Genital tract fistula: a case series from a tertiary centre in South Africa.

INTRODUCTION AND HYPOTHESIS: We describe the demographic profile, aetiology, management and surgical outcomes in women with genital tract fistula presenting to a tertiary urogynaecology unit. METHODS: This retrospective audit included 87 patients managed in our unit between 2008 and 2015. Frequencies and means with standard deviations are presented for categorical and continuous data. Continuous dependent variables are categorized as above or below the median for bivariate analyses performed using the chi-squared test (α = 0.05). RESULTS: The mean age of the women was 34.7 years, 64.4% were Black African, 70.2% were multiparous, 49.4% were married, 82.8% were employed, and 21.8% were HIV-infected, with 47.4% on antiretroviral treatment. Vesicovaginal (47.1%) and rectovaginal (41.4%) fistula were the most frequent injuries. The majority of the injuries (67.8%) were obstetric, with 26.4% occurring during caesarean delivery. Repair had been attempted previously in 43.7% of patients. In 63.2% of the repairs the approach was vaginal and in 35.6% abdominal. Interposition grafts were used in 23% of repairs. In 85.1% of patients the initial repair at our centre was successful. Patients with multiple repairs were more likely to have complications (p = 0.03). HIV infection was not significantly associated with complications. CONCLUSIONS: A high rate of successful repair was found, with previous unsuccessful repairs associated with poorer outcomes, highlighting the need for centralized management.

The surgical management of H-type rectovestibular fistula: a case report and brief review of the literature.

H-type rectovestibular fistula is a rare anorectal malformation with poor consensus on an optimal operative management. We report our management of a recurrent fistula and review previously described operative techniques. Full excision of the tract without apposing suture lines or perineal body dissection simplifies the repair while minimizing complications and recurrence risk.

[Perianal fistulas in Crohn's disease: treatment results at an interdisciplinary unit]. / Perianale Crohn-Fisteln : Ergebnisse der Behandlung in einer interdisziplinären Sprechstunde.

BACKGROUND: Approximately one third of patients with Crohn's disease develop perianal fistulas. This study was conducted to determinate outcome predictors in patients treated at a specialized multidisciplinary unit. PATIENTS AND METHODS: Between May 2005 and May 2008, all patients with perianal Crohn's fistulas were treated by the same surgeon and a gastroenterologist specialized in managing patients with Crohn's disease. Deep fistulas were treated by fistulotomy. For high fistulas, a noncutting seton was placed followed by maintenance treatment with azathioprine and/or infliximab. "Optimal outcome" was recorded when (a) there was no need for diverting stoma, (b) complete healing was achieved by fistulotomy, or (c) fistula symptoms were under control, i.e. there was no need for treatment extension during follow-up. RESULTS: Thirty-four male and 32 female patients underwent 100 surgical interventions. The most frequent types of fistula were high trans-sphincteric (62%) and high intersphincteric (15%). Eleven of the 32 females presented with rectovaginal fistulae. At the study end, complete healing was observed in 12 patients and 32 had good control of fistula symptoms. Seven required proctectomy, fistula symptoms were not under control in 12, and three required diverting stoma. Altogether 44 patients (67%) achieved optimal outcome. The following factors were predictors of nonoptimal outcome by multivariate analysis: presence of Crohn's colitis (P=0.01), age at the onset of Crohn's disease <20 years (P=0.02), and types of fistula not suitable for fistulotomy (P=0.05). CONCLUSIONS: The multidisciplinary approach at specialized units will lead to successful outcome in >60% of patients with Crohn's perianal fistulas. The presence of Crohn's colitis, young age at disease onset, and presence of high fistulas are indicators of poor prognosis.

Complex obstetric fistulas.

Obstetric fistulas are rarely simple. Most patients in sub-Saharan Africa and parts of Asia are carriers of complex fistulas or complicated fistulas requiring expert skills for evaluation and management. A fistula is predictably complex when it is greater than 4 cm and involves the continence mechanism (the urethra is partially absent, the bladder capacity is reduced, or both); is associated with moderately severe scarring of the trigone and urethrovesical junction; and/or has multiple openings. A fistula is even more complicated when it is more than 6 cm in its largest dimension, particularly when it is associated with severe scarring and the absence of the urethra, and/or when it is combined with a recto-vaginal fistula. The present article reviews the evaluation methods and main surgical techniques used in the management of complex fistulas. The severity of the neurovascular alterations associated with these lesions, as well as inescapable limitations in staff, health facilities, and supplies, make their optimal management very challenging.

Espectro clínico de la fístula rectovaginal: análisis de 38 pacientes / Clinical phantom of rectovaginal fistula: analysis of 38 patients

Se revisa en forma retrospectiva los resultados del tratamiento quirúrgico de 38 pacientes intervenidas en forma consecutiva por una fístula rectovaginal (FRV) en un período de 12 años. Se define como simple una FRV baja, menor de 2.5 cm y de origen traumático o infeccioso y compleja una FRV alta, mayor de 2.5 cm y de origen neoplásico, actínico o inflamatorio. La etiología más común fue la neoplásica en el 39 por ciento (15/38) de los casos: debido a persistencia tumoral de un cáncer cervicouterino (Ca CU) tratado con radioterapia y/o cirugía en 10 pacientes, cáncer de recto en 3 y cáncer de ano en 2. En 2 pacientes con cáncer de recto se efectuó cirugía radical con conservación de esfínteres en una de ellas y exenteración posterior en la otra con una sobrevida de 70 meses libre de enfermedad y fallecimiento a los 60 meses respectivamente. En los 2 casos de cáncer anal se realizó una exenteración posterior por persistencia tumoral luego de recibir radioquimioterapia según el esquema de Nigro. La FRV actínica se presentó en el 34 por ciento (13/38) de los casos, 12 de las cuales fueron sometidas a una operación de Parks (anastomosis coloanal con mucosectomía rectal) con éxito en todos los casos, quedando un 40 por ciento de ellas con algún disturbio de la continencia. 4 pacientes (11 por ciento) corresponden a una complicación quirúrgica luego de cirigía pélvica, 3 de las cuales cierran sólo mediante una desfuncionalización. Las FRV de origen obstetrico (16 por ciento) se corrigieron mediante una reparación local generalmente mediante un colgajo rectal grueso y reparación esfinteriana simultánea con resultados satisfactorios . En los casos de persistencia tumoral por Ca CU se logró una desfuncionalización adecuada en la mayoría de los casos mediante una sigmoidostomía en asa con una sobrevida de hasta 26 meses. En esta serie, el 84 por ciento de los casos corresponden a FRV complejas y el 50 por ciento de ellas fueron sometidas a una reparación de cirugía radical por vía abdominal sin necesidad de una ostomía definitiva. Las series de FRV son muy heterogéneas probablemente por patrones de referencia distintos, lo que hace difícil hacer un análisis comparativo

Rectovaginal fistulas.

The treatment of rectovaginal fistulas is controversial. The choice of the technique used for repair depends on many factors. Therefore the classification, etiology and treatment are discussed, in order to help decision making in the management of this troublesome disease.

Five-layer repair of rectovaginal fistula using a vaginal approach. A case report.

We present a case of a rectovaginal fistula which was revealed as an incidental finding at the time of posterior colporrhaphy. We describe a previously unreported 5-layer repair through a vaginal approach in preference to the more frequently reported approaches of endoanal flap or conversion to a fourth degree tear. The diagnosis and management of rectovaginal fistulas is discussed.

H-type rectovaginal fistula associated with the Currarino triad.

We describe a case of H-type rectovaginal fistula associated with the Currarino triad (anorectal stenosis, sacral defect, presacral mass). Presenting symptoms included passage of feces per vaginam, signs of intestinal subocclusion without perianal inflammation, left leg paresis and foul-smelling urine. An anterior sacral meningocele was repaired at the age of three months. At age 18 months the fistula was excised through a perineal approach after creation of a protective colostomy. Diagnostic and therapeutic aspects of this malformation are discussed.

The Noble-Mengert-Fish operation-revisited: a composite approach for persistent rectovaginal fistulas and complex perineal defects.

OBJECTIVE: Our aims were to evaluate the full-thickness anterior rectal wall advancement flap in the treatment of primary and recurrent or persistent rectovaginal fistulas, evaluate the surgical exposure for composite repair of site-specific perineal defects, and categorize clinical manifestations of site-specific perineal defects caused by obstetric injury. STUDY DESIGN: This is a prospective study of all patients with fecal incontinence from rectovaginal septal defects and complex perineal obstetric injuries treated by the Noble-Mengert-Fish operation. RESULTS: Thirty-four patients were classified into groups on the basis of site-specific perineal defects. Anatomic success was 94.2%. Functional success was excellent in 76.5%, good in 14.7%, fair in 5.9%, and poor in 2.9%. CONCLUSION: The Noble-Mengert-Fish operation is effective for primary and recurrent or persistent rectovaginal fistulas. The circumanal surgical exposure permits concomitant repair of all perineal defects.

Laparoscopic treatment of type IV rectovaginal fistula.

Fistulas between the anorectum and vagina may arise from several causes. Treatment depends on their etiology and location, as well as the surgeon's experience. Operative laparoscopy was successful in two women with type IV (mid)rectovaginal fistula in whom previous surgical attempts failed. Our experience suggests that mid and high rectovaginal fistulas can be effectively treated by laparoscopy in the hands of experienced endoscopic surgeons.

Repair of congenital H-type vestibuloanorectal fistula through the posterior midsagittal approach: case report.

The posterior midsagittal approach was successfully used for the repair of congenital H-type vestibuloanorectal fistula in a patient 1.5 months old. Technical details of the operation which consisted of two main parts are described. Identification and dissection of the fistulous tract started following midsagittal division of the sphincters and the posterior half of the rectum with the patient in a knee-chest position. The dissected part of the fistulous tract was inverted per vagina. Completion of dissection and excision of the fistulous tract were accomplished with the patient in the lithotomy position. The main advantage of the procedure was the ability to completely excise the fistula under direct vision.

Diagnóstico y tratamiento de las fístulas rectovaginales / Diagnosis and treatment of the recto-vaginal fistulae

Se revisa el tema de las fístulas rectovaginales, clasificándolas en altas y bajas y analizando sus causas entre las que se destacan las traumáticas de origen obstétrico, cuya frecuencia ha disminuido en las últimas décadas (atención médica del parto y aumento de cesáreas). En cambio, las causas neoplásica y actínica han aumentado proporcionalmente. Se consideran algunos aspectos clínicos y diagnósticos orientados a una clasificación de complejidad que permita elegir la técnica de reparación quirúrgica más adecuada a cada caso. Se mencionan las diversas alternativas quirúrgicas existentes, haciendo hincapié en la importancia de la preparación preoperatoria

Fístula rectovaginal: clasificación y manejo / Rectovaginal fistula: classification and management

Se presenta la experiencia en el tratamiento quirúrgico de la fístula rectovaginal (FRV) en el período compredido entre enero de 1980 y julio de 1992. La serie está constituida por 15 mujeres cuya edad promedio fue de 49 años, con un margen entre 16 y 82 años. El tiempo de evolución, desde la aparición de los síntomas de ístula hasta la primera consulta, fue de 30 días para el menor hasta 17 años para el más prolongado. La causa más frecuente fue la traumática (43,7 por ciento), correspondiendo el resto a enfermedades inflamatorias, congénitas y un caso de origen desconocido. El 56,2 por ciento correspondió a fístulas bajas y el 68,7 por ciento fue de pequeño tamaño. El enema baritado se practicó en el 50 por ciento de la serie. Se realizó reparación de Parks y, en 4 pacientes con fístulas de etiología actínica se realizó colostomía derivativa. La evolución fue buena en todos los casos en que se trató la fístula, no comprobándose en ninguno recidiva en controles alejados hasta 8 años. No hubo mortalidad en la serie

[Rectovaginal fistulas in adults]. / Fistules recto-vaginales de l'adulte.

Recto-vaginal fistulas have multiple causes and a wide range of clinical and anatomical features. Simple fistulas, defined by a low situation, a traumatic origin, and a small size are accessible to simple means of cure. They can be operated from a vaginal approach, with conversion into a third degree perineal tear followed by repair of the perineal body, and the anal canal; they can be managed from a transanal approach, using endorectal flap advancement technique. Complex fistulas, defined by the etiology (IBD, radiation enteritis, cancer, postoperative), a high situation, or a large size, require larger and more sophisticated operations such as a combined abdomino-perineal approach or a muscle flap technique. Among the numerous techniques described for the cure of recto-vaginal fistulas, the authors emphasize those currently used by the most experienced teams of colo-rectal or gynecological surgeons.

[Magnetic resonance imaging in perianal Crohn's disease]. / Kernspintomographie bei perianalem Morbus Crohn.

Magnetic resonance imaging (MRI) was undertaken in a prospective study of 34 consecutive patients (21 women, 13 men; median age 31 [18-53] years) suspected of having active perianal Crohn's disease. The results of the investigation were compared with those obtained by independent observers on proctological and intraoperative examination (n = 31). A total of 58 fistulas and 21 abscesses were noted intraoperatively, 47 fistulas and all 21 abscesses by MRI, and 40 fistulas and 13 abscesses proctologically. The proctological examination proved to be more sensitive in demonstrating short subcutaneous or anovaginal fistulas (three of four subcutaneous and two of five anovaginal fistulas were not shown by MRI). Intersphincteric, ischiorectal and supralevator involvement was shown better by MRI. These results indicate that in perianal Crohn's disease MRI is a useful addition to proctological examination.

Fístulas rectovaginales / Rectovaginal fistulas

Motiva este trabajo las escasas comunicaciones encontradas en la bibliografía nacional sobre un tema de discutida táctica terapéutica.Se presenta una clasificación etiológica de las fístulas rectovaginales. Se analizan 18 casos operados donde predominan las de origen traumático (50%). En la mayoría de los casos se efectuó la colpoperineografia como operación de elección con resultado exitoso en el 90,9%. La morbilidad fue de 27,7%y la mortalidad global del 0%. Se describe la técnica preferida por los autores y se mencionan otras técnicas propuestas. En las fístulas benignas, la persistencia de la actividad actínica y de otros procesos inflamatorios invalidaron los procedimientos plásticos locales, obligando a realizar una colostomía y diferir el cierre de la fístula. Las fístulas de origen neoplásico se trataron con criterio oncológico resectivo, a no ser que medien contraindicaciones, en cuyo caso efectuamos colostomías derivativas

Fístulas rectovaginales / Rectovaginal fistulas

Motiva este trabajo las escasas comunicaciones encontradas en la bibliografía nacional sobre un tema de discutida táctica terapéutica.Se presenta una clasificación etiológica de las fístulas rectovaginales. Se analizan 18 casos operados donde predominan las de origen traumático (50%). En la mayoría de los casos se efectuó la colpoperineografia como operación de elección con resultado exitoso en el 90,9%. La morbilidad fue de 27,7%y la mortalidad global del 0%. Se describe la técnica preferida por los autores y se mencionan otras técnicas propuestas. En las fístulas benignas, la persistencia de la actividad actínica y de otros procesos inflamatorios invalidaron los procedimientos plásticos locales, obligando a realizar una colostomía y diferir el cierre de la fístula. Las fístulas de origen neoplásico se trataron con criterio oncológico resectivo, a no ser que medien contraindicaciones, en cuyo caso efectuamos colostomías derivativas