistent approach to assessment, selection of surgical procedure, and postoperative care are applied. Successful closure is seen more often in women who have not undergone previous attempts at repair before referral, and as a result a pattern of surpra-regional management is proposed. Whilst overall the number of urogenital fistulae seen in the UK appears to be decreasing, there is a suggestion from these data that the rate of fistula formation following hysterectomy may be increasing; we are currently investigating this possibility through detailed interrogation of a national dataset. OBJECTIVE: To review demography, aetiology, surgery and outcomes of women with urogenital fistula seen in one unit over the last 25 years; to provide data for comparison with a parallel study based on Hospital Episode Statistics. PATIENTS AND METHODS: This is a prospective case series from a tertiary urogynaecology centre providing a de facto supra-regional fistula service. The women included had confirmed urogenital fistula referred between January 1986 and December 2010. Index cases were identified from a surgical database; data were entered prospectively and updated as appropriate; statistics are largely descriptive. The primary outcome is the patient's report of absence of urinary leakage. Secondary outcomes include operative or postoperative complications, anatomical closure of the fistula, other residual or new urinary symptoms, and the need for further intervention. RESULTS: In all, 348 women with urogenital fistula were referred; two-thirds were of surgical aetiology, with almost half following hysterectomy. Although 11% followed childbirth, most of these followed operative obstetric interventions. Spontaneous closure occurred in 6.9% of women and 291 underwent surgical treatment. The anatomical closure rate at first operation was 95.7%, although 2.2% reported residual urinary incontinence. The success rates were similar regardless of aetiology, although successful fistula closure was significantly more likely in women who had not had attempts at closure before referral (98.2 vs 88.2%; Fisher's exact test; P= 0.003). CONCLUSION: High rates of fistula closure are reported regardless of aetiology, although previous unsuccessful repair militates against successful outcome; this emphasises the appropriateness of centralisation of the management of this increasingly rare condition in UK practice.

Vaginal repair of supratrigonal vesicovaginal fistulae--a 10-year review.

INTRODUCTION AND HYPOTHESIS: A 10-year retrospective study was done to determine the outcome of vaginal repair for supratrigonal vesicovaginal fistulae (VVF). METHODS: One hundred thirty-two urinary fistulae were managed from 2001 to 2011 which include 34 ureterovaginal and 98 lower urinary tract fistulae. Fifty-three out of 98 were supratrigonal VVF, 49 were of benign etiology and 4 were malignancy induced. Further analysis of 49 supratrigonal VVF of benign etiology revealed that 38 (77.5%) were of gynecological origin and 11 (22.5%) obstetric. Forty-three were primary and six were recurrent VVF. Thirty (61.2%) supratrigonal VVF were repaired vaginally and 19 (38.8 %) abdominally. Mean follow-up period was 51.7 months. RESULTS: The successful outcome for vaginal and abdominal repair was 86.7% and 100%, respectively (p value = 0.26). Overall, 91.8% supratrigonal VVF were cured at our first attempt. CONCLUSIONS: Majority of supratrigonal VVF can be approached vaginally with success rate comparable to abdominal approach.

Comparison of two classification systems for vesicovaginal fistula.

INTRODUCTION AND HYPOTHESIS: This study aims to compare the prognostic value of two obstetric fistula classification systems. METHODS: Prospective analysis of 202 patients evaluated for obstetric fistula (OF) at the General Referral Hospital of Panzi, Bukavu, DRC, from April through December 2009. Fistula classification using both Goh's and Waaldijk's systems, as well as preoperative, surgical, and follow-up assessment were included. Receiver operating characteristics (ROC) curves were used to compare the accuracy of the two systems to discriminate successful closure from persistent fistula. RESULTS: Two hundred two women underwent fistula repair. Ten were lost to follow-up. At longest follow-up, 181 patients (88.3%) had successful fistula closure. On multivariate analysis, the independent variables of multiparity and a primary or secondary repair were more likely to have a successful closure. In Waaldijk's system, no single component was more predictive of successful closure than another. In Goh's system, type 4 fistulae were more likely to have failed closure compared to those with type 1 or 2 (p = 0.0144). When comparing ROC curves, Goh's system had significantly better ability to predict successful closure than the Waaldijk's system, p = 0.0421. CONCLUSIONS: Waaldijk and Goh are the two most commonly used obstetric fistula classification systems. In this series of OF patients at Panzi Hospital in the Democratic Republic of Congo, Goh's classification system demonstrated a significantly better prediction of OF closure than the Waaldijk's system.

Outcome of repeat supratrigonal obstetric vesicovaginal fistula repair after previous failed repair.

INTRODUCTION: Currently, surgical repair for vesicovaginal fistula (VVF) provides excellent results, but the recurrent VVF is difficult to treat as compared to primary. PATIENTS AND METHODS: Sixty-eight patients (44 primipara and 24 multipara) with recurrent VVF repair from January 2002 to December 2007 were included in present study. The mean size of fistula was 2.8 cm (1.0-6.5). The previous surgical repair was through the abdominal route in 50 patients (73.53%) and through the vaginal route in the remaining 18 patients (26.47%). RESULTS: The procedure was successful in 62 of 68 patients (91.17%). The mean duration of surgery was 146.6 min (100-210). Mean blood loss was 160 ml (110-400) and mean hospital stay was 5.6 days (4-10). Eight patients developed complications. CONCLUSION: Recurrent VVF is difficult to treat, but excellent results can still be achieved by strictly sticking to the principals of surgical repair for VVF.

The use of rotational bladder flap and hemostatic matrix sealant (FloSeal): a modified transabdominal approach to repair supratrigonal and complex vesicovaginal fistula.

Vesicovaginal fistula (VVF), commonly caused by prolonged obstructed labor, is one of the worst complications of childbirth and poor obstetric care in the developing world. We investigated the clinical efficacy and outcome of technical modifications of the current transperitoneal supravesical technique for supratrigonal and complex vesicovaginal fistula. We studied a total of 20 patients with iatrogenic supratrigonal and complex vesicovaginal fistula following obstetric trauma and hysterectomy. All patients underwent a modified transabdominal technique: the modifications consisted of passing a Foley catheter through the fistulous opening, inflating the balloon, and applying traction on the catheter to provide effective anchorage and to minimize the oozing from the cystotomy edges. The cystotomy was directed in the parasagittal line, and medial side of the bladder was rotated as a flap into the bladder defect; the urethral de Pezzare catheter was used for urinary drainage. We used hemostatic matrix sealant (FloSeal, Baxter BioSurgery, Westlake Village, California) to promote healing and hemostasis. The vesicovaginal fistula was successfully corrected in all patients after the first attempt, and no significant bladder dysfunction or decrease in bladder capacity was seen after repair. Interposition flaps were used in all patients, and six patients (30%) required ancillary procedures for other associated anomalies at the time of fistula repair. At a mean follow-up of two years, fourteen women were sexually active, and 5 (35%) from this group of patients complained of mild-to-moderate dyspareunia. In our study, supratrigonal VVFs were repaired with a transabdominal, transperitoneal, transvesical approach. Tailoring the cystotomy in a parasagittal line permitted closure of fistula by rotation of bladder flap into the defect. This excellent method should be a viable option when repairing complex VVF.

Vulvar pseudoverrucous papules and nodules secondary to a urethral--vaginal fistula.

Irritant contact dermatitis is a common cause of genital eruptions representing at least one-fifth of presenting anogenital symptoms. A spectrum of inflammatory reactions have been identified, some of them with features severely mimicking more serious dermatoses, which may lead unnecessary workup and treatments. We report a case of a 10-year-old girl who presented at birth with cloacal atresia involving the rectum and the urethra. A diverting colostomy and a urethral-vaginal fistula were created to correct the deformity. Physical examination reveals numerous shiny, white-gray, pseudoverrucous papules and nodules coalescing into plaques over the vulva and its surrounding skin. Histological examination showed psoriasiform epidermal hyperplasia with a marked reactive acanthosis and altered cornification with parakeratosis, hypogranulosis, and pale keratinocytes in the upper reaches of the epidermis. The lesions regress when the irritating factor was removed. This case represents a peculiar form of presentation of perianal pseudoverrucous papules and nodules, usually secondary to urinary incontinence or encopresis (inability to control the elimination of stool) after surgery for Hirschsprung disease. Because similar findings have not been previously observed in patients with urethral-vaginal fistula, we attempt to extend the spectrum of presentations for a better knowledge of this condition.

Vesicovaginal fistula following large-loop excision of the transformation zone in a chronic systemic glucocorticoid user.

A 42-year-old woman with a history of a large-loop excision of transformation zone for cervical intraepithelial neoplasia III four years previously visited our outpatient department for cervical intraepithelial neoplasia I that newly detected by colposcopy-directed punch biopsy. Her other medical conditions include systemic lupus erythematosus on daily prednisolone 15 mg during 19 years. After second large-loop excision of transformation zone, delayed vesicovaginal fistula was confirmed by indigo carmine leakage test, computed tomography scan, and cystoscopy. Fistula was primarily repaired with indwelling double-J catheters with anchoring omentum on suture site.