Surgical Outcomes of Genitourinary Fistulae: An analysis of 26 cases

By
Dr.MohsinShakil,Dr.Riaz Ahmed, Dr.ShafaqHanif

Abstract:

Background:Genitourinary Fistulae are known complications of prolonged labour and pelvic surgery.
The cornerstone of treatment is surgery. Successful outcomes hinge on detailed evaluation of the
site of the fistula, appropriate timing and technique of surgery.Limited hospital resources naturally
affect positive outcomes. This study examines cases managed at minimal facility hospitals of Azad
Jammu and Kashmiri.e., DHQ Teaching Hospital,Mirpur and AIMS Hospital Muzaffarabad, from 2001
to 2015.

Objectives: To study the presentation, aetiology, evaluation of different treatment options and
treatment related complications.

Methods: All patients reporting with urinary incontinence due to genitourinary fistulae were
enlisted according to selection criteria. Patients were investigated to determine the cause of fistula.
Evaluation of the site and size of the fistula was done by clinical examination. IVU, EUA and
urethrocystoscopy were used to develop treatment plan; treatment and follow up to assess and
document the progress including treatment result, complications and quality of life.

Results:26 patients wereincluded in thestudy. Iatrogenic injury was the leading cause with 18 cases
of post-hysterectomy fistula, 4 cases of post C-section and 4 cases were due to prolonged
labour.There were 22 Vesico Vaginal (VVF) fistulae and 4 cases of Uretero Vaginal fistulae.
Cystoscopic size of less than 0.5 cm was noted in 4 cases, 13 cases had fistulae greater than 0.5 cm
while 9 cases were not evaluated. 9 cases of UVF and 5 VVF cases were not evaluated
cystoscopically. Co-morbidities were present in 5 patients, 3 hypertensive and 2 diabetics were
included in the study.5 fistuale were treated conservatively, transvesical approach was used in 3
patients. 4 patients had ureteric re-implanation. 13 patients had a repair with omental interposition.
Complications observed included failure to heal in 2 patients, 6 patients developed wound sepsis
and 1 patient required re-exploration for a retained gauze.

Conclusion:

Majority of the genitourinary fistulaein this study were of iatrogenic aetiology. Duration and the size
of fistula were the determinant of the chosen treatment method.

Keywords: Vesicovaginal fistula, Surgical repair, Complications of repair

Introduction:

Genitourinary fistulae have been a source of untold misery for women since ancient times.
Prolonged labour is the primary cause of vesicovaginal fistulae in underdeveloped countries (1,2).
Developed countries have gynaecologic surgery as the major contributor (3). Whatever the cause,
the effects of uncontrolled passage of urine are devastating to the sufferer. Women not only find
themselves having to manage a constantly wet body but also face social rejection (4). The magnitude
of the problem worldwide is not fully known but it is estimated to be more than 2 million with
50,000 to 100,000 new casesevery year (5). Treatment options include repair by the vaginal or
abdominal route, electocautery, fibrin glue,electrocautery and endoscopic approach, laparoscopic
repair, interposition grafts or flaps (6).Surgical repair has success rates of up to 95% while open
surgical repair is the gold standard for VVF (7,8). There are few studies on factors affecting outcome
of surgical repair. The current study reviews factors influencing surgical repair.

Patients and Methods:

This retrospective study was carried out on patients presenting at District Headquarters Hospital
Mirpur and AbbassInstitute of Medical Sciences, Muzzafarabad. Patients undergoing surgery for VVF
from 2001 to 2015 were included in this study.

Patients who had been previously operated were also included inthe study. A detailed history was
taken and the patient examined. Routine baseline investigations were ordered. An IVU was ordered
to evaluate the fistula site. All patients underwent an EUA. Cystoscopic evaluation was performed to
determine size and position of fistula. A decision to operate via the intra-abdominal or vaginal route
was made.

Vaginal repairs were carried out in the lithotomy position. Standard dissection and repair technique
were employed in vaginal repairs. Patients undergoing abdominal repair were operated under spinal
or general anaesthsia.

Refrences:

1: Raut V, Bhattacharya M. Vesical fistulae -- an experience from a developing country. J Postgrad

Med. 1993;39:20-21 Abstract

2: Sarker B, Ghoshroy S, Saha SK, Mukherjee A, Ganguly RP, Saha S. A study of genitourinary fistulae
in North Bengal. J ObstetGynecol Ind. 2001;51:165-169

3: Hilton P. Surgical fistulae. In: Staskin D, Cardozo L. Textbook of Female Urology and
Urogynecology. Oxford, UK: Isis Medical Media; 2001: 691-709

4: Cottingham J, Royston E. Obstetric fistula: A review of available information Geneva: World Health
Organization;1991.

5:United Nations Population Fund. The Second Meeting of the Working Group for the Prevention
and Treatment of Obstetric Fistula. October 30-November 1, 2002; Addis Ababa, Ethiopia

6: Bose CK, Basu A, Kanjilal S, Basu S. Giant SupratrigonalVesicocervicovaginal Report Fistula -- A

Case Report, Medscape General Medicine. 2005;7(4):74
7: McFadden E, Sarah JT, Bocking A, Rachel F, Mabeya H.Retrospective review of predisposing
factors and surgicaloutcomes in obstetric fistula patients at a single teaching hospitalinWestern
Kenya. J ObstetGynaecol Can. 2011; 33: 30-5.

8: Javed A, Abdullah A, Faruqui N, Shah SS, Mehdi B, Pirzada AJ: Doctor!Will I be dry? Factors
determining recurrence after vesicovaginal fistularepair. JPMA 65: 954; 2015