Robotic management of congenital urethra-vaginal fistula with transverse vaginal septum

ABSTRACT Introduction: The transverse vaginal septum (TVS) with congenital urethra-vaginal fistula (CUVF) is a rare anomaly of the mullerian duct (1, 2). Incomplete channelling of the vaginal plate, or an abnormality in the fusion of the vaginal component of mullerian duct with the urogenital sinus results in TVS (1, 3, 4). High CUVF occurs due to the persistent communication between the urogenital sinus and utero-vaginal primordium at the tubercle sinus, whereas low CUVF is due to excessive apoptosis of the vaginal plate during channelling (5). The principles of management of CUVF with TVS include: 1) TVS resection, 2) Create a neovagina. We present a case of CUVF with TVS managed by robotic assistance. Material and methods: A 24-year-old female, married for 3 years, presented with cyclical hematuria since menarche, dyspareunia and primary infertility. Examination revealed blind ending vagina 4cm from the introitus. Magnetic resonance imaging revealed a fistulous communication between urethra and vagina, and TVS. Cystourethroscopy confirmed a proximal urethra-vaginal fistula. Urethroscopy guided puncture of the TVS was performed, tract dilated and a catheter was placed across it. Robotic assisted transvaginal approach was planned. Air docking of robot was performed. Traction on the catheter was given to identify the incised edges of the septum. Vaginal flaps were raised laterally, fistulous tract was excised. Proximal vagina mucosa was identified and vaginoplasty was performed. Result: Patient's postoperative recovery was uneventful. Urethral catheter was removed after 5 days. She had normal voiding and menstruation. Vaginoscopy performed at 1st month follow-up, revealed an adequate vaginal lumen. Vaginal moulds were advised for 6 weeks during the night, following which she resumed her sexual activity. She conceived 6 months post-surgery, and delivered a child by caesarean section. Conclusion: We successfully managed this case by resection of septum, neovagina creation and thereby achieving normal menstruation and conception. The advantages of robotic approach were magnification, precision and manoeuvrability in a limited space, avoiding a vaginal release incision.

Economic burden of obstetric fistula among patients in the National Obstetric Fistula Centre, Nigeria

Background: Obstetric fistula (OF) continues to be a major health problem in developing countries such as Nigeria. It is a communication between the vagina and bladder/rectum following prolonged obstructed labor that leads to urine/and fecal leakage per vaginam. There is a paucity of information on cost of accessing care by women with OF. Objective: The study was to evaluate the cost implications of accessing care and treatment among women with OF in the National Obstetric Fistula Centre, Ningi Bauchi, state. Materials and Methods: A prevalence-based cost-of-illness approach was employed in this study to estimate the cost of fistula treatment from the patients' perspective. Data on costs of health-care utilization of services rendered to the patients in the facility and indirect costs were estimated. The data were analyzed with the Statistical Package for the Social Sciences (SPSS V21). Results: A total of 75 women participated in the study. The total costs incurred by all the 75 patients amounted to Nigerian Naira (NGN) 8211640.00 (USD 26923.41). The average cost of accessing care for fistula per patient was NGN109488.50 (USD 358.98). Direct cost accounted for 5751740.00 (USD 18858.16), whereas the indirect cost was 2785600.00 (USD9133.11). There was a significant difference in cost of care between patients that were teenagers compared to those who were not (P = 0.04) and the type of treatment (P < 0.001). Conclusions: The cost of illness of OF is high in the studied area, and the patients are from the low socioeconomic background. Both the direct and indirect costs were high relative to the national minimum wage in Nigeria. The age of the patients and the type of treatment received by the patient accounted for the differences in cost of illness between the patients.

Transvaginal repair of neobladder vaginal fistula with martius flap

ABSTRACT Introduction: Neobladder vaginal fistula (NVF) is a known complication after cystectomy and orthotopic diversion in women, occurring in 3-5% of women. Possible risk factors for fistula formation include compromised tissue vascularity due to surgical dissection and/or radiotherapy, suture line proximity, local tissue recurrence, and injury to the vaginal wall during dissection. The surgical repair of a NVF can be challenging secondary to vaginal shortening, atrophy, local inflammation from chronic exposure to urinary leakage, and the proximity of the neobladder to the anterior vaginal wall. In this video, we present transvaginal repair of a NVF with Martius flap interposition. Materials and Methods: This is the case of a 47 year old woman with a history of radical cystectomy and creation of a Studer pouch secondary to bladder cancer two years prior who subsequently developed a NVF. Evaluation included an office cystoscopy which demonstrated a 3-4mm left-sided neobladder vaginal fistula at the level of the ileal-urethral anastomosis. No pelvic organ prolapse or evidence of bladder cancer recurrence was appreciated. Results: A vaginal approach for the NVF repair was performed with a Martius flap interposition. A water-tight closure was achieved without any intraoperative or immediate postoperative complications. The urethral Foley was removed at 2 weeks and by 4 weeks the patient did not report any urinary leakage. Conclusions: Neobladder vaginal fistula is a rare complication following cystectomy and orthotopic urinary diversion that can be repaired using a transvaginal approach. A Martius flap interposition is important to augment success of the repair. If a transvaginal approach fails a transabdominal approach or conversion to cutaneous diversion may be necessary.

Neovagina construction and continent cutaneous urinary reservoir using a previous orthotopic ileal neobladder

ABSTRACT Standard radical cystectomy (RC) in women involves removal of the distal ureters, bladder, proximal urethra, uterus, ovaries, and adjacent vagina. Furthermore, pelvic organ-preserving RC to treat selected women has become an accepted technique and may confer better postoperative sexual and urinary functions than standard RC, avoiding complications such as incontinence, prolapse, neobladder-vaginal fistula (NVF), and sexual dysfunction, without compromising oncological outcome. This article reports a different surgical approach: a patient who underwent a cutaneous continent reservoir and neovagina construction using a previous ileal orthotopic neobladder after RC. Patient presented no complications and she has no evidence of recurrent disease and is sexually active, with a satisfactory continent reservoir. This case is the first report of this procedure that was able to treat concomitant dyspareunia caused by short vagina and neobladder-vaginal fistula. In conclusion, standard radical cystectomy with no vaginal preservation can have a negative impact on quality of life. In the present case, we successfully treated neobladder fistula and short vagina by transforming a previous ileal orthotopic neobladder into two parts: a continent reservoir and a neovagina. However, to establish the best approach in such patients, more cases with long-term follow-up are needed.

Risk factors, ascribed causes and effects of obstetric fistula among women in northern Ghana: a case control studies

Background: Obstetric fistula is a demoralizing maternal morbidity. In Ghana, majority of the fistula occur in the northern sector. This study sought to identify the risk factors, ascribed causes and effect of obstetric fistula. Methods: A matched case control study was conducted from April to June 2013. The fistula patients were taken from the Fistula Centre in Tamale whiles the controls were from the Tamale Teaching hospital. Eligible cases were confirmed fistula patients admitted for fistula repair while controls were women who have delivered but without obstetric fistula. Cases and controls were matched on year, region and district of index delivery. Results: the following factors were associated with obstetric fistula; age below 20 years, total labour duration more than 24 hours, height 150 cm and below, still birth, operative delivery, residence in a rural area and lack of formal education. Divorce rate among cases over the period was 55.3% while that among the controls was 2.3%. About 20% of cases were likely to be currently using alcoholic beverages compared to 6% in controls (OR=5.3, 95% CI= 1.4 ­19.7). 40% of cases currently have no living child compared to 2% of controls. Majority of fistula patients blame lack of health facilities and an act of God as a cause of fistula. Conclusions: Majority of women who suffer obstetric fistula are young, poor, of short stature, illiterate and resident in remote areas. There is widespread lack of understanding of the causes of Obstetric fistula among women

¿Dosis menores de Radioterapia generan mayor riesgo de Fístulas Vaginales en pacientes con Cáncer de Cuello Uterino? / Do lower doses of Radiotherapy generate higher risk of Vaginal Fistulas in patients with Cervical Cancer?

Introducción: El tratamiento del cáncer de cuello uterino con radiaciones ionizantes y quimioterapia radiosensibilizadora puede tener como complicación la generación de fístulas vaginales. El objetivo del presente estudio fue establecer la prevalencia de fístulas vaginales en un grupo de pacientes que recibieron radioterapia convencional versus radioterapia 3D. Métodos: El presente estudio retrospectivo fue realizado en el Hospital de Solón Espinosa Ayala, SOLCA- Quito. Se registraron las pacientes que recibieron radioterapia externa ya sea en modalidad 2D o 3D más braquiterapia o refuerzo externo de dosis, con quimioterapia concurrente o sin esta última en el período de estudio Enero 2008 a Diciembre 2012. Para el análisis se compararon los tipos de radioterapia y se reporta Odds Ratio. Resultados: Se registraron 315 casos en el grupo de Radioterapia Convencional 2D (R2D) y 299 casos en el grupo de radioterapia Conformacional 3D (R3D). La prevalencia de fístulas en el grupo R2D fue de 10 casos (1.62 %) y en el grupo R3D fue de 8 casos (1.31 %), Odds ratio de 1.19 (IC95 % 0.46 a 3.06) P =0.71. De los 18 casos de fístulas, 9 casos (50 %) fueron con refuerzo externo, 6 casos (33 %) por braquiterapia y 3 casos (17 %) sin refuerzo. El refuerzo externo vs braquiterapia mostro un OR=4.77 IC 95 % (1.66 ­ 13.65) P =0.04. La dosis de radioterapia usada en el tratamiento de Braquiterapia fue de 87.5 ±2.5 Gy vs Refuerzo 68 ±2.5 Gy P <0.001. Conclusión: No existe diferencia entre la prevalencia en los grupos de Radioterapia convencional versus Radioterapia 3D. La radioterapia de refuerzo es un factor de riesgo para fístulas vaginales comparado con la braquiterapia, aun cuando la dosis de radioterapia fue menor en este grupo.

Introduction: The treatment of cervical cancer with ionizing radiation and radiosensitizing chemotherapy can have as a complication the generation of vaginal fistulas. The aim of the present study was to establish the prevalence of vaginal fistulas in a group of patients who received conventional radiotherapy versus 3D radiotherapy. Methods: The present retrospective study was carried out at the Solón Espinosa Ayala Hospital, SOLCA-Quito. The patients who received external radiotherapy either in 2D or 3D modality plus brachytherapy or external dose reinforcement, with concurrent chemotherapy or without the latter in the study period January 2008 to December 2012, were registered. For the analysis, radiotherapy types were compared and Odds Ratio is reported. Results: 315 cases were registered in the 2D Conventional Radiotherapy group (R2D) and 299 cases in the Conformacional 3D radiotherapy group (R3D). The prevalence of fistulas in the R2D group was 10 cases (1.62 %) and in the R3D group it was 8 cases (1.31%), Odds ratio 1.19 (95 % CI 0.46 to 3.06) P = 0.71. Of the 18 cases of fistulas, 9 cases (50 %) were externally reinforced, 6 cases (33 %) by brachytherapy and 3 cases (17%) without reinforcement. The external reinforcement vs. brachytherapy showed an OR = 4.77 IC 95 % (1.66 - 13.65) P = 0.04. The dose of radiotherapy used in the Brachytherapy treatment was 87.5 ± 2.5 Gy vs Reinforcement 68 ± 2.5 Gy, P <0.001. Conclusion: There is no difference between the prevalence in the groups of conventional radiotherapy versus 3D radiotherapy. Booster radiotherapy is a risk factor for vaginal fistulas compared to brachytherapy, even when the dose of radiotherapy was lower in this group.

Características e diagnóstico diferencial das doenças inflamatórias intestinais / Characteristics and differential diagnosis of inflammatory bowel diseases

As doenças inflamatórias intestinais (DIIs) compreendem, principalmente, a doença de Crohn (DC) e a retocolite ulcerativa (RU), ambas idiopáticas, porém relacionadas a uma resposta imunológica anormal à microbiota bacteriana da luz intestinal. Na RU a inflamação é difusa, restrita à mucosa e inespecífica, com comprometimento contínuo da parede, principalmente do reto, enquanto na DC as lesões são descontínuas, podem comprometer todas as camadas da parede e afetar qualquer parte do trato gastrointestinal. O quadro clínico é comum e compreende diarreia, febre e dores abdominais, podendo cursar também com manifestações extraintestinais. O diagnóstico é feito através dos dados clínicos, achados radiológicos e histológicos, sem haver, no entanto, nenhuma característica que isoladamente feche o diagnóstico de DII específica.

Inflammatory bowel diseases (IBDs) comprise mainly Crohn?s disease (CD) and ulcerative colitis (UC), both are idiopathic but believed to be related to an abnormal immune response to bacterial microbiota in the intestinal lumen. In RU diffuse inflammation is restricted to the mucosa and is nonspecific, with continued commitment that stars at rectum?s wall. In DC, the injuries are discontinuous, involve all layers of the intestinal wall and can affect any part of the gastrointestinal tract. The clinical picture of both is diarrhea, fever, abdominal pain, and may present with extraintestinal manifestations. The diagnosis is made by the junction of clinical, radiological and histological findings, without having, however, a feature alone that leads to a diagnosis of a specific IBD.

Fistules urogenitales: etude epidemiologique et clinique dans deux hopitaux generaux du district de la Tshopo; Kisangani-RDC

Introduction : Les fistules vesico-vaginales et recto-vaginales; veritable humiliation pour la femme; constituent un probleme majeur de Sante Publique de par sa forte prevalence principalement pour les pays pauvres (Afrique sub-saharienne et Asie du Sud-est). Dans cette etude; notre objectif a ete d'evaluer l'ampleur des fistules genito-urinaire et rectales a Kisangani et ses environs et d'en ressortir les causes ainsi que les caracteristiques des fistuleuses. Materiel et methodes : Une etude descriptive transversale retrospective basee sur l'analyse documentaire a ete menee dans les Hopitaux Generaux de Reference de Makiso-Kisangani (a Kisangani) et de Banalia (a Banalia) du 29 Aout au 08 Novembre 2013; apres sensibilisation des femmes par l'UNFPA. Resultats : La frequence des fistules genitourinaires et rectales a ete de 0;005 dans la ville de Kisangani et de 0;012 a Banalia soit une frequence globale de 0;008 soit 8 cas pour 1000 femmes survenant chez les femmes agees de 20 a 34 ans(45;61) avec des extremes d'age de 5 a 75 ans. 54;38 d'entr'elles etaient Mariees; 63;16 menageres; 80;71 de bas niveau d'instruction. Les femmes habitant les milieux peripheriques ou eloignes des centres hospitaliers ont ete les plus nombreuses soit 69;6 pour Kisangani et 67;6 pour Banalia. Les fistules souvent obstetricales (85;91) lors des accouchements a domiciles (50;8) etaient le plus souvent de type simple (57;89); a leur premiere reparation (52;63) et evoluant depuis de 2 mois a 55 ans. Les fistules traumatiques dues au viol a represente 1 ;75. La prise en charge a ete chirurgicale essentiellement basse dans 84;21 de cas avec un taux de succes de 82;46. Conclusion : La lutte contre les accouchements a domicile et les conflits armes et l'organisation des campagnes de prise en charge des fistuleuses constituent des strategies majeures de riposte contre les fistules vaginale

Placenta percreta with a vaginal fistula after successful management by uterine transverse fundal incision and subsequent cesarean hysterectomy

Placenta previa presents a highest risk to pregnancy, and placenta accreta is the most serious. Placenta accreta requires cesarean delivery and often results in massive obstetric hemorrhage and higher maternal morbidity. Challenges associated with cesarean delivery techniques may contribute to increased maternal blood loss and morbidity rates. Several recent obstetric studies reported the usefulness of transverse uterine fundal incision for managing placenta accreta. We present a case of placenta percreta that was treated by a transverse fundal incision. We successfully avoided cutting through the placenta and helped decrease maternal blood loss. After delivery, the patient underwent a cesarean hysterectomy. Postoperative day 48, she experienced watery discharge and was diagnosed with vaginal fistula. We present our case and review the literature.

audit of fistula in females of Multan

To find out the factors involved in fistula formation causing increased prevalence of fistula despite improved health facilities. This descriptive study was carried out in the Department of Obstetrics and Gynaecology, Nishtar Hospital, Multan from January 2006 to December 2007. A total of 66 patients were included in the study. Out of 20068 admitted patients 66 were found to be having fistula with frequency of 0.32%. Genito-urinary fistula were amongst 58 of 66 patients [80.3%] and recto-vaginal fistula in rest of 13 patients [19.7%]; frequency being 0.26% and 0.06% respectively. latrogenic causes were accountable for 47 fistula patients [71.2%] and obstructed labour was culprit for 19 of 66 patients [28.8%]. So, surgical trauma came out to be the major reason for fistula formation. Mean age was 34 years and mean parity 4. fistula size was 0.5-4 cm, while success rate for repair was 90.9% [6 failed out of 66]. In our study surgical trauma, responsible for major bulk of fistula patients, proved to be the main culprit for increasing prevalence of fistula in Multan

Fístula colovaginal en una anciana con enfermedad diverticular complicada / Colovaginal fistula in an elderly woman with complicated diverticular disease

Se presenta el caso clínico de una anciana con fístula colovaginal consecutiva a enfermedad diverticular complicada, intervenida quirúrgicamente por los autores para realizarle una fistulotomía seguida de sigmoidectomía del segmento dañado, con anastomosis terminoterminal y cierre del orificio de la cúpula vaginal, que garantizó una favorable evolución posoperatoria.

The clinical case of an elderly woman with colovaginal fistula after a complicated diverticular disease is reported, who was operated by the authors with the purpose of performing fistulotomy followed by sigmoidectomy of the damaged segment with termino-terminal anastomosis and closing of vaginal vault hole, warranting a favorable postoperative course.

Colecistectomía transvaginal asistida por minilaparoscopia: con uso de instrumental convencional: experiencia inicial / Transvaginal cholecystectomy assisted with minilaparoscopy: with conventional instruments: initial experience

Describir la técnica quirúrgica en la colecistectomía transvaginal sin cicatriz visible con el uso de instrumental laparoscópico convencional, en el Hospital “Dr. Domingo Luciani”. Caracas. Se presenta caso de paciente femenina de 52 años de edad, con litiasis vesicular sintomática a quien se le practica colecistectomía transvaginal. Se realizó colecistectomía transvaginal sin complicaciones intraoperatorias. No se administraron analgésicos orales ni parenterales, el alta hospitalaria se dio a las 12 horas del procedimiento. Evolución satisfactoria de la paciente con un seguimiento de 30 días. La cirugía asistida por minilaparoscopia puede considerarse intermedia entre el NOTES, y la cirugía laparoscópica. El siguiente caso demuestra la factibilidad y seguridad del procedimiento realizado por cirujanos generales con entrenamiento laparoscópico y con el uso de instrumental convencional.

Describe the surgical technique in the transvaginal cholecystectomy without a scar using conventional laparoscopic instruments, in the “Dr. Domingo Luciani” Hospital. Caracas. Presents female patient 52 years old, with sintomatic gallstones who is practicing transvaginal cholecystectomy. Was performed transvaginal cholecystectomy without intraoperative complications. No analgesics were administered oral or parenteral, was discharged at 12 hours of the procedure. There was a satisfactory progress of the patient with a follow upof 30 days. Minilaparoscopy assisted surgery can be considered intermediate between NOTES, and laparoscopic surgery. The following case demonstrates the feasibility and safety of the procedure performed by general surgeons with laparoscopic training and the use of conventional instruments.

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

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

Evaluation of urogenital fistulas by magnetic resonance urography / Avaliação das fístulas urogenitais por urorressonância magnética

OBJETIVO: As fístulas vesicovaginais e ureterovaginais são complicações incomuns, secundárias a doenças ou a cirurgias pélvicas. O sucesso terapêutico dessas fístulas depende de adequada avaliação pré-operatória para o diagnóstico e visualização do seu trajeto. Este trabalho tem o objetivo de demonstrar o potencial da urorressonância no diagnóstico das fístulas urogenitais e na visualização dos seus trajetos. MATERIAIS E MÉTODOS: Foram analisados, retrospectivamente, os prontuários médicos e as imagens radiológicas e de urorressonância magnética de sete pacientes do sexo feminino com diagnóstico de fístula urogenital. Para a urorressonância foram realizadas seqüências 3D-HASTE com saturação de gordura. RESULTADOS: Seis pacientes apresentavam fístula vesicovaginal e uma paciente tinha diagnóstico de fístula ureterovaginal à direita. Com a utilização da urorressonância magnética, foi possível demonstrar o trajeto da fístula em seis das sete pacientes (85,7 por cento), sem a necessidade de cateterização vesical ou da injeção de contraste. CONCLUSÃO: Este estudo demonstra o potencial e a aplicabilidade da urorressonância na avaliação dessas fístulas.

OBJECTIVE: Vesicovaginal and ureterovaginal fistulas are unusual complications secondary to pelvic surgery or pelvic diseases. The therapeutic success in these cases depends on an appropriate preoperative evaluation for diagnosis and visualization of the fistulous tract. The present study is aimed at demonstrating the potential of magnetic resonance urography for the diagnosis of vesicovaginal and ureterovaginal fistulas as well as for defining the fistulous tracts. MATERIALS AND METHODS: Seven female patients clinically diagnosed with vesicovaginal or ureterovaginal fistulas had their medical records, radiological and magnetic resonance images retrospectively reviewed. Magnetic resonance urography included 3D-HASTE sequences with fat saturation. RESULTS: Six patients presented vesicovaginal fistulas and, in one patient, a right-sided ureterovaginal fistula was diagnosed. Magnetic resonance urography allowed the demonstration of the fistulous tract in six (85.7 percent) of the seven patients evaluated in the present study, without the need of bladder catheterization or contrast injection. CONCLUSION: This study demonstrates both the potential and applicability of magnetic resonance urography in the evaluation of these types of fistulas.

Bilan retrospectif des fistules urogenitales obstetricales de 2001 a 2003 au Burkina Faso

Pour analyser les fistules urogenitales au Burkina Faso en vue de la mise en place d'un programme national; une etude transversale a visee quantitative et qualitative en janvier 2004 a ete realisee dans les formations sanitaires de reference. L'etude quantitative a analyse les donnees disponibles sur les annees 2001; 2002 et 2003. L'etude qualitative a permis d'interviewer des femmes vivant avec la fistule et les responsables des services de sante. Au cours des 3 ans sur environ 1 500 000 accouchements attendus dans le pays; 347 cas de fistules ont ete identifies soit un taux d'incidence de 23;1 pour 100 000 accouchements (IC a 9520;8 - 25;7). Les femmes avec fistules etaient jeunes et surtout sans emploi remunere avec des antecedents de dystocie a l'accouchement. Les fistules etaient le plus souvent recentes; de tailles petites ou moyennes et localisees au niveau de la cloison vesico-vaginale. Les resultats de la chirurgie etaientmarques par un taux d'echec de l'ordre de 17;5. Quatre femmes sur 12 interviewees ont declare avoir ete abandonnees par le conjoint. Sur 47 hopitaux visites; seulement 4 avaient un personnel qualifie pour la realisa- tion de la prise en charge quotidienne des fistules. Une organisation non gouvernementale aidait les patientes pour l'obtention de soins. Un atelier national de validation a permis de faire des propositions pour l'amelioration de la situation. Les resultats montrent la necessite de la mise en place d'un programme national qui devrait etre evalue pour voir les acquis obtenus apres cette etude

Lesiones ureterales en la cirugía ginecológica / Ureteral lesions in gynecological surgery

Se presentan 58 pacientes entre 24 y 65 años, con una edad media de 44,5 años, las que sufrieron lesiones ureterales, en cirugías ginecológicas. Presentaron fístulas ureterovaginales 50 pacientes, lo que significó el 86,2 por ciento. Hubo dos pacientes con fístulas bilaterales, 4 ligaduras de uréteres y 2 fístulas a cavidad. La etiología predominante fue histerectomía simple en casi 69 por ciento e histerectomía ampliada en 24 por ciento. No hubo por causas obstétricas. La soluciones se implementaron inmediatamente de hecho el diagnóstico y sin nefrostomías previas, salvo excepciones, en pacientes en mal estado general, derivadas de otros centros. Se realizó 28 ureteroneocistostomías con técnica de Leadbetter-Politano. A 24 pacientes se les hizo colgajo vesical con técnica de Boari Cassatti y además en un caso fue bilateral. Las otras soluciones fueron cateterismo, anastomosis término terminal y uretero anastomosis con conducto ileal en una paciente irradiada y con cistitis actínica. Los resultados fueron buenos con todas las medidas usadas, excepto la exclusión de un riñón en la Boari Cassatti bilateral y 2 leves ureterectasias, sin síntomas, al año de control, también con la técnica de reimplante con colgajo vesical.

Management of ureterovaginal fistula

To evaluate the outcome of surgical management of uretero-vaginal fistula [UVF]. It was a descriptive study. Setting and Duration of study: The study was conducted at the Department of Urology, Chandka Medical College teaching Hospital and Almas Kidney and Lithotripsy Centre Larkana from February 1995 to November 2006. The criterion for selection of the patients and screening workup included complete history, clinical examination and investigations like complete blood count and biochemistry, ultrasound, intravenous urography and retrograde ureteric brash or ureterogram were performed to confirm the level of fistula and also to assess the function of affected kidney. The neo-ureterocystostomy was made with modified Lich Gregoir, Boari Ockeblade flap, Psoas hitch and endoscopic methods as deemed necessary. Our study included 20 cases. The ages of the patients ranged from 22 year to 45 years [average 36 years]. We used modified Lich George method, Boari Ockeblade flap, Psoas hitch method and internal stenting in 09[45%], 05[25%], 04[20%] and 02[10%] of cases respectively. The ureteric catheter or DJ stent were kept postoperatively in 06[30%] and 04[20%] cases respectively. Although all patients had no leakage after surgery; but 06[30%] cases developed transient urgency, frequency, dysuria and persistent pain. These were resolved with conservative treatment. The complications occurred in 4[20%] cases which were wound infection in 01[05%], recurrent urinary tract infection in 02[10%] cases and 01[5%] developed a small bladder capacity. There was no significant difference in outcome of different techniques, rather choice depends upon individual case and preference of surgeon. We conclude that modified Lich surgical procedure is simple, successful and quick method of treatment for repairing the cases of uretero-vaginal fistulae. We suggest bilateral ureteric catheterizations prior to difficult female pelvic and gynecological surgery to prevent such disaster