changing scenario of female fistula

Dr. Amita Jain Consultant UrogynaecologistMedanta Institute of Kidney & Urology Medanta -The MedicityGurgaon, Haryana -122001, INDIA

Female Genital Fistula(FGF) is a socially debilitating problem with important medicolegal implications.

In the developing nations, nearly 5 million women annually suffer severe morbidity with obstetric fistulae being the foremost on the list. (WHO 1991)

Around > 2 million women living with fistula, with approximately 50,000 to 100,000 cases occurring annually, mostly in Africa, Asia, and the Arab world. Stanton C et al, Int J Gynaecol Obstet 2007, 99:S4-S9.

The unmet need for fistula repair is estimated to be as high as 99%. Ahmed S et al, Int J Gynaecol Obstet 2007, 99:S1-S3.

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• 74 years• C/O Involuntary leakage of urine with coughing, sneezing & change in posture • Co - morbidities

Old age (Postmenopausal)Past multiple surgeries - Wertheim’s hysterectomy followed by Radiotherapy – carcinoma cervix 1986 - Laparotomy - intestinal obstruction 1990 - Repeated urethral dilatation - retention of urine 2008 - Abdominal Sacrocolpopexy - vaginal vault prolapse March 2010HypertensionHypothyroidismOsteoarthritis DR AMITA JAIN

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Aa+2.0

Ba+1.0

C-5

Gh7

Pb 3.5

TVL7

Ap-3

Bp-3

D0

POPQ

STAGE III CYSTOCELE

Urethral Hypermobility +Stress leak +

General & Neurological Examination: normal



SENSATION Bladder filling

Pdet

First Sensation 110 cc 10 cmH2O

Strong Desire 280 cc 11 cmH2O

Max Cyst Capacity

280 cc 15 cmH2O

Bladder filling Pabd Pdet

1 156 cc 13 cmH2O 10 cmH2O

2 248 cc 10 cmH2O 7 cmH2O

3 276 cc 10 cmH2O 11 cmH2O

SENSATION RESULTS LEAK POINT PRESSURES



Total bladder capacity 281cc

Peak flow rate 7ml/s

Pdet at peak flow 15 cmH2O

Average flow rate 3 ml/s

Residual Urine 0 ml

Opening Pdet 9 cmH2O



Braided Suture Piercingbladder wall



Blind pit at Ant. Vaginal wall ( ? healed fistula opening)

Negative Three Swab Test

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prohibited

Suture Removal

3 weeks

Cystocele Repair&

Midurethral Sling Placement



Peak Flow Rate

15 ml/s

Average Flow Rate

7 ml/s

Voided Volume

267 ml

Voided Time

24 s

Flow Time

24 s

Post Void Residual

150 cc



• Able to hold & void herself

• Fully continent ( Pads not required)

• Clean Intermittent Self Catheterisation (3 times a day)



• 54 years• Recurrent UTI • On & off pinkish foul smelling vaginal discharge

• Past Surgical History - Lap Hysterectomy 2 yrs back (Menorrhagia cause ? fibroid uterus) - Cholecystectomy 20 yrs back - Incisional hernia repair 16 yrs back

• Co-morbidities - Hypertension 3-4 months - Diabetes Mellitus 3-4 months

1.5 yrs



Per speculum:

- Black colored material at the apex of vaginal vault

- Foul smelling black to brown dirty discharge soiling the walls of vaginal vault



Impression:

Low Rectovaginal fistula



A black colored ? Suture at the apex of vaginal vault



On removal – black brown colored infected material drained.

Communicating path traced through a probe.



Abdominal Repair



Vaginal opening traced



No communicating path into sigmoid colon or rectum



Edges of Vaginal opening freshened up & closed



No foul smell discharge

Not a single episode of UTI



• 54 years• Pain in left loin – 1 month• Continuous urinary leakage – 1 month• H/O present illness - D & C for menorrhagia 4 months back. - f/b Vaginal hysterectomy with left oophorectomy after one month - C/O continuous significant vaginal bleeding in postop - re-evaluated after 2 weeks & some stiches were put through vaginal route - developed high grade fever after 2 days f/b urinary incontinence • Past H/O - Tubal ligation 30 yrs back• No Co - morbidities



Findings: Moderate Left sided Hydroureteronephrosis with dilatation of left ureter in its entire extent with abrupt cut off at distal end, which appears to merge with vaginal stump




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Abrupt cut off at 2 cm distance from left ureteric

orifice



Post Hysterectomy Iatrogenic Left Ureteric

Trauma with Vesico-vaginal fistula



Left Percutaneous Nephrostomy 4 weeks

Cystoscopy + O’Conner’s VVF Repair* + Left Ureteric Reimplantation (stented)

[ discharged on POD 5 with SPC in situ]

“The best approach for complex fistulas is transabdominal using the O'Connors bivalve technique.” O'Connor VJ et al. Suprapubic closure of vesicovaginal fistula. J Urol. 1973;109:51–4.



At 2 Weeks

Findings:

•Well maintained bladder outline

•No leak

DJ Stent removal done



Normal KFT

Normal findings of DTPA Scan and USG Whole Abdomen



• 31 years• Continuous urinary leakage per vaginum for 2 year

• Past Surgical History - MTP with tubal ligation (continous leakage in postop) - Hysterectomy with reimplantation of right ureter - Cystoscopy (0.5 cm sized fistula inferomedial to left ureteric orifice, right ureteric orifice not seen) + LRGP + LDJS - 2 failed attempts of vaginal repair of VVF - LRGP + Left Laser endoureterotomy + Laser fulgration of VVF

• No Co-morbidities



USG KUB: B/L Chronic Renal Parenchymal Disease

KFT: Bld Urea 93 mg/dl S. Creatinine 4.76 mg/dl

Hb 8 g/dl

Urine C/S: E Coli >10 cfu/ml



Impression: B/L contracted Kidneys, Re-implantation of right ureter ? into bowel (dilated 8 mm), DJ Stent on left side, 4 mm sized focal defect in posterior wall of UB communcating to vaginal stump (fluid in endovaginal canal)



Renal Transplantation after Fistula Repair



• 52 years• Continuous urinary leakage per vaginum for 2 year• Large bed sore over sacrum• Past History - Received multiple courses of chemoradiation for Ca Cervix (grade III) diagnosed in 1999 - Multiple cystoscopies for gross hematuria in 2009 - Cystoscopic fulgration & angioembolisation in Aug 2009 - Admitted in ICU for septicemia - on catheter removal at discharge noticed continuous leakage of urine • No Co-morbidities



Left small sized kidney

Right normal sized kidney

No Ureterovaginal fistula/ no ureteric stricture



Frozen Pelvis

Large Vesico-vaginal fistula



Small capacity bladder

Fluffy tissue inside

Patchy inflammation

Supratrigonal large irregular hole at

left side of posterior wall



Urinary Diversion ( Transverse Colonic Urinary Conduit)



POD3 Myelosuppresion with pancytopenic sepsis B/L Parotitis with right parotid abscess Respiratory failure with Metabolic Acidosis Acute Renal Failure with Dyselectrolytemia Liver Dysfunction with Hypoalbuminemia Paralytic ileusPOD 11 Anastomotic leakageConservative Management in ICU by Multidisciplinary Team

DR AMITA JAIN


prohibited

Went home on full recovery after 6 weeks

Doing well at 2years 6 months



Obstretical fistulas are associated with high incidence of recurrence and failure rates due to their large size and presence of ischaemic tissues. Arrow SS et al, Obstet Gynecol Surv. 1996;51:568–74.

Postsurgical fistulas are result of more direct and localised trauma to otherwise healthy tissue, so having better results after repair. Hadley HR. Vesicovaginal fistula. Curr Urol Rep. 2002;3:401–7.



To date improvements in health care facilities may have led to change in etiological aspect of FGF.

Surgical correction is still a great challenge and requires a team approach for better results.

“Prevention is better than cure".

THANKSDR AMITA JAIN


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Dr. Amita JainUrogynaecology Clinic

12th Floor, OPD Wing,Medanta -The Medicity

Gurgaon, Haryana -122001, INDIATel: +91 124 4141 414 [email protected] www.medanta.org

MOB. +91-9871136110 http://www.urogynecologistindia.in/

http://amitajainurogynaecolgist.blogspot.in/http://www.linkedin.com/mbox?displayMBoxItem=&itemID=I225857003_75

Medanta Institute of Kidney & Urology

changing scenario of female fistula

Education

prior permission

black colored material

vaginal discharge1

vaginal wall

apex of vaginal vault

fistula repair

suture removal

int j gynaecol obstet