A clinical study of various presentations and different modalities in management of vesico-vaginal fistula

Background: Vesicovaginal fistula (VVF) is an abnormal opening between the bladder and the vagina that results in continuous and unremitting urinary incontinence. It is the most distressing complications of gynecologic and obstetric procedures. Materials and methods: It was a prospective study conducted at Gandhi Medical College and Hospital in Department of Urology from February 2014 to July 2015 for a period of 18 months. All cases were subjected to clinical examination, ultrasonography, IVP, cystoscopy, vaginoscopy, and cystogram for confirmation of diagnosis. All cases were managed surgically by different modalities and results were analyzed. Results: Our study included the patients in the age group of 18 to 56 years. 22 patients presented with continuous urine leak with voiding and 13 patients presented with voiding in addition to incontinence of urine. Out of 35 cases 25 were secondary to Gynecological surgeries and 10 were of Obstetric fistulas. Conclusion: The diagnosis of VVFs has traditionally been based on clinical methods and dye testing. The best chance of a successful repair is at the first attempt. The arguments about the most appropriate route for repair continue and are not clarified by the publications so far. However, the role of interposition grafts at both abdominal and vaginal repairs is viewed positively.

The Significance of Inverted Tear-drop Sign in Cystography of Women with Stress Urinary Incontinence / 대한비뇨기과학회지

PURPOSE: A finding of only subtle open bladder neck unaccompanied by leakage at resting state, without any other symptoms suggesting overt intrinsic sphincter incompetence, is commonly observed during cystographic evaluation for women with stress urinary incontinence (SUI). We tried to define whether this finding has any clinical significance in aspect of intrinsic sphincter deficiency. MATERIALS AND METHODS: A retrospective study was undertaken in a series of women whose diagnoses were SUI in our hospital. The appearance of contrast medium in the proximal urethra at resting state without overt leakage on cystogram was named as inverted tear-drop (ITD) sign. Quantification of ITD sign was made by measuring vertical and anterior-posterior (AP) distances of this area. Various clinical and urodynamic parameters were compared between the patients who had inverted tear-drop sign (ITD group) and those not (non-ITD group). RESULTS: A total of 453 women underwent fluoroscopic cystography and ITD sign was observed in 273 (60.2%). Analyses were performed in a total of 290 women (ITD group 186, non-ITD group 104). There was a significant difference in mean age between non-ITD (47.0+/-9.4 years) and ITD group (51.7+/-9.5 years). Several clinical factors such as frequency, urgency, urge incontinence, duration of symptoms, parity, previous pelvic surgery, previous anti-incontinence surgery, urine leakage volume by one hour pad test were not significantly different between two groups. However, a ITD sign was significantly more likely to be in groups of patients with menopause and those with a low valsalva leak point pressure (VLPP). VLPP was significantly lower in ITD group (87.1+/-2.7cmH2O) than in non-ITD group (99.0+/-4.1cmH2O). VLPP in ITD group has a negative correlation with vertical (p=0.0001. r=-0.498) and AP length (p=0.0014, r=-0.23) of tear-drop area. Maximal urethral closure pressure was significantly lower in ITD group (48.2+/-1.4cmH2O) than in non-ITD group (56.2+/-2.0cmH2O). ITD group has more advanced types by Blaivas classification than non-ITD group. CONCLUSIONS: Our results suggest that cystographic ITD sign at rest might reflect some loss of intrinsic sphincter function. When surgeons are planning to operate SUI patients, ITD sign could be considered as an additional parameter in choosing operation method.

The value of immediate postoperative cystogram in transurethral prostatectomy

Twenty-five consecutive cystograms were performed immediately following transurethral prostatectomy. The value of routine post-operative cystograms was demonstrated. It enables the resectionist to confirm not only visible perforations, but also enables him to diagnose occult extravasations. Significant vascular absorption can also be demonstrated. These findings forewarn the Resectionist of any likely post-operative complication. The management of bladder perforation and urinary extravasation was also discussed. (Summary)

Fractionated Cystogram in Bladder Tumors / 대한비뇨기과학회지

Temeliescu first demonstrated that bladder expansion could be evaluated by serial instillations of contrast medium. If bladder capacity is not exceeded, each instillation results in a symmetrical expansion of the normal bladder. When the muscular wall of the bladder is infiltrated by tumor, its capacity to expand is lost at the site of invasion. There are several methods of staging bladder tumors. To standardize the nomenclature and to facilitate the exchange of information, the I.U.C.C. had adopted a clinical stage classification. The value of a standardized classification is obvious. From a prognostic point of view one of the most important features is to determine if the tumor has invaded muscle. Careful bimanual examination under anesthesia will properly stage the tumor in about 80 per cent of cases. However, this degree of accuracy is only achieved by those seeing large numbers of bladder tumors. In certain instances, accurate staging of this disease is still a problem, which has led to the development of additional X-ray technique and non-operative means of more precisely staging the tumors. Angiography, double contrast barium cystography and perivesical gas insufflation have been used to visualized bladder tumors. However, these various techniques are of little assistance in determine the degree of invasion and, consequently, little additional information may be obtained, furthermore, certain techniques are distressing to the patient and are not without serious morbidity. Complications of angiography include hemorrhage, aneurysm formation, impaired vascular supply to the lower limbs and embolism. In addition these techniques require highly skilled personnel and elaborate equipment, thereby restriction their use. Fractionated cystography is a simple method of evaluating muscle invasion by a bladder tumor. It requires no complicated equipment and carries little or no morbidity. The time required for doing the procedure is little more than that for conventional cystograms. 10 cases of bladder tumors done fractionated cystography, which were admitted to our Urologic Department during Jan., 1970 to present, were reported. Utilizing a modification of Temeliescu's technique, we have been studying bladder tumors since Jan. 1970. They were investigated by comparing with previous papers.