Turnbull-Cutait Pull-Through Procedure Is an Alternative to Permanent Ostomy in Patients With Complex Pelvic Fistulas.

BACKGROUND: A permanent stoma is frequently recommended in the setting of complex or recurrent rectovaginal fistulas because of the high failure rate of reconstructive procedures. The Turnbull-Cutait pull-through procedure is a salvage operation for motivated patients desiring to avoid permanent fecal diversion. OBJECTIVE: To analyze the cure rates of complex rectovaginal fistulas after the Turnbull-Cutait pull-through procedure based on cause. DESIGN: After the institutional review approval board, a retrospective review of women who underwent the procedure (1993-2018) for a rectovaginal fistula was conducted. Patients' demographics, cause, and postoperative outcomes were analyzed. SETTING: Colorectal surgery department at a tertiary center in the United States. PATIENTS: Adult women with a rectovaginal fistula who underwent a colonic pull-through procedure were included. MAIN OUTCOME MEASURES: Recurrence after the colonic pull-through procedure. RESULTS: There were 81 patients who underwent colonic pull-through; of those, 26 patients had a rectovaginal fistula, had a median age of 51 (43-57) years, and had a mean BMI of 28 ± 3.2 kg/m 2 . A total of 4 patients (15%) had a recurrence and 85% of the patients healed. Ninety-three percent of the patients healed after the prior anastomotic leak. Patients with a Crohn's disease-related fistula had a 75% cure rate. The Kaplan-Meier analysis showed a cumulative incidence of recurrence of 8% (95% CI, 0%-8%) within 6 months after surgery and 12% at 12 months. LIMITATIONS: Retrospective design. CONCLUSIONS: The Turnbull-Cutait pull-through procedure may be the last option to preserve intestinal continuity and successfully treat rectovaginal fistulas in 85% of cases. EL PROCEDIMIENTO PULLTHROUGH DE TURNBULLCUTAIT ES UNA ALTERNATIVA A LA OSTOMA PERMANENTE EN PACIENTES CON FSTULAS PLVICAS COMPLEJAS: ANTECEDENTES:Con frecuencia se recomienda un estoma permanente en el contexto de una fístula rectovaginal compleja o recurrente debido a la alta tasa de fracaso de los procedimientos reconstructivos. El procedimiento de extracción de Turnbull-Cutait es una operación de rescate para pacientes motivados que desean evitar la desviación fecal permanente.OBJETIVO:Analizar las tasas de curación de la fístula rectovaginal compleja después del procedimiento de extracción de Turnbull-Cutait según la etiología.DISEÑO:Después de la junta de aprobación de revisión institucional, se realizó una revisión retrospectiva de mujeres que se sometieron a un procedimiento (1993-2018) por fístula rectovaginal. Se analizaron los datos demográficos, la etiología y los resultados posoperatorios de los pacientes.AJUSTE:Departamento de cirugía colorrectal en un centro terciario en los Estados Unidos.PACIENTES:Mujeres adultas con fístula rectovaginal que se sometieron a extracción del colon.RESULTADO PRINCIPAL:recurrencia después de la extracción del colon.RESULTADOS:Hubo 81 pacientes que tenían extracción colónica, de esas 26 fístulas rectovaginales con una mediana de edad de 51 (43 - 57) años, y un índice de masa corporal promedio de 28 ± 3,2 kg/m2. Un total de 4 (15%) pacientes tuvieron una recurrencia y el 85% de los pacientes se curaron. El noventa y tres por ciento de los pacientes se curaron después de la fuga anastomótica previa. Los pacientes con fístula relacionada con EC tuvieron una tasa de curación del 75%. El análisis de Kaplan Meier mostró una incidencia acumulada de recurrencia del 8% [95% intervalo de confianza 0%-18%] dentro de los 6 meses posteriores a la cirugía y del 12% a los 12 meses.LIMITACIONES:Diseño retrospectivo.CONCLUSIONES:El procedimiento de extracción de Turnbull-Cutait puede ser la última opción que se puede ofrecer para preservar la continuidad intestinal y tratar la fístula rectovaginal con éxito en el 85% de los casos. (Traducción-Yesenia.Rojas-Khalil).

Concomitant vesicovaginal fistula and rectovaginal fistula in a patient with a neglected pessary placed for pelvic organ prolapse.

INTRODUCTION: Pelvic organ prolapse is a very frequent affection especially in elderly women. Vaginal pessary is a common conservative treatment and recommended as first line therapy. Guidelines recommend to do a regular follow up every 6 to 12 months with a healthcare professional. We report the case of a patient with neglected vaginal pessary who had a vesicovaginal and a concomitant rectovaginal fistula. CASE REPORT: A 84-year-old woman was admitted for chronic pelvic pain and vaginal discharge. An entrapped cube pessary was removed and the diagnostic of a 3cm rectovaginal fistula with a vesicovaginal fistula was made. The patient had a two-stage surgery, vaginal way then open abdominal way, for closing the fistulas. CONCLUSION: Although vaginal pessary is a good conservative treatment for POP, it shall not be neglected or serious complications can be caused.

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

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

Womens' experiences of living with obstetric fistula in Ghana-time for the establishment of a fistula centre of excellence.

OBJECTIVE: To explore the experiences of women living with Obstetric Fistula in Ghana. DESIGN: A descriptive qualitative design involving face-to-face semi-structured interviews following institutional ethical approval. SETTING: Urban and rural setting in the Mfantseman Municipal Area (MMA) in the Central Region (CR) of Ghana PARTICIPANTS: A purposive sample of thirty- two women who had experienced obstetric fistula (OBF) FINDINGS: Three core themes emerged and these were i) Women's perceptions of OBF, ii) Experiences of women living with OBF iii) Coping strategies of women living with OBF CONCLUSION AND IMPLICATIONS FOR PRACTICE: There is a need for a multi-agency coordinated approach to the treatment and management of OBF in Ghana. The findings support the need for a dedicated specialist fistula centre to treat women and to meet the educational needs of health care professionals with strategies to prevent as well as support women with OBF. The hub and spoke organisation design for health care systems has proved beneficial in other health settings providing a level of quality that would not be possible otherwise. It is time to end the suffering of women living with obstetric fistula.

Experiences of Rectovaginal Fistula in Anorectal Malformation.

BACKGROUND: Rectovaginal fistulas (RVFs) are very rare malformations in females with anorectal malformations (ARMs). Here, we share the clinical features of RVF and report the long-term outcomes. METHODS: RVF patients were classified using a retrospective analysis of ARM patients who underwent operations at Seoul National University Hospital between January 1999 and May 2017. The Krickenbeck continence scoring system was used to evaluate bowel function 5 and 10 years after surgery. RESULTS: Of the total 460 ARM patients, 203 were female, 7 of whom were diagnosed with RVF. The median age and weight at the time of anorectoplasty were 292 days (range, 140-617) and 8.2 kg (range, 5.5-12), respectively. Six patients had associated anomalies and three patients underwent redo-anorectoplasty. Voluntary bowel movements were observed in 6 out of 7 patients at 5 and 10 years of age. Soiling was observed in all patients at the age of five years and in 6 out of 7 patients at the age of ten years. Constipation was observed in 6 out of 7 patients at both five and ten years of age. CONCLUSIONS: An RVF is a very rare malformation, accounting for 1.5% of total ARMs and 3.4% of ARMs in females. Long-term counseling, education, and guidance are needed for effective management of patients' bowel movements. TYPE OF STUDY: Prognosis study LEVEL OF EVIDENCE: Level IV.

One-stage repair of anorectal malformations in females with vestibular fistula: a systematic review and meta-analysis.

PURPOSE: Females with recto-vestibular fistula (RVF) can be managed either by one-stage sagittal anorectoplasty (SARP) or by conventional multi-stage approach with colostomy followed by SARP. Our aim was to define which approach, one-stage or multi-stage, is safer and more beneficial. METHODS: Using a defined search strategy, two investigators identified all comparative studies on the mentioned procedures. The study was conducted under PRISMA guidelines. The meta-analysis was performed using RevMan 5.3. Data are mean ± SD. RESULTS: Of 649 titles/abstracts screened, 13 full-text articles were analyzed. Three studies were included (156 females). One-stage SARP was associated with increased risk of wound infection (24.3 ± 8.7%) compared to multi-stage approach (10.9 ± 2.5%; p < 0.01) and increased risk of wound dehiscence (16.2 ± 4.8% vs. 2.4 ± 1.1%, respectively; p < 0.01). The incidence of anorectal stenosis was higher following one-stage repair (33.3%) vs. multi-stage approach (10.7%; p < 0.05). No differences were found with regards to redo SARP in both groups (12.9 ± 7.3% vs. 4.8 ± 0.8%; p = ns). At follow-up, the prevalence of soiling and constipation were similar after one-stage (19.7 ± 10.3% and 29.5 ± 5.4%) and multi-stage repair (13.7 ± 8.9% and 28.7 ± 4.4%; p = ns). CONCLUSIONS: In females with RVF, the SARP performed without protective colostomy increases the risk of postoperative complications. However, this one-stage approach seems not to be associated with reduced fecal continence.

Functional Outcomes After Rectal Resection for Deep Infiltrating Pelvic Endometriosis: Long-term Results.

BACKGROUND: Curative management of deep infiltrating endometriosis requires complete removal of all endometriotic implants. Surgical approach to rectal involvement has become a topic of debate given potential postoperative bowel dysfunction and complications. OBJECTIVE: This study aims to assess long-term postoperative evacuation and incontinence outcomes after laparoscopic segmental rectal resection for deep infiltrating endometriosis involving the rectal wall. DESIGN: This is a retrospective study of prospectively collected data. SETTINGS: This single-center study was conducted at the University Hospital of Bern, Switzerland. PATIENTS: Patients with deep infiltrating endometriosis involving the rectum undergoing rectal resection from June 2002 to May 2011 with at least 24 months follow-up were included. MAIN OUTCOME MEASURES: Aside from endometriosis-related symptoms, detailed symptoms on evacuation (points: 0 (best) to 21 (worst)) and incontinence (0-24) were evaluated by using a standardized questionnaire before and at least 24 months after surgery. RESULTS: Of 66 women who underwent rectal resection, 51 were available for analyses with a median follow-up period of 86 months (range: 26-168). Forty-eight patients (94%) underwent laparoscopic resection (4% converted, 2% primary open), with end-to-end anastomosis in 41 patients (82%). Two patients (4%) had an anastomotic insufficiency; 1 case was complicated by rectovaginal fistula. Dysmenorrhea, nonmenstrual pain, and dyspareunia substantially improved (p < 0.001 for all comparisons). Overall evacuation score increased from a median of 0 (range: 0-11) to 2 points (0-15), p = 0.002. Overall incontinence also increased from 0 (range: 0-9) to 2 points (0-9), p = 0.003. LIMITATIONS: This study was limited by its retrospective nature and moderate number of patients. CONCLUSIONS: Laparoscopic segmental rectal resection for the treatment of deep infiltrating endometriosis including the rectal wall is associated with good results in endometriotic-related symptoms, although patients should be informed about possible postoperative impairments in evacuation and incontinence. However, its clinical impact does not outweigh the benefit that can be achieved through this approach. See Video Abstract at http://links.lww.com/DCR/A547.

Exploring the needs and challenges of women reintegrating after obstetric fistula repair in northern Ghana.

OBJECTIVE: to explore the cultural, social and economic needs and challenges of women in northern Ghana as they resume their day-to-day lives post obstetric fistula repair. DESIGN: a critical ethnographic approach. SETTING: a state run fistula treatment center in Tamale, northern Ghana, and 24 rural communities in northern Ghana. PARTICIPANTS: ninety-nine (N=99) participants were recruited using purposive, convenience and snowball sampling. The sample consisted of women (N=41) who had experienced an obstetric fistula repair and their family members (N=24). Health care providers (N=17) and stakeholders (N=17) who had specialised knowledge about reintegration programs at a community or national level were also included. FINDINGS: the needs and challenges of northern Ghanaian women post obstetric fistula repair were historically and culturally rooted. A woman's psychosocial acceptance back into her community post obstetric fistula was significant to her well-being but many women felt they had to 'prove' themselves worthy of acceptance and hid any signs of urinary incontinence post obstetric fistula repair. The cost of treatment compounded by a woman's inability to work while having the obstetric fistula exaggerated her economic needs. Skills training programs offered assistance but were often not suited to a woman's physical capability or geographic location. Many women who have experienced obstetric fistula along with women leaders have initiated obstetric fistula awareness campaigns in their communities with the aim of overcoming the challenges and improving the reintegration experiences of others who have had an obstetric fistula repair. CONCLUSION: developing understanding about the needs and challenges of women post obstetric fistula is an important step forward in creating social and political change in obstetric fistula care and reintegration. IMPLICATIONS FOR PRACTICE: Strategies to support women reintegrating to their communities post obstetric fistula repair include exploring alternative forms of skills training and income generation activities, creating innovative pre and post obstetric fistula health education and community awareness to reduce the perception of the condition as 'incurable', and promoting peer advocacy.

Urinary tract infection among fistula patients admitted at Hamlin fistula hospital, Addis Ababa, Ethiopia.

BACKGROUND: Urinary Tract Infection (UTI) causes a serious health problem and affects millions of people worldwide. Patients with obstetric fistula usually suffer from incontinence of urine and stool, which can predispose them to frequent infections of the urinary tract. Therefore the aim of this study was to determine the etiologic agents, drug resistance pattern of the isolates and associated risk factor for urinary tract infection among fistula patients in Addis Ababa fistula hospital, Ethiopia. METHODS: Across sectional study was conducted from February to May 2015 at Hamlin Fistula Hospital, Addis Ababa, Ethiopia. Socio-demographic characteristics and other UTI related risk factors were collected from study participants using structured questionnaires. The mid-stream urine was collected and cultured on Cysteine lactose electrolyte deficient agar and blood agar. Antimicrobial susceptibility was done by using disc diffusion method and interpreted according to Clinical and Laboratory Standards Institute (CLSI). Data was entered and analyzed by using SPSS version 20. RESULTS: Out of 210 fistula patients investigated 169(80.5%) of the patient were younger than 25 years. Significant bacteriuria was observed in 122/210(58.1%) and 68(55.7%) of the isolates were from symptomatic cases. E.coli 65(53.7%) were the most common bacterial pathogen isolated followed by Proteus spp. 31(25.4%). Statistical Significant difference was observed with history of previous UTI (P = 0.031) and history of catheterization (P = 0.001). Gram negative bacteria isolates showed high level of resistance (>50%) to gentamicin and ciprofloxacin, while all gram positive bacteria isolated were showed low level of resistance (20-40%) to most of antibiotic tested. CONCLUSIONS: The overall prevalence of urinary tract infection among fistula patient is 58.1%. This study showed that the predominant pathogen of UTI were E.coli followed by Proteus spp. It also showed that amoxicillin-clavulanic acid was a drug of choice for urinary tract bacterial pathogens.

[Quality of life and symptoms before and after surgical treatment of rectovaginal fistula]. / Évaluation de la qualité de vie et des symptômes avant et après prise en charge chirurgicale des fistules rectovaginales.

INTRODUCTION: Rectovaginal fistula requires a complex management because it has an important psychological impact associated with impaired quality of life of patients. Thus, the aim of our study was to evaluate the improvement of the quality of life of patients after surgical management. METHODS: This is a retrospective study. We included patients operated between 2009 and 2014 for the treatment of a rectovaginal fistula, whose data were available and who agreed to answer a questionnaire. We evaluated the satisfaction of short-term and long-term patients on the answer to the basic PFDI-20 and PFIQ-7 questionnaires. We then evaluated whether there was an improvement in symptoms and quality of life after surgery. RESULTS: Nine patients were included but only 4 patients completed the PFDI-20 and PFIQ-7 questionnaires. Fistula was secondary to either surgical intervention (44%, n=4) or complicated perineal tear (44%, n=4) or unknown cause (11%, n=1). After surgery, we found the short term a significant decrease in stool incontinence, as there was no stool incontinence (0/5) in the postoperative period, while preoperatively 55% (5/9) (P=0.03). Postoperatively, 33% (3/9) of the patients had genital discomfort and 44% (4/9) had gas incontinence compared to 0% preoperatively (P=0.2 and P=0.6). There appears to be an improvement in pelvic static disorders after surgical management. However, we found a slight improvement in nauseous leucorrhoea in the immediate postoperative period, as the prevalence decreased from 33% (3/9) preoperatively to 22% (2/9) postoperatively (P>0.9). In the long term, we observed an improvement in the sensation of perineal heaviness and gas incontinence because only 25% (1/4) of the 75% (3/4) preoperative patients still showed slight discomfort (P=0.5). The quality of life and the emotional state of the patients were no altered postoperatively. Indeed, preoperatively, 50% (2/4) of the patients reported anxiety compared to 0% (0/4) postoperatively (P=0.4). Similarly, 75% (3/4) complained of a decrease in their quality of life (social, sports, etc.) preoperatively compared with 0% (0/4) postoperatively (P>0.9). CONCLUSION: A simple surgical management of rectovaginal fistulas would allow a significant decrease in stool incontinence and improved quality of life and their emotional state, which confirms the beneficial effect of this therapeutic strategy. LEVEL OF EVIDENCE: 4.

Enterovaginal or Vesicovaginal Fistula Control Using a Silicone Cup.

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

Anal Canal Adenocarcinoma in a Patient with Longstanding Crohn's Disease Arising From Rectal Mucosa that Migrated From a Previously Treated Rectovaginal Fistula.

BACKGROUND This study reports the pathogenesis of anal canal adenocarcinoma in a patient with longstanding Crohn's disease (CD). CASE REPORT A 50-year-old woman with a 33-year history of CD presented with perianal pain of several months' duration. She had been treated surgically for a rectovaginal fistula 26 years earlier and had been treated with infliximab (IFX) for the previous 4 years. A biopsy under anesthesia revealed an anal canal adenocarcinoma, which was removed by abdominoperineal resection. Pathological examination showed that a large part of the tumor consisted of mucinous adenocarcinoma at the same location as the rectovaginal fistula had been removed 26 years earlier. There was no evidence of recurrent rectovaginal fistula, but thick fibers surrounded the tumor, likely representing part of the previous rectovaginal fistula. Immunohistochemical analysis using antibodies against cytokeratins (CK20 and CK7) revealed that the adenocarcinoma arose from the rectal mucosa, not the anal glands. CONCLUSIONS Mucinous adenocarcinoma can arise in patients with CD, even in the absence of longstanding perianal disease, and may be associated with adenomatous transformation of the epithelial lining in a former fistula tract.

A Systematic Review Assessing Medical Treatment for Rectovaginal and Enterovesical Fistulae in Crohn's Disease.

BACKGROUND: Rectovaginal and enterovesical fistulae are difficult to treat in patients with Crohn's disease. Currently, there is no consensus regarding their appropriate management. AIM OF THE STUDY: The aim of the study was to review the literature on the medical management of rectovaginal and enterovesical fistulae in Crohn's disease and to assess their response to treatment. METHOD: A literature search of MEDLINE, EMBASE, Science Citation Index Expanded, and Cochrane was performed. RESULTS: Twenty-three studies were identified, reporting on 137 rectovaginal and 44 enterovesical fistulae. The overall response rates of rectovaginal fistulae to medical therapy were: 38.3% complete response (fistula closure), 22.3% partial response, and 39.4% no response. For enterovesical fistulae the response rates to medical therapy were: 65.9% complete response, 20.5% partial response, and 13.6% no response. Specifically, response to anti-tumor necrosis factor therapy of 78 rectovaginal fistulae was: 41.0% complete response, 21.8% partial response, and 37.2% no response. Response of 14 enterovesical fistulae to anti-tumor necrosis factor therapy was: 57.1% complete response, 35.7% partial response, and 7.1% no response. The response to a combination of medical and surgical therapy in 43 rectovaginal fistulae was: 44.2% complete response, 20.9% partial response, and 34.9% no response. CONCLUSIONS: Medical therapy, alone or in combination with surgery, appears to benefit some patients with rectovaginal or enterovesical fistula. However, given the small size and low quality of the published studies, it is still difficult to draw conclusions regarding treatment. Larger, better quality studies are required to assess response to medical treatment and evaluate indications for surgery.

Patient and disease characteristics associated with late tumour stage at presentation of cervical cancer in northwestern Tanzania.

BACKGROUND: About two thirds of patients with cervical cancer in Tanzania present with advanced tumor stage, leading to significant morbidity and mortality. We designed a study to determine the factors associated with the late tumour stage at presentation among patients with cervical cancer in Mwanza. METHODS: This cross-sectional study recruited women at Bugando Medical Centre (BMC) with histologically confirmed cervical cancer from November 2013 to April 2014. Patients were recruited serially until the sample size was reached. RESULTS: A total of 202 women with histologically confirmed cervical cancer were recruited. The mean age of the patients was 50.5 ± 13.3 years. The majority of patients (n = 129, 63.9%) were diagnosed with late stage disease (IIB-IVB). Patients also presented with severe anemia (n = 78, 38.6%), urinary tract infections (n = 74, 36.6%), hydronephrosis (n = 43, 21.2%), elevated serum creatinine levels (n = 33, 16.3%), vesicovaginal fistula (VVF), (n = 13, 6.4%), lung metastasis (n = 5, 2.4%), metastasis to the urinary bladder (n = 4, 1.9%), rectovaginal fistula (RVF) (n = 3, 1.4%), liver metastasis (n = 2, 0.9%) and hydroureter (n = 2, 0.9%). In multivariate logistic regression, factors associated with late stage at presentation were attending to alternative health practitioners and lack of personal initiative to seek care to formal health facilities (OR 2.3; 95% CI 1.2-4.2, p = 0.011 and OR 2.0; 95 % CI 1.0-3.8, p = 0.028) respectively. CONCLUSION: Communities should be sensitized to women's empowerment, provide community education on early symptoms of cervical cancer, and the importance of early hospital attendance.

Beyond repair - family and community reintegration after obstetric fistula surgery: study protocol.

BACKGROUND: Obstetric fistula is a debilitating birth injury that affects an estimated 2-3 million women globally, most in sub-Saharan Africa and Asia. The urinary and/or fecal incontinence associated with fistula affects women physically, psychologically and socioeconomically. Surgical management of fistula is available with clinical success rates ranging from 65-95 %. Previous research on fistula repair outcomes has focused primarily on clinical outcomes without considering the broader goal of successful reintegration into family and community. The objectives for this study are to understand the process of family and community reintegration post fistula surgery and develop a measurement tool to assess long-term success of post-surgical family and community reintegration. METHODS: This study is an exploratory sequential mixed-methods design including a preliminary qualitative component comprising in-depth interviews and focus group discussions to explore reintegration to family and community after fistula surgery. These results will be used to develop a reintegration tool, and the tool will be validated within a small longitudinal cohort (n = 60) that will follow women for 12 months after obstetric fistula surgery. Medical record abstraction will be conducted for patients managed within the fistula unit. Ethical approval for the study has been granted. DISCUSSION: This study will provide information regarding the success of family and community reintegration among women returning home after obstetric fistula surgery. The clinical and research community can utilize the standardized measurement tool in future studies of this patient population.

Living with constant leaking of urine and odour: thematic analysis of socio-cultural experiences of women affected by obstetric fistula in rural Tanzania.

BACKGROUND: Obstetric fistula is a worldwide problem that affects women and girls mostly in Sub Saharan Africa. It is a devastating medical condition consisting of an abnormal opening between the vagina and the bladder or rectum, resulting from unrelieved obstructed labour. Obstetric fistula has devastating social, economic and psychological effect on the health and wellbeing of the women living with it. This study aimed at exploring social-cultural experiences of women living with obstetric fistula in rural Tanzania. METHODS: Women living with obstetric fistula were identified from the fistula ward at CCBRT hospital. Sixteen individual semi structured interviews and two (2) focus group discussions were conducted among consenting women. Interviews were transcribed verbatim and transcripts analysed independently by two researchers using a thematic analysis approach. Themes related to the experiences of living with obstetric fistula were identified. RESULTS: Four themes illustrating the socio-cultural experiences of women living with obstetric fistula emerged from the analysis of women experiences of living with incontinence and odour. These were keeping clean and neat, earning an income, maintaining marriage, and keeping association. Women experiences of living with fistula were largely influenced by perceptions of people around them basing on their cultural understanding of a woman. CONCLUSION: Living with fistula reveals women's day-to-day experiences of social discrimination and loss of control due to incontinence and odour. They cannot work and contribute to the family income, cannot satisfy their husband's sexual needs and or bear children, and cannot interact with members of the community in social activities. Women experience of living with fistula was influenced by perceptions of people around them. In the eyes of these people, women who leak urine were of less value since they were not capable of carrying out ascribed social roles.

Access to essential paediatric surgery in the developing world: a case of imperforate anus with rectovaginal and rectocutaneous fistulas left untreated.

Anorectal malformations consist of a wide spectrum of conditions which can affect both sexes and involve the distal anus and rectum as well as the urinary and genital tracts. Patients have the best chance of a good functional outcome if the condition is diagnosed early and efficient anatomic repair is promptly instituted. This report describes a rare case of imperforate anus associated with both rectovaginal and rectocutaneous fistulas in a 6-year-old Filipino girl. The case highlights shortcomings in the healthcare delivery system combined with socio-economic factors that contributed to the delay in both diagnosis and the institution of adequate treatment. Care and preventive measures that can be implemented in low-resource settings to reduce the impact of birth defects are also discussed.

Fístula rectovaginal y enterocutánea espontáneas: potenciales complicaciones durante la terapia con fármacos antiangiogénicos en cáncer renal / Spontaneous enterocutaneous and rectovaginal fistula: potential complications during therapy with anti-angiogenic drugs in renal cancer

Se presentan dos casos de fístula, enterovaginal y enterocutánea asociadas a tratamiento con pazopanib, un inhibidor de la angiogénesis para el tratamiento de cáncer renal metastásico. El tiempo entre el inicio del fármaco y la aparición de la fístula fue de 6 y 16 meses, respectivamente; en ninguno de los casos hubo antecedentes de radioterapia o cirugía previa en la zona donde surgió la complicación. Según lo reportado en la literatura, alrededor de un 70% de pacientes se benefician de un tratamiento conservador. Las fístulas enterovaginales y enterocutáneas, suponen menos del 1% de las complicaciones publicadas por el uso de fármacos antiangiogénicos; a pesar de eso, es una complicación que deberíamos tener presente, pues se reporta una mortalidad cercana al 30%. A través de este artículo, queremos trasmitir nuestra experiencia en este tipo de complicación, ya por su baja incidencia, es indudable, que esta por vía de información, nos podemos apoyar los diferentes especialistas que tratan a estos pacientes; tomando las precauciones necesarias y decidiendo un manejo adecuado

We present two cases of enterovaginal and enterocutaneous fistulae associated to treatment with pazopanib, which is an angiogenesis inhibitor for the treatment of metastatic renal cancer. The times from drug administration and the first appearance of a fistula were 6 and 16 months, respectively. None of the cases had a history of surgery or radiotherapy in the area where the complication was observed. Enterovaginal and enterocutaneous fistula represent less than 1% of all published complications caused by the use of antiangiogenic drugs. However, they must be taken into account as the reported mortality rate is close to 30%. Given its low incidence, we believe that sharing this data is a great way to help specialists who have to treat these patients to take the necessary precautions and decide on an adequate approach

Creation of a neovagina in a patient with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome and previously corrected rectovestibular fistula concomitant with imperforate anus.

BACKGROUND: Congenital absence of uterus and vagina (CAUV) when associated with anorectal malformations is usually diagnosed and repaired in infancy at the time of anorectoplasty. Long-term observations of patients are scarce and do not justify early vaginal reconstruction. Question arises whether creation of a neovagina can be safely and successfully performed when the patient is mature. CASE: The patient, diagnosed with MRKH syndrome at 16 years of age, underwent repair of rectovestibular fistula and imperforate anus ("cut-back" procedure, temporal sigmostomy and sagittal anterior anorectoplasty) in infancy. At 18, modified Wharton vaginoplasty was performed with a good anatomico-functional outcome. SUMMARY AND CONCLUSIONS: Early repair of anorectal malformation and postponed vaginal reconstruction seem to be a viable option for patients with congenital rectovestibular fistula and anal atresia concomitant with CAUV.