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.

Obstetric fistula in low-resource countries: an under-valued and under-studied problem--systematic review of its incidence, prevalence, and association with stillbirth.

BACKGROUND: Obstetric fistula (OF) is a serious consequence of prolonged, obstructed labor in settings where emergency obstetric care is limited, but there are few reliable, population-based estimates of the rate of OF. Stillbirth (SB) is another serious consequence of prolonged, obstructed labor, yet the frequency of SB in women with OF is poorly described. Here, we review these data. METHODS: We searched electronic databases and grey literature for articles on OF in low-resource countries published between January 1, 1995, and November 16, 2014, and selected for inclusion 19 articles with original population-based OF incidence or prevalence data and 44 with reports of frequency of SB associated with OF. RESULTS: OF estimates came from medium- and low-HDI countries in South Asia and Africa, and varied considerably; incidence estimates ranged from 0 to 4.09 OF cases per 1000 deliveries, while prevalence estimates were judged more prone to bias and ranged from 0 to 81.0 OF cases per 1000 women. Reported frequency of SB associated with OF ranged from 32.3 % to 100 %, with estimates from the largest studies around 92 %. Study methods and quality were inconsistent. CONCLUSIONS: Reliable data on OF and associated SB in low-resource countries are lacking, underscoring the relative invisibility of these issues. Sound numbers are needed to guide policy and funding responses to these neglected conditions of poverty.

Musculoskeletal sequelae in patients with obstetric fistula - a case-control study.

BACKGROUND: Obstetric fistula is essentially a result of pelvic injury caused by prolonged obstructed labour. Foot drop and walking difficulties in some of these women signify that the injury may extend beyond the loss of tissue that led to the fistula. However, these aspects of the pelvic injury are scarcely addressed in the literature. Here we specifically aimed at assessing musculoskeletal function in women with obstetric fistula to appreciate the extent of the sequelae of their pelvic injury. METHODS: This case-control study compared 70 patients with obstetric fistula with 100 controls matched for age and years since delivery. The following was recorded: height, weight, past and present walking difficulties, pain, muscle strength and joint range of motion, circumference and reflexes. Differences between groups were analysed using independent sample t-test and chi-square test for independence. RESULTS: A history of leg pain was more common among cases compared to controls, 20% versus 7% (p = 0.02), and 29% of the cases had difficulties walking following the injuring delivery compared to none of the controls (p ≤ 0.001). Of these, four women reported spontaneous recovery. Cases had 7° less range of motion in ankle dorsal flexion (95%CI: -8.1, -4.8), 8° less ankle plantar flexion (95%CI: -10.6, -6.5), 12° less knee flexion (95%CI: -14.1, -8.9), and 4° less knee extension (95%CI: 2.9, 5.0) compared to controls. Twelve % of the cases had lower ankle dorsal flexion strength (p = 0.009). Foot drop was present in three (4.3%) compared with none among controls. Women with fistula had 4° greater movement in hip extension (95%CI: -5.9, -3.1), 2° greater hip lateral rotation (95%CI: 0.7, 3.3) and 9° greater hip abduction (95%CI: 6.4, 10.7). Twelve % of the cases had stronger medial rotation in the hip (p = 0.04), 20% had stronger hip lateral rotation (p ≤ 0.001), 29% had stronger hip extension (p ≤ 0.001), and 15% had stronger hip abduction (p = 0.04) than controls. CONCLUSIONS: Women with obstetric fistula commonly experienced walking difficulties after the delivery, had often leg pain and reduced function in the ankle and knee joints that may have been compensated by increased motion and strength in the hip.

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.

Manejo laparoscópico de las fístulas vesico vaginales / Laparoscopic vesicovaginal fistula repair

OBJETIVO: La Fístula Vesicovaginal (FVV) es una patología infrecuente y de difícil manejo, siendo la histerectomía abdominal su principal causa. Presentamos nuestra experiencia en la reparación laparoscópica con sutura intracorpórea de las FVV.MÉTODOS: Entre enero de 2006 y enero del 2008 se realizaron 8 reparaciones por vía laparoscopia de FVV. Se describe la técnica quirúrgica (O'Conor transperitoneal) y se analizan variables demográficas, quirúrgicas y resultados de la serie. RESULTADOS: La edad media de las pacientes fue de 45 años. El tiempo medio entre la histerectomía y la reparación laparoscópica fue de 22 meses. El tiempo quirúrgico medio total (vesical y laparoscópico) fue de 123 minutos. El tiempo medio de hospitalización fue de 4.7 días y el tiempo medio de cateterización vesical fue de 10 días. Se registró una complicación postoperatoria. El control radiológico mediante una cistografía reveló indemnidad de la reparación en todos los casos. No hubo recurrencia de la fístula, con un tiempo promedio de seguimiento de 32 meses. CONCLUSIÓN: En nuestra opinión, el abordaje laparoscópico permite cumplir con todos los principios para la reparación de fístulas vesicovaginales. La reducción de la morbilidad y la eficacia del procedimiento, lo transforman en una excelente alternativa en manos de cirujanos experimentados(AU)

OBJECTIVES: Vesicovaginal fistulas are uncommon and remain a surgical challenge. Abdominal hysterectomy remains their main cause. We present our experience in laparoscopic repair of vesicovaginal fistula. METHODS: Between January 2006 and January 2008, 8 laparoscopic transvesical procedures for VVF repair were performed at our institution (O'Connor technique). For each case we analyzed demographic and surgical variables as well as the outcome. Surgical technique is also described. RESULTS: Average patient age was 45 years. All patients had past history of hysterectomy and subsequent history of urine leak through vagina, with a mean evolution time of 22 months. The average operative time was 150 minutes and the mean hospital stay 4.7 days. All patients evolved without complications except one who had urinary tract infection (Pseudomonas aeruginosa) that was treated with antibiotics. After a mean follow up of 32 months, there were no recurrences. CONCLUSION: In experienced hands, transvesical transabdominal laparoscopic vesicovaginal fistula repair is a feasible and safe procedure, preserving all the advantages of minimally invasive surgery(AU)

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.

Reparación laparoscópica de fístula vésico-vaginal sin cistotomía intencional y guiada por transiluminación vaginal / Laparoscopic Repair of Vesico-Vaginal Fistula Without Intentional Cystotomy and Guided by Vaginal Transillumination

Objetivos: La reparación de una fístula vésico-vaginal (FVV) por vía laparoscópica permite una excelente exposición, lo que facilita su ejecución a través de una cistotomía pequeña. En algunos casos la localización de la fístula sin apertura vesical previa resulta difícil. Se presenta una maniobra empleando transiluminación por vía vaginal para facilitar la localización de la fístula y para reducir el tamaño de la apertura vesical durante la reparación laparoscópica sin cistotomía intencional. Material y métodos: Un total de 4 pacientes con FVV supra-trigonal producida post-histerectomía recibieron reparación laparoscópica. A todas se les realizó exploración física, prueba con colorante, uretrocistoscopia y pielografía intravenosa. Se localizó la fístula empleando el cistoscopio que se introduce por la vagina y se coloca sobre el orificio fistuloso. La luz emitida guía la disección laparoscópica en el plano entre la vagina y la vejiga justo sobre la fístula, sin realizar cistotomía intencional previa. Resultados: La edad media de las pacientes fue de 42 (38-47) años. En todos los casos el tamaño aproximado de la cistotomía no alcanzó los 2cm. El tiempo operatorio promedio fue 160 (120-186) minutos y el tiempo de sondaje 10 días. No hubo recurrencias. Conclusiones: La reparación laparoscópica de la FVV sin cistotomía intencional con disección directa sobre el trayecto fistuloso, guiada por transiluminación vaginal, es efectiva porque localiza rápidamente la fístula en todos los casos, reduce el tamaño de la apertura vesical, acorta los tiempos operatorios, disminuye los síntomas irritativos y minimiza los riesgos de dehiscencia y fuga (AU)

Objectives: Repair of vesico-vaginal fistula (VVF) by laparoscopy provides excellent exposure, which facilitates their implementation through small cystotomy. In some cases is difficult to locate the fistula without the prior opening of the bladder. We present a maneuver using vaginal transillumination to locate the fistula and to reduce the size of the opening bladder during laparoscopic repair without intentional cystotomy. Material and methods: A total of 4 patients with supra-trigonal FVV produced post-hysterectomy received laparoscopic repair. All patients underwent physical examination, dye test, urethrocystoscopy and intravenous pyelography. Fistula was located using a cystoscope inserted through vagina and placed over the fistula. The emitted light guide laparoscopic dissection in to the plane between the vagina and the bladder just above the fistula, without previous intentional cystotomy. Results: The mean age of patients was 42 (38-47) years. Bladder opening size did not reach 2cm. The mean operative time was 160 (120-186) minutes and catheterization time was 10 days. There were no recurrences. Conclusions: The laparoscopic repair of VVF without intentional cystotomy, by direct dissection of the fistulous tract guided by vaginal transillumination is effective; because it quickly locates the fistula in all cases, reduces the size of the bladder opening, shortens operative times and reduces irritative symptoms (AU)

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.

Obstetric vesicovaginal fistula as an international public-health problem.

Vesicovaginal fistula is a devastating injury in which an abnormal opening forms between a woman's bladder and vagina, resulting in urinary incontinence. This condition is rare in developed countries, but in developing countries it is a common complication of childbirth resulting from prolonged obstructed labour. Estimates suggest that at least 3 million women in poor countries have unrepaired vesicovaginal fistulas, and that 30 000-130 000 new cases develop each year in Africa alone. The general public and the world medical community remain largely unaware of this problem. In this article I review the pathophysiology of vesicovaginal fistula in obstructed labour and describe the effect of this condition on the lives of women in developing countries. Policy recommendations to combat this problem include enhancing public awareness, raising the priority of women's reproductive health for developing countries and aid agencies, expanding access to emergency obstetric services, and creation of fistula repair centres.

Surgical repair of vesicovaginal fistulas.

Despite the many controversies surrounding the proper surgical repair of vesicovaginal fistulas, the current methods available allow surgeons to select the procedure best suited for each specific problem. Because each fistula is unique, surgeons will often be required to individually vary their approach and technique. Regardless of whether a transabdominal or transvaginal approach is selected, the concepts of using healthy tissue in tension-free closures and reinforcing the closures in high-risk situations will ensure success nearly all of the time. A urinary diversion should be considered in the rare situation where the fistula has failed even the most technically sound repair.

Urinary and faecal incontinence following delayed primary repair of obstetric genital fistula.

OBJECTIVE: To evaluate: (1) the factors associated with the development of obstetric genitourinary fistula, (2) the incidence of urinary and faecal incontinence following closure of the fistula and (3) the urodynamic findings in women with persistent urinary incontinence. DESIGN: An observational clinical study. SETTING: A specialised fistula unit in a developing country. POPULATION: Women following successful anatomical closure of obstetric genitourinary fistula. METHODS: Fifty-five women were enrolled from the Fistula Hospital in Ethiopia, following obstetric fistula repair. Their case records were reviewed and details regarding (1) antecedent obstetric factors, (2) the site, size and type of fistula and (3) pre-operative bladder neck mobility and vaginal scarring were recorded. All women were questioned regarding symptoms of faecal and urinary incontinence. Women reporting urinary incontinence following fistula repair underwent urodynamic investigations. MAIN OUTCOME MEASURES: Clinical and urodynamic assessment. RESULTS: The mean age of the women was 23 years (range 16-45 years). The fistula in 38 women (69%) followed the first delivery and in 17 women (31%) following a subsequent delivery. The mean duration of labour was four days (range 1-9 days). Forty-four women (80%) had an isolated vesico-vaginal fistula and 11 (20%) had a combined vesico-vaginal and recto-vaginal fistula. The mean diameter of the fistula was 2.9 cm (0.5-6 cm). Successful repair occurred in all women. Thirty women (55%) reported persistent urinary incontinence and 21 (38%) altered faecal continence at follow up. In the former group, urodynamic investigations identified genuine stress incontinence in 17 women (31%), detrusor instability in two (4%) and mixed incontinence in 11 (20%). CONCLUSION: This study demonstrates the high rate of successful closure of the fistula in a specialised fistula unit, but highlights the problem of persistent urinary incontinence following closure.

[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.