Doctor! Will I be dry? Factors determining recurrence after vesicovaginal fistula repair.

OBJECTIVE: To evaluate various prognostic factors which determine outcome after surgical repair of vesicovaginal fistula. METHODS: The retrospective study was conducted at Koohi Goth Fistula Hospital, Karachi, and comprised data related to patients having undergone vesicovaginal fistula repair from January 2007 to June 2012. Multivariate analysis of the record was done using SPSS 19 software determining odds ratio with 95% confidence interval. RESULTS: Record of 640 patients were analysed with an overall success in 558(87.2%) cases. Multivariate analysis determined that the recurrence of vesicovaginal fistula was significantly related to multiplicity (9-fold recurrence risk), pre-operative size (10-fold recurrence risk for fistula >2cm compared to <1cm), secondary repair (5-fold risk) and duration of the fistula (3-fold risk).Interposition of flap and delayed reconstruction (between 6 weeks and 1 year) was related to successful surgical outcome. Age, parity, aetiology, route of repair and location of fistula were not significant (p>0.05 each) prognostic factors for recurrence. CONCLUSIONS: Successful surgical repair of vesicovaginal fistula require careful evaluation of various factors, including number, size, previous attempts to surgical repair and duration of fistula.

Role of alpha-1 blocker in expulsion of stone fragments after extracorporeal shock wave lithotripsy for renal stones.

BACKGROUND: Renal stone disease is a significant and worldwide health problem. Recent advances in stone management have allowed kidney stones to be treated using extracorporeal shock wave lithotripsy (ESWL), uretero-renoscopy (URS), and percutaneous nephrostolithotomy (PCNL). Recently, medical expulsion therapy (MET) has been investigated as a supplement to observation in an effort to improve spontaneous stone passage rates. PATIENTS AND METHODS: This study was a randomized, controlled, prospective study to determine whether the administration of Alpha-1-adrenergic receptor antagonists as an adjunctive medical therapy, increases the efficacy of ESWL to treat renal stones. Sixty patients with renal stones of 0.5-1.5 Cm in size (average size 1.2 Cm) were included in this study underwent ESWL followed by administration of Alpha-1-adrenergic receptor antagonists at department of Urology Liaquat National Hospital Karachi from Feb 2008 to Sept 2008. This was a comparative study and patients were divided into two groups. In group A patients received conventional treatment Diclofenac sodium, Anti Spasmodic (Drotverine HCl) as required and Proton Pump inhibitor (Omeprazole 20 mg) once daily after shock wave lithotripsy. In group B patients received alpha-1 blocker, Alfuzosin HCI 5 mg twice daily in addition to conventional treatment. All patients were instructed to drink a minimum of 2 litres water daily. Ultrasound guided Dornier Alpha Impact Lithotripter was utilised for shock wave lithotripsy. RESULTS: Of the 60 patients, 76.7% of those receiving Alfuzosin and 46.7% of controls had achieved clinical success at 1 month (p = 0.01). The mean cumulative diclofenac dose was 485 mg per patient in the Alfuzosin group and 768 mg per patient in the control group (p = 0.002). This difference was statistically significant. CONCLUSION: Alfuzosin therapy as an adjunctive medical therapy after ESWL is more effective than lithotripsy alone for the treatment of patients with large renal stones and is equally safe. It increases the expulsion rates of stones, decreases time to expulsion, and decreases need for analgesia during stone passage.