Urogenital fistulae: a prospective study of 50 cases at a tertiary care hospital

The misfortunate incident of formation of a ureogenital fistula remains a major challenge for surgical urologists worldwide. Such fistulae may not be a life-threatening problem, but surely the women face demoralization, social boycott and even divorce and separation. The fistula may be vaginal, recto-vaginal or a combination of the two. The World Health Organization [WHO] has estimated that in the developing nations, nearly 5 million women annually suffer severe morbidity with obstetric fistulae being the foremost on the list. The objective of our study was to enunciate the patient demography, patient profile, incidence, type of surgery, as well as the long-term outcomes encountered in the management of all types of genital fistulae at a tertiary care centre. 50 consecutive patients, attending the outpatient department with urogenital fistulae, were studied during the period of 5 years from July 2009. All female patients with complaints of urinary incontinence and fecal incontinence and dribbling, patients having a history of obstructed labor, radiotherapy, instrumental delivery, foreign body or trauma and with a history of hysterectomy [abdominal/ vaginal] and lower segment caesarean section [LSCS] were included. A thorough urological examination included a dye study using methylene blue, Renal function tests, X-ray KUB nad intravenous urography [IVU]. Cystoscopy along with examination under anaesthesia [EUA] were done to assess the actual extent of injury. All patients were subjected to appropriate surgical interventions via the same combination of surgeons. Post operatively, prophylactic antibiotics were administered to all patients and patients were managed till discharge and followed thereafter via regular outpatient visits for a period of 3 years. Age of patients ranged from 21 to 40 years. 64% patients hailed from rural areas, 76% were from the lower socio-economic strata, 40% illiterate and 69% were short Statured. Vesico vaginal fistulae [VVF] was seen in 64% cases of which 50% were due to obstructed labor, 19% cases post LSCS and 31% cases post total abdominal hysterectomy [TAH]. 68% of urogenital fistulae were between 1 to 3 cms. We obtained a 75% cure rate in UVF, 87.5% cure rate in RVF while a 93.75% cure rate was observed in patients with VVF, 765 of all patients were cured while 8% had a recurrence, probably due to the large size of fistula. Genital fistula is preventable, yet it remains a significant cause of morbidity among females of reproductive age group. Despite facilities available, certain conditions like physical, social, economic, illiteracy, and a very casual attitude towards maternal health and children birth practices limit utilization of services for women. It is important that the modern health care providers should be aware of these aspects, so that they can recognize services that are appropriate and acceptable to the people. Thus, one must agree that in cases of urogenital fistulae, "prevention is better than cure"

Fístula vesico vaginal: modificación de técnica quirúrgica / Vesicovaginal fistula: modification of the surgical technique

Las fístulas vesicovaginales se conocen desde la antigüedad. Mahfouz describió una en una momia egipcia, actualmente la causa más frecuente es la histerectomía, el éxito de la reparación de la fístula, depende de: tiempo de establecida la fístula, etiología, localización, estudio de la paciente y la fístula, técnica quirúrgica y experiencia del urólogo. Se realizó un estudio descriptivo longitudinal para de mostrar las ventajas de la modificación en la técnica quirúrgica, entre los años 2001 y 2008 en el servicio de Urología del Hospital Docente Iluminado Rodríguez de Jagüey Grande, Matanzas, se operaron 21 pacientes, las edades comprendidas entre 21 y 50 años y el motivo de ingreso, incontinencia de orina y antecedente de una operación quirúrgica ginecológica. Se utilizaron los archivos del hospital para obtener los datos recogidos de las historias clínicas. La distribución etárea fue del 76 por ciento de los casos entre los 31 y 45 años, que denota su gran frecuencia entre mujeres en edad fértil y de mayor desarrollo socio-económico, resultaron estadísticamente significativas las histerectomías abdominales en la génesis de la fístula con más del 85.7 por ciento. Se comprobó que la vía de abordaje quirúrgico más utilizada en la reparación fue la abdominal y por lo general de localización retrotrigonal. Se logra recuperación de la función urinaria fisiológica y ahorro de $ 750.00, en cada caso y la regresión a la tranquilidad familiar, la vida laboral y social de todas las pacientes.

Vesicovaginal fistulas are known from the ancient times. Mahfouz described one in an Egyptian mummy. Nowadays the most frequent cause is the hysterectomy. The success in repairing a fistula depends on: time of fistula's formation, aetiology, location, study of the patient and the fistula, surgical technique and urologist's experience. We carried out a longitudinal descriptive study to state the advantages of the modification of the surgical techniques, in the years from 2001 and 2008 at the Urology Service of the Teaching Hospital Iluminado Rodríguez of Jagüey Grande, Matanzas. 21 21-to-50 years-old patients were operated. The causes of entering the hospital were urine incontinence and antecedents of gynaecologic surgical intervention. The hospital records were used to obtain the data collected in the patients' clinical records. 76 per cent of the cases were between 31 and 45 years old, denoting its great frequency among women in fertile age and of the higher socio-economic status, being statistically significant abdominal hysterectomies in the fistula genesis with more than 85.7 per cent. We proved that the most used surgical treatment use was the abdominal one, and generally the location was retrotrigonal. It was achieved the recovering of the physiologic urinary function and $ 750.00 were saved in each case. All the patients recovered the familiar peace, and returned to social and laboral life.

Vesicovaginal fistula [VVF]

Vesicovaginal fistula is not an uncommon condition. It gives rise to multiple socio-psychological problems for women usually of younger age. It can be prevented by improving the level of education, health care and poverty. Early diagnosis and appropriate treatment is required to help the patient. Preoperative assessment, treatment of co-morbid factors, proper surgical approach and technique ensures success of surgery. Postoperative care of the patient is equally important to avoid surgical failure

Vesico-vaginal fistula: interposition flap, a key to success

Vesico-vaginal Fistula [VVF] is an abnormal communication between bladder and vagina that causes continuous discharge of urine into vaginal vault. The objective of this study is to describe current trends of aetiology and repair of Vesico-vaginal Fistulae. This is a Descriptive Study, conducted at Armed Forces Institute of Urology, Rawalpindi and Combined Military Hospital, Kharian between May 2001 and May 2007. All patients diagnosed as cases of vesico-vaginal fistulae were included in the study. Their demographic profile and repair success was determined. A total of 86 patients were included in the study. The mean age of the patients was 35.5 years [range 25-46]. Total abdominal hysterectomy was the most common cause [53% of the cases] followed by obstetric causes [43.92% of the cases]. Success rate of the surgery in the study was 97.5%. The common causes of vesico-vaginal fistula in this study were total abdominal hysterectomy and obstetric causes. The success rate was high, yet the attempt should be made to prevent this socially distressing condition

Contributing factors of Vesico-Vaginal Fistula (VVF) among Fistula Patients in Dr.Abbo's National Fistula et Urogynecology Centre - Khartoum 2008

"Background: Vesico-vaginal Fistula (VVF) is defined as an abnormal communicating tract extending between the bladder (vesico-) and the vagina resulting in continuous involuntary discharge of urine into the vaginal vault. Vesico-vaginal fistula is still a persisting scourge in the developing countries; including Sudan in which new cases of obstetric fistula were estimated to occur every year"" #he ob$ectives of this work were to study the contributing factors of vesico-vaginal fistula in Sudanese patients"" Methods: the design was descriptive; cross-sectional; community-based study"" A total of 2 patients with vesicovaginal fistula presented to the Fistula (entre in )Khartoum Teaching hospital from July to August 2 ;; were investigated using an administrated; semi-structured questionnaire"" Results: The study revealed that 44""2of patients were 1;-24 years old; "";were teenagers when married (1; yrs old)"" While 7of the patients were illiterates; 62"";were married to illiterate husbands"" (; "";) were poor; (4 ""4) were from western regions of Sudan"" The study showed that labor was responsible for 9 ""4of VVF of whom 9""6were primiparous; 42""6delivered at home"" It was found that 4 ""4of the total deliveries were by forceps as long as 27""7were emergency caesarian sections"" (3""2) of the deliveries were attended by traditional birth attendants and ""3of cases stayed in labor for more than 24 hours; as long as 3""2were not in regular antenatal care"" Conclusion:The vesico-vaginal fistula in Sudan resulted mainly from obstructed labor"" the victim was mostly a young woman; a primigravida; who was poor; illiterate; not on regular antenatal care et being in labor more than 24 hours"" Most deliveries were carried at home; attended by traditional Birth Attendants in most cases"" the deliveries were mostly assisted by forceps; or conducted as emergency caesarian sections"" To prevent VVF; the study suggested raising awareness of women at bearing age; improve transportation; besides inclusion of the issue in the curricula of schools and universities"""

Obstetric trauma is the commonest cause of urogenital fistulae

To determine incidence of different types of urogenital fistulae, their frequency and success rate of different methods of repair. This descriptive study was conducted at Armed Forces Institute of Urology and Department of Obstetrics and Gynecology, Military Hospital Rawalpindi from January 1997 to January 1998. A total of 44 patients were included in the study. Diagnosis was made by taking comprehensive history, detailed examination and appropriate investigations. Data regarding aetiological and risk factors was gathered. The incidence was 0.26%. Obstetric trauma, mostly prolonged and obstructed labour, was responsible for 53.3% cases and 40% were result of surgical trauma and miscellaneous causes. Forty percent of fistulae were vesico vaginal and same number was simple in type. Nearly 55% were repaired by abdominal route and 75% were successful in 1[st] attempt. Obstetric trauma was the commonest cause of urogenital fistulae. Majority were repaired by abdominal route and 75% were successful in first attempt. Improvement in maternity care in rural areas, easy approach to specialist care and better training of staff in instrumental deliveries may help to decrease the incidence of these fistule

Fístula vesicovaginal: nuestra experiencia / Bladder-vaginal fistula: our experience

Entre enero de 1992 y diciembre de 2006 se operaron 26 pacientes con el diagnóstico de fístula vesicovaginal. El 88.4 por ciento de las fístulas fueron producidas por histerectomía transabdominal, 92,3 por ciento eran de localización retrotrigonal, 80,8 por cientoo de las pacientes se operaron por vía transvesical extraperitoneal. De las 26 pacientes operadas sólo 3 (11.6 por ciento) recidivaron y resolvieron con una segunda operación. Se analizan los parámetros y esquemas de estudio y tratamiento utilizados para solucionar esta entidad en el primer intento quirúrgico.

From January 1992 to December 2006, 26 patients with vesico-vaginal fistula were surgically operated. 88.4% of the fistulas were produced by trans-abdominal hysterectomy. 92.3% of the cases had retrotrigonal fistulas. 80.8% of the patients were operated by extraperitoneal transvesical way. 3 (11.6%) out of the 26 patients surgically operated showed recurrence, thus, they were subjected to a second operation. The parameters, study charts and treatment previously followed were analyzed in order to resolve this medical entity with only one surgical treatment.

Vesico vaginal fistula: prevention is possible

A prospective study was conducted at Lady Willingdon hospital Lahore from Jan,2002 to Dec, 2004. During the mentioned period 22 patients were admitted with the diagnosis of urinary tract fistula. Among these most of the patients [i.e, 45%] were young belonging to age group 20-30 years. According to the causes 72% were due to obstetrical causes, 23% due to surgical causes and 5% were due to malignant. Regarding to the location of the fistula 14% were juxtauretheral,28% low vaginal, 35% mid vaginal,09% high vaginal and 14% were vault fistulae.Out of 22 patients first surgical repair failure occurred in four patients

Results and predictions of success of vesico-vaginal fistula repair at a national reference level in Rwanda

Objective:Vesico-vaginal fistulas (VVF's) cause enormous harm to women in developing countries. This prospective study intends to highlight epidemiological; etiological and pathological data; and to define predictors of surgical results in a national referral hospital setting. Material and Methods:All consecutive patients with VVF presenting at the Kigali Hospital Centre of Rwanda between 1997 and 2001 were included. Data on epidemiology; pathology; therapy and outcome were prospectively obtained. The risk factors for therapeutic failure were identified by multivariate analysis. Results Ninety eight percent of all cases were of obstetrical origin. Twenty five percent of VVF were categorized as simple; 64as complex and 11as complicated. Complete closure and continence were obtained in 87 (77.7) cases and closure with moderate incontinence in 7 cases (6.3). In 18 cases (16) closure failed even after 3 surgical attempts. The independent risk factors for therapeutic failure were vaginal fibrosis (p0.001) and total destruction of the bladder p=0.002).Conclusion: We conclude that failure is basically linked to the level of destruction of the bladder neck as well as the magnitude of pelvic scarring. Surgery of complex and complicated VVF remains a challenge and requires multi-skilled surgeons. The lasting solution is the development of maternity services and the training of health personnel in reproductive health