Urorectal fistula repair using different approaches: operative results and quality of life issues

ABSTRACT Purpose: To evaluate efficacy of urorectal fistula (URF) repair using different approaches and the clinical factor determinant of success, and also the morbidity associated to the procedure and health-related quality of life (HRQoL) in male survivors of pelvic malignancies. Material and Methods: Retrospective evaluation of 39 patients with URF primarily intervened in three institutions using different surgical approaches. Success was defined as effective fistula closure. Variables evaluated included demographics, previous treatments, surgical approach, ancillary surgeries, complications and HRQoL by using a standardized non-validated specific questionnaire. Median follow-up from surgery to interview was 55 months (interquartile range 49, range 4-112). Factors determinant of success were investigated using logistic regression. Safety of the procedure was evaluated by Clavien-Dindo scale. Deterioration of continence and erectile function and other HRQoL issues were evaluated. Results: Prostate cancer treatment was the predominant etiology. The success rate for fistula repair was 89.5%. The surgical approach was not related to failed repair (p=0.35) or complications (p=0.29). Factors associated with failure were complications (p=0.025), radiotherapy (p=0.03), fistula location (p=0.04) and fistula size (p=0.007). Multivariate analysis revealed fistula size was the only independent determinant of failure (OR 6.904, 1.01-47.75). Complications occurred in 46.2% and severe complications in 12.8%. The mortality related to the procedure was 2.6%. Urinary incontinence was present before repair in 26.3% and erectile dysfunction in 89.5%. Fistula repair caused de novo urinary incontinence in 7.9% and deterioration of erectile status in 44.7%. Globally 79% were satisfied after repair and only 7.9% rated HRQoL as unhappy. Trans-sphincteric approach was related to less deterioration of erectile function (p=0.003), and higher perceived satisfaction in QoL (p=0.04). Conclusions: The surgical approach elected to correct URF is not determinant of success nor of complications. Fistula size appears as independent determinant for failure. Transsphincteric approach could be advantageous over other procedures regarding HRQoL issues.

Quiluria renal izquierda idiopática asociada al embarazo / Idiopathic left renal quiluria associated with pregnancy

Introducción: La eliminación de orina que con tiene grandes cantidades de material quiloso y adquiere un aspecto lechoso se conoce con el nombre de quiluria. Salvo en las regiones donde es endémica, la filariasis linfática, principal etiología, se considera en general como un trastorno raro. Objetivo: Describir un caso de quiluria asociada al embarazo. Caso clínico: Paciente femenina de 32 años de edad, con múltiples ingresos en el Servicio de Nefrología del Hospital Celia Sánchez Manduley desde el año 2007 por presentar orinas de color blanquecino, cuadro que comenzó con el primer embarazo, el síntoma desapareció y luego reapareció con el segundo embarazo, primero de forma intermitente y después, adquirió carácter permanente, con hematuria, proteinuria, edemas y otras alteraciones clínicas y bioquímicas. Conclusiones: La nefrectomía está indicada en la quiluria, cuando pone en riesgo la vida del paciente o afecta su calidad de vida, si no se tienen otras alternativas terapéuticas(AU)

Introduction: The elimination of urine containing large amounts of chyllous material and acquiring a milky appearance is known as quiluria. Except in regions where it is endemic, lymphatic filariasis, the main etiology, is generally considered to be a rare disorder. Objective: To describe a case of chyluria associated with pregnancy. Clinical case: 32-year-old female patient with multiple admissions to the nephrology service at Hospital Celia Sánchez Manduley since 2007 for presenting whitish urine, a clinical picture that began with the first pregnancy. The symptom disappeared, then reappeared with the second pregnancy, first intermittently and then became permanent with hematuria, proteinuria, edema and other clinical and biochemical alterations. Conclusions: Nephrectomy is indicated in chyluria when it puts the patient's life at risk and affects the quality of life, if there are no other therapeutic alternatives(AU)

Laparoscopically assisted anorectoplasty and the use of the bipolar device to seal the rectal urinary fistula / Anorretoplastia laparoscópica e a utilização do selamento bipolar da fistula retourinária

ABSTRACT Background: The anorectal anomalies consist in a complex group of birth defects. Laparoscopic-assisted anorectoplasty improved visualization of the rectal fistula and the ability to place the pull-through segment within the elevator muscle complex with minimal dissection. There is no consensus on how the fistula should be managed. Aim: To evaluate the laparoscopic-assisted anorectoplasty and the treatment of the rectal urinary fistula by a bipolar sealing device. Method: It was performed according to the original description by Georgeson1. Was used 10 mm infraumbilical access portal for 30º optics. The pneumoperitoneum was established with pressure 8-10 cm H2O. Two additional trocars of 5 mm were placed on the right and left of the umbilicus. The dissection started on peritoneal reflection using Ligasure(r). With the reduction in the diameter of the distal rectum was identified the fistula to the urinary tract. The location of the new anus was defined by the location of the external anal sphincter muscle complex, using electro muscle stimulator externally. Finally, it was made an anastomosis between the rectum and the new location of the anus. A Foley urethral probe was left for seven days. Results: Seven males were operated, six with rectoprostatic and one with rectovesical fistula. The follow-up period ranged from one to four years. The last two patients operated underwent bipolar sealing of the fistula between the rectum and urethra without sutures or surgical ligation. No evidence of urethral leaks was identified. Conclusion: There are benefits of the laparoscopic-assisted anorectoplasty for the treatment of anorectal anomaly. The use of a bipolar energy source that seals the rectal urinary fistula has provided a significant decrease in the operating time and made the procedure be more elegant.

RESUMO Racional: As anomalias anorretais consistem de um grupo complexo de defeitos congênitos. A anorretoplastia laparoscópica permite melhor visualização da fístula retourinária e propicia o posicionamento do reto abaixado dentro do complexo muscular do elevador do ânus com mínima dissecção. Não há consenso na literatura sobre o melhor tratamento dessa fístula. Objetivo: Avaliar a anorretoplastia laparoscópica e o selamento bipolar da fístula retourinária. Método: Ela foi realizada de acordo com a descrição original de Georgeson1. Utilizou-se o acesso infraumbilical com portal de 10 mm para a ótica de 30º. O pneumoperitônio foi estabelecido com pressão de 8-10 cm de H2O. Dois trocárteres adicionais de 5 mm foram colocados à direita e à esquerda da cicatriz umbilical. A dissecção foi iniciada na reflexão peritoneal usando Ligasure(r). Com a redução do calibre do reto distalmente, foi identificada a fístula para a o trato urinário. O local do novo ânus foi definido por meio da localização do complexo muscular do esfíncter anal externo, utilizando-se estimulador eletro muscular externamente. Por fim, foi confeccionada uma anastomose entre o reto e o novo local do ânus. Uma sonda uretral de Foley foi deixada durante sete dias. Resultados: Sete meninos foram operados, seis com fístula retoprostática e um retovesical. O período de seguimento variou de um a quatro anos. Os dois últimos pacientes operados foram submetidos ao selamento bipolar da fístula entre o reto e a uretra, sem suturas ou ligadura cirúrgica com pontos. No seguimento em longo prazo não houve evidências de fístulas urinárias. Conclusão: Há benefícios da anorretoplastia laparoscópica para o tratamento de anomalia anorretal. O uso de uma fonte de energia bipolar que promova o selamento da fístula retourinária propiciou redução significativa do tempo cirúrgico e tornou o procedimento mais elegante.

Duplicación rectal extrofiada asociada a malformación anorrectal y transposición pene-escrotal con hipospadias perineal: Reporte de un caso clínico / Exstrophy of rectal duplication associated with anorectal malformation and penoscrotal transposition with perineal hypospadias: A case report

Se presenta el caso de un paciente masculino quien requirió tratamiento por agenesia anorrectal con fístula rectouretral y transposición pene-escrotal con hipospadias perineal, acompañados de una masa perineal. La tumoración perineal se encontró íntimamente adherida y en continuidad al recto, lo que la hace compatible con una duplicación rectal extrofiada. La reconstrucción quirúrgica de la anomalía se realizó en etapas hasta lograr resultados funcionales y estéticos aceptables.

We present the case of a male patient who required treaatment due to anorectal agenesis with recto urethral fistula and penoscrotal transposition with perineal hypospadias, associated with a perineal tumor. The perineal tumor was found strongly adhered and contiguous to the rectum which makes it compatible with an exstrophy of rectal duplication. Surgical reconstruction of the birth defect was performed in stages until acceptable biological function and esthetic results were obtained.

Endoscopic use of cyanoacrylate glue in the treatment of urethral fistula

Purpose The aim of this video is to demonstrate an endoscopic and minimally invasive repair of an urethrocutaneous fistula with cyanoacrylate glue. Materials and Methods: A 56 year-old-man with post-infectious urethral stricture and recurrent perineal abscess formation due to urethral fistulas. Results The operative time was 60 minutes, no major complications were observed perioperatively and postoperatively. At a follow-up time of 6 months the patient had no evidence of recurrent fistula and abscess formation. CONCLUSIONS The endoscopic use of cyanoacrylate glue represents a safe and minimally invasive approach that might be offered as a first line option for the treatment of urinary fistulas in selected patients, especially those with narrow and long tracts. .

Laparoscopic urorectal fistula repair: value of the salvage prostatectomy and review of current approaches

The surgical approach and repair for urorectal fistulas [URF] is a challenging task A variety of techniques have been described to treat URFs and the laparoscopic approach has approved as an efficient tool for even some complex fistulas. We aimed to report our laparoscopic experience for complex URF repair with special emphasis on salvage prostatectomy. The study included four men [59-75 years], with laparoscopic repair for complex URFs; URF developed after TUR-P in patient 2 and 3 and after radical prostatectomy in patient 4. Patient 1 had received combined radiotherapy and chemotherapy for the rectum carcinoma and developed thereafter a prostatic abscess which resulted at the end to URF, Laparoscopic salvage prostatectomy was performed for patient 1 and 2. Transvesical laparoscopic approach was performed for patient 3 and transperitoneal transvesical technique was performed for patient 4. A tunica vaginalis flap was used for patient 1 and a peritoneal interposition flaps were developed in patients 2 and 4. The range of operative time was 114-283 min. Blood loss was 50-600 cc. and no patients needed intraoperative blood transfusion. Post-operative hospital stay was 12-34 days. The urethral catheter was removed on postoperative day 11-32 and the cystographies showed no leakage of contrast except in patient 1. Laparoscopic URF repair is safe and efficacious in experienced hands even in complex cases and salvage laparoscopic prostatectomy seems like a valuable operative option, However the technique requires advanced experience, particularly with pelvic surgery and intracorporeal suturing

Dartos flap coverage of the neourethra following repair for primary hypospadias, reoperative hypospadias and urethrocutaneous fistulas: it is a safe approach / Emprego de um retalho pediculado do músculo dartos para cobertura da neouretra na cirurgia primária de hipospádias, reoperações de hipospádias e correção de fístulas uretrocutâneas

Purpose: Urethrocutaneous fistula and neourethral dehiscence are frequently seen complications of hypospadias surgery requiring reoperation. In this study we report the experience of one surgeon with dartos flap coverage in primary hypospadias, reoperative hypospadias and urethrocutaneous fistulas repair. Methods: A total of 23 patients underwent hypospadias and urethrocutaneous fistulas repair from January 2006 to May 2009. Fourteen patients were operated on for primary hypospadias repair at our institution and 9 patients were admitted for hypospadias complications such as failed hypospadias repair and urethrocutaneous fistula. In all the patients, the dartos flap was dissected and transposed to cover the neourethra. Operative results were recorded. Results: The primary surgical procedure was a one-stage repair in 61 percent (n = 14); tubularised incised plate (TIP) urethroplasty in 43 percent (n = 6) and a Mathieu procedure in 57 percent (n = 8). Urethrocutaneous fistulas complicating the previous initial hypospadias repair were anterior in 33 percent (n = 2), middle in 33 percent (n = 2) and proximal in 33 percent (n = 2). Repair of the fistula was successful on the first attempt in all patients. The reason for redo surgery in 3 patients was complete dehiscence and the patients had distal shaft hypospadias. COconclusion: Dartos flap coverage of the neourethra seems to be an effective method of reducing the fistulous complication rate following primary and secondary hypospadias repair.

Objetivo: Fístulas uretrocutâneas e deiscências são complicações frequentes na cirurgia das hipospádias necessitando reoperações. Este estudo é baseado na experiência pessoal de um cirurgião utilizando um retalho pediculado do músculo dartos para cobertura da neouretra na correção primária de hipospádias, reoperações de hipospádias e correção de fístulas uretrocutâneas. Métodos: Vinte e três pacientes foram operados sendo 14 submetidos a cirurgia primária de hipospádia e 9 a reoperações por insucesso da correção primária ou por fístulas uretrocutâneas. Em todos os pacientes, um retalho pediculado do músculo dartos foi mobilizado e utilizado para recobrir a neouretra. Resultados: Para a cirurgia primária da hipospádia foi utilizada técnica de correção em um só tempo (n=14): uretroplastia tubularizada com incisão da placa (TIP) em 43 por cento (n=6) e técnica de Mathieu em 57 por cento (n=8). As fístulas uretrocutâneas resultantes de correções primárias anteriores eram de localização anterior em 33 por cento (n=2), média em 33 por cento (n=2) e proximal em 33 por cento (n=2). A correção das fístulas uretrocutâneas resultou em sucesso em todos os pacientes. Três pacientes necessitaram de reoperação por deiscência completa e em todos a hipospádia era distal. Conclusões: O emprego do retalho pediculado do músculo dartos para recobrir a neouretra é um método eficaz que reduz a incidência de fístulas em cirurgias primárias e nas reoperações de hipospádias.

Transperineal repair of rectourethral fistula: surgical technique and a case report.

A 60-year old Thai male diagnosed as iatrogenic rectourethral fistula. Preoperative investigation with intravenous pyelogram revealed connection between urethra and rectum. Colonoscopy also revealed fistula opening at mid-rectum. He underwent surgery via transperineal approach. Intraoperative fistula localization was performed using Methylene blue injection via foley catheter. The fistula tract was identified and divided exposing blue-staining tract. Rectal opening and urethral opening were repaired Fecal and urthral diversion were performed Postoperative period was uneventful. The final pathologic report of fistula tract was fibrosis. The perineal and rectal wounds were healed without complication. The suprapubic cystostomy catheter was removed at the end of the second month together with the colostomy closure.

Reparación laparoscópica de fístulas genitourinarias / Laparoscopic management of genitourinary fistula

Objetivo: Las fístulas del tracto genitourinario comúnmente ocurren como una complicación de cirugía pélvica y en especial de procedimientos ginecológicos. Su reparación constituye un desafío para los urólogos. El objetivo de esta presentación es describir la técnica para reparación laparoscópica de fístulas vesicovaginales y ureterovaginales, presentando la experiencia y resultados con dichas técnicas. Material y Método: Entre enero de 2007 y febrero de 2009, 8 pacientes sometidas a cirugía ginecológica presentaron como complicación una fístula genitourinaria. Cuatro pacientes presentaron fístulas ureterovaginales (FUV) y 4 pacientes presentaron fístulas vesicovaginales (FVV). Todas ellas se repararon por vía laparoscópica. Resultados: La reparación laparoscópica fue realizada sin complicaciones en todos los casos. Se realizaron 4 neoimplantes con flap de Boari por vía laparoscópica. El tiempo promedio de cirugía fue 202,5 min (Rango: 180-240 min). La estadía hospitalaria promedio fue de 6 días (Rango: 4-7 días). El seguimiento promedio es de 16 meses (Rango: 9-28 meses). En todas las pacientes se demuestra indemnidad de la vía urinaria. En el caso de las FVV, el tiempo promedio de cirugía fue 161,3 min (Rango: 135-180 min), El tiempo promedio de hospitalización fue 4 días (Rango: 3-5 días). Seguimiento promedio 8 meses (Rango: 4-10 meses). Todas las pacientes evolucionaron en forma satisfactoria. Conclusiones: El manejo de las fístulas genitourinarias secundarias a cirugía ginecológica es posible de realizar por vía laparoscópica respetando los conceptos de la cirugía clásica.

Objective: The genitourinary tract fistulas commonly occur as a complication of pelvic surgery, especially gynecologic procedures. Repair is a challenge for urologists. The aim of this presentation is to describe the technique for laparoscopic repair of vesicovaginal fistula and ureterovaginal, presenting the experience and results with these techniques. Material and Methods: Between January 2007 and February 2009, 8 patients undergoing gynecological surgery had genitourinary fistula as a complication. 4 patients had ureterovaginal fistulas (FUV) and 4 patients had vesicovaginal fistulas (FVV). All of them were repaired by laparoscopic surgery. Results: The laparoscopic repair was performed without complications in all cases. 4laparoscopic ureteroneocystostomy with boari flap was performed. The average time of surgery was 202.5 min (range: 180-240 min), the average hospital stay was 6 days (range: 4-7 days).The average follow-up was 16 months (range: 9-28 months). All patients demonstrated indemnity of the urinary tract. In the case of the FVV, the average time of surgery was 161.3min (range: 135-180 min), the length of hospital stay was 4 days (range: 3-5 days). The average of 8 months (range: 4-10 months). All patients evolved in a satisfactory manner. Conclusions: The management of genitourinary fistula secondary to gynecological surgery is possible to perform laparoscopic respecting the classical concepts of surgery.

[Modified method for treatment rectourethral fistulas]

To evaluate modified technique [Delorme operation] for treatment recto urethral fistules [14] were treated with this technique from 1999 to Dec 2005; the fistule was congenital in 5 patients [35.7%], traumatic in [4] patients [28.6%], iatrogenic in 2 patients, and primary in 3 patients [21.4%]. The fistule was near dentate line in 3 patients [21.4], and above it in 11 patients [78.6%]. The fistule above verumontanum in 6 patients [42.5%], and below 8 patients [57.1%]. The operation after colostomy was done trans midline perineal incision, and rectal mucosa and sub mucosa was stripping off the muscularis layer for 1-2 cm above the fistule, then closeding the orifice, the mucosa rotated by [45] degree. The success cutting and sphincter was performed in 4 patients [28.6%] rate 100% without any recurrence, and without complications. The operation was easy to done without recurrence the fistule and without complications

Diagnosis and management of ureterovaginal fistula in a resource-constrained setting: experience at a district hospital in northern Nigeria

During 2007 we were invited at different times to review and manage four women with ureterovaginal fistula following caesarean section performed in different rural hospitals. We describe our experience of a simple technique of diagnosis and management of these indigent patients in a resource-constrained hospital. The condition was diagnosed by the three-swab test in all four patients, and abdominopelvic ultrasound was employed to help find the ureter involved. Transvesical ureteral implantation with a stent was carried out. Stent was removed after 2 weeks. All four patients were dry. Amidst the complexity of and sophistication of modern health care, it is important to remind ourselves of the common occurrence of this distressing condition following caesarean section and the use of a well known simple diagnostic technique and subsequent management in resource-poor communities

Acceso transanal transesfinteriano sagital anterior para la reparación de fístulas vésico-rectales / Anterior transanal, transsphincteric sagittal approach for fistula repair secondary to laparoscopic radical prostatectomy: a simple and effective techniq

Introducción: Presentamos nuestra experiencia en la reparación de fístulas vésico-rectales mediantela utilización del acceso transanal, transesfinteriano sagital anterior. Material y métodos: Se presenta la experiencia en 5 pacientes portadores de una fístula recto-vesical después de prostatectomía radical. En 3 pacientes la prostatectomía radical fue por vía laparoscópica y en 2 por técnica abierta retropúbica. En 1 paciente la fístula se hizo evidente después de radioterapia por cáncer prostático operado con márgenes positivos. En los 5 pacientes se confirmó la presencia de fístula mediante el examen dígito rectal y la cistoscopia. Tres de ellos tenían una colostomía previa. Todos los pacientes fueron tratados mediante el acceso transanal, transesfinteriano sagital anterior. Resultados: El tiempo entre el diagnóstico y la reparación osciló entre 1 y 3 meses. La reparación fue exitosa en los 5 pacientes. El rango de seguimiento fue entre 12 y 38 meses. Ninguno de los pacientes presentó incontinencia fecal ni estenosis anal, como tampoco incontinencia urinaria. Conclusiones: El acceso transanal, transesfinteriano, sagital anterior logra una buena exposición quirúrgica, permite la fácil identificación del trayecto fistuloso y brinda el acceso a tejido bien vascularizado para realizar el cierre. Esta técnica quirúrgica es sencilla, efectiva y reproducible.

Introduction: To report our experience with the anterior, transanal, transsphinteric sagittal approach in the correction of rectourinary fistulas. Material and methods: We present our experience in 5 patients with a recto-vesical fistula after radical prostatectomy. In 3 patients radical prostatectomy was laparoscopic and open retropubic technique in2. In 1 patient the fistula was evident after radiotherapy for positive margins after prostate cancer surgery. The diagnosis was confirmed in all patients by digital examination and cystoscopy. Three of them had a prior colostomy. All patients were treated by anterior, transanal, transsphinteric sagittal approach. Results: The time between diagnosis and he repair between 1 and 3 months. The repair was successful in 5 patients. The range of follow-up was between 12 and 38 months. None of the patients had fecal incontinence, anal stricture or urinary incontinence. Conclusions: The anterior, transanal, transsphinteric sagittal surgery achieved a good exposure, allows easy identification of the fistulous tract and provides access to well-vascularized tissue for closure. This surgical technique is simple, effective and reproducible.

Transanal repair of rectourethral and rectovaginal fistulas

We evaluated the efficacy and safety of repair of the rectourethral and rectovaginal fistulas with transanal approach using the Latzko technique. We repaired 8 fistulas with transanal approach. Fistulas were rectourethreal in 5 patients, and in the only woman of the series, they were rectovaginal and vesicovaginal, In 3 patients, the fistulas has been diagnosed following prostatectomy, urethral stricture repair, and colonic resection and radiotherapy due to rectosigmoid cancer in 3, 2 and 1 patients, respectively. Complying with Latzko technique, the fistula orifice was exposed and a fusiform incision was made with the orifice in its center. The mucosa lying between the incision and the orifice was excised in the direction of the incision to the orifice, leaving the fistula edges to meet. Then, the edges were closed, followed by closure of the muscular layers above it. Finally, the edges of the rectal mucosa were closed. Two patients had 2 fistulas and 4 had 1 fistula who were all managed by transanal approach. During a median follow-up period of 44 months, no serious complication was noted, except for recurrence of deep vein thrombosis in 1 patient with a positive history for this complication. Hospitalization period was 1 to 7 days. It seems that transanal repair is a simple and effective technique with minimal complication rate in the treatment of rectourethral fistulas. Regardless of the etiology, this method can be used as the preferred therapeutic technique. Further studies are necessary to confirm our findings

The York-Mason technique for recto-urethral fistulas

OBJECTIVE: Recto-urethral fistula formation following radical prostatectomy is an uncommon but potentially devastating event. There is no consensus in the literature regarding the treatment of these fistulas. We present here our experiences treating recto-urethral fistulas. MATERIAL AND METHODS: We analyzed 8 cases of rectourethral fistula treated at our institution in the last seven years. Seven of the patients underwent repair of the fistula using the modified York-Mason procedure. RESULTS: The causes of the fistula were radical retropubic prostatectomy in five patients, perineal debridement of Fournier's gangrene in one, transvesical prostatectomy in one and transurethral resection of the prostate in the other patient. The most common clinical manifestation was fecaluria, present in 87.5 percent of the cases. The mean time elapsed between diagnosis and correction of the fistula was 29.6 (7-63) months. One spontaneous closure occurred after five months of delayed catheterization. Urinary and retrograde urethrocystography indicated the site of the fistula in 71.4 percent of the cases. No patient presented recurrence of the fistula after its correction with the modified York-Mason procedure. CONCLUSION: The performance of routine colostomy and cystostomy is unnecessary. The technique described by York-Mason permits easy access, reduces surgical and hospitalization times and presents low complication and morbidity rates when surgically correcting recto-urethral fistulas.

OBJETIVO: As fístulas reto-uretrais são de acesso difícil e por vezes complexo, sendo seu fechamento espontâneo raro. Com o diagnóstico precoce e aumento do número de intervenções, principalmente a cirurgia por adenocarcinoma da próstata localizado, sua incidência apesar de rara vem crescendo. Nós demonstramos a nossa experiência dos casos de fístulas reto-uretrais entre 2000 a 2006 com uma serie de oito pacientes, sendo que sete realizaram correção da fístula pela Técnica de York Mason modificada. MATERIAL E MÉTODO: Nos retrospectivamente analisamos os prontuários de todos os casos de fístulas reto-uretrais tratados no nosso serviço no período de 2000 a 2006. Sete de oito pacientes realizaram reparo da fístula através do procedimento de York Mason modificado. RESULTADOS: Cinco pacientes tiveram a fístula como conseqüência da Prostatectomia Radical Retropúbica, sendo os outros três após debridamento devido a Fasceíte de Fournier, Prostatectomia Transvesical e Ressecção Transuretral da Próstata. A fecalúria foi o quadro clínico prevalente em 87,5 por cento dos casos, o tempo médio entre o diagnóstico e a correção da fístula foi de 29,6 (7-63 meses) ocorreu um fechamento espontâneo após cinco meses de sondagem vesical de demora, a Uretrocistografia Retrograda e Miccional demonstrou a localização da fístula em 71,4 por cento. Nenhum paciente apresentou recidiva da fístula após correção pela técnica de York Mason modificada. A colostomia foi realizada em 50 por cento dos casos e não ocorreram casos de incontinência fecal ou estenose anal. CONCLUÇÃO: Após identificação de fístula reto-uretral, não é necessário à realização de colostomia e cistostomia de rotina. Sua correção pela técnica descrita por York Mason modificada nos propicia fácil acesso a sua localização, diminui o tempo cirúrgico e de internação, com baixos índices de complicações e morbidade.

Obstetric Urinary Fistulas in KwaZulu-Natal - What is the Extent of this Tragedy?

Background. This study describes the demographics and clinical characteristics of women with obstetric fistulas attending the urogynaecological unit at King Edward VIII Hospital (KEH); KwaZulu-Natal (KZN); South Africa. Method. A prospective clinical review of all women admitted with the diagnosis of an obstetric fistula at KEH from 1999 to 2003. Results. A total of 41 cases from the rural areas of KZN and the Eastern Cape were identified. The mean age was 29 years (range 15 - 51 years); and 21 were primi- gravidas; 14 of whom had unplanned pregnancies. All were from low socioeconomic backgrounds and had limited or no access to antenatal care; either due to their social cir- cumstances or to lack of health care facilities. The duration of labour was prolonged in all; there were 5 live births; and 2 neonatal deaths. Conclusion. Obstetric fistulas are still common in KZN and the Eastern Cape; and occur mainly in women from rural areas

Primary reconstruction is a good option in the treatment of urinary fistula after kidney transplantation

OBJECTIVES: urinary fistula is a morbid complication after renal transplantation leading to graft losses and patient death. We review and update our data on urinary fistula after renal transplantation and the outcome after surgical and conservative management. MATERIALS AND METHODS: the charts of 1046 renal transplants were reviewed. Transplants were performed through an extended inguinotomy; vascular anastomoses to the iliac vessels and urinary reconstruction accomplished through the Gregoir technique. Fistulae were diagnosed by urinary leaks through the incision or by the occurrence of a collection in the iliac fossa. Patient was treated surgically or conservatively according to the characteristics of the fistula and patient clinical status. RESULTS: Thirty one fistulae were diagnosed (2.9 percent). Twenty nine leaks due to ureteral necrosis and 2 due to reimplantation fault. The incidence of leaks among cadaver and live donor transplants was 3.22 percent and 2.63 percent, respectively (p = 0.73). Among diabetic and non diabetic patients the incidence of urinary leaks was 6.4 percent and 2.6 percent, respectively (p = 0.049). Treatment consisted in anastomosis of the graft ureter or pelvis with the ureter of the recipient in 17 cases with success in 13 (76.5 percent). Prolonged bladder drainage was employed in 7 cases and the fistula healed in 4 (57 percent). Ureteral reimplantation was performed in 3 cases and did not work in any of them. Ureteral ligature plus nephrostomy was employed in two cases and worked in one (50 percent). Percutaneous nephrostomy and ureteral stenting with double J catheter were employed in one case each and worked in both. CONCLUSIONS: The anastomosis of the graft ureter with the ureter of the recipient is a good method for treating urinary fistulae after renal transplantation when local and systemic conditions are good. Ureteral ligature associated to nephrostomy should be applied in cases of unfavorable local conditions or clinically unstable patients.

[Uretero-vaginal fistula: technique of the loosed ureteral catheter in the retroperitoneum for the individualization of the distal ureteral segment]

The uretero - vaginal fistula are rare and mostly iatrogenic. The diagnosis is easy since all the signs are collected and lot of therapeutic modalities were described in the literature. it's a patient of 40 years old who present urinary leak one week after a haemostatic hysterectomy for uterine rupture. She was surgically treated with uretero - ureteral anastomosis with easier individualization of the distal ureteral segment by using the technique of the loosed ureteral catheter in the retropenitoneum. This technique allows end to end uretero-ureterostomy conserving the physiologic antireflux system and avoiding the complications of the ureterovesical reimplantations

Surgical Outcome of Female Genital Fistula in Korea

This purpose of this study was to establish a new standard for the surgical management of female genital fistula in Korea. From January 1992 to October 2001, 117 patients with female genital fistula who were admitted to the departments of obstetrics and gynecology, urology and general surgery were analyzed. Nine patients with congenital etiologies and 48 patients who were treated conservatively were excluded. The relationships between surgical outcome and the cause of fistula, the location of fistula, and the various surgical methods were analyzed. In spite of appropriate surgical treatment, fistulas due to cervix cancer management had the worst prognosis. In terms of location, fistula recurrence after surgical repair was most common in the bladder fundus and base. The transvaginal and transrectal approaches are suitable for fistulas located in the lower vagina. The transabdominal approach is appropriate for fistulas located in the functional portions such as the bladder and ureter, for fistulas which are difficult to expose surgically by either the vaginal or rectal approach, or in cases with severe adhesions. In cases of cervix cancer, extra care should be taken during surgical expiration or definitive radiotherapy, especially when the areas involved are the bladder fundus and base. The nature of the surgical approach should be decided by the location of the fistula, the functional importance of the area, and the degree of surgical exposure during the corrective procedures.