thomas j.i.p. raassen, carrie ngongo, marietta …...fistula is a fistula between bladder/ureter and...
TRANSCRIPT
Iatrogenic Urogenital Fistulas
Thomas J.I.P. Raassen, Carrie Ngongo, Marietta Mahendeka
GMNHC 2015, Mexico City October 18 - 21
MESSAGE
l Iatrogenic fistulas are a separate group l All cadres of service providers are
involved l Training needs to be improved l Alternatives for CS need to be used
BACKGROUND
l From June 1994 – September 2012, 5.959
VVF/RVF-repairs l In over 65 hospitals in Eastern Africa and Asia l 805 Iatrogenic Fistulas, which is 13,2%
PATHOPHYSIOLOGY
An Iatrogenic Genitourinary Fistula is a fistula between bladder/ureter and uterus/cervix/vagina, resulting from surgery performed by a medical person
IATROGENIC FISTULAS
3 Types l Uretero-(cervico)-vaginal fistulas l Vault fistulas
l Vesico-(utero)-cervico-vaginal fistulas
OPERATIONS
l Caesarean Section (CS)
l CS/Hysterectomy for ruptured uterus
l Hysterectomy for gynecological reasons
RISK FACTORS
l Prior uterine operations, especially CS l Endometriosis l Cervical myoma l Prior pelvic radiation l Inexperienced operators l Difficult circumstances in our setting
URETERO-(CERVICO)-VAGINAL FISTULAS
PATHOPHYSIOLOGY
This is a lesion to the distal ureter during CS, CS/hysterectomy for ruptured uterus, or hysterectomy for gynecological reasons
URETERO-CERVICO- VAGINAL FISTULA
Dr. Kees Waaldijk
URETERO-(CERVICO)-VAGINAL FISTULAS
l Post CS alone 138 (50,6%) l Post Ruptured Uterus, Repaired 16 (5,8%) l Post Ruptured Uterus, Hysterectomy 57 (20,9%) (Obst) 211 l Post Hysterectomy (Gyn) 62 (22,7%) 62 Total 273
PRIOR LAPAROTOMY
l C-section x 1 20 l C-section x 2 9 l C-section x 3 2
Total 31 (11,6%)
OPERATOR l Specialist 26 l Registrar 9 l Medical Officer 145 (53,1%) l AMO/CO 93 (34,1%)
Total 273
VAULT FISTULAS
PATHOPHYSIOLOGY The vault fistula is a connection between
the bladder and the apex of the vagina (vault) and it occurs after total abdominal hysterectomy. It borders on the anterior edge of the vaginal scar
VAULT FISTULA
VAULT FISTULAS 2 GROUPS l Post Total Abdominal Hysterectomy 95
for gynecological indication l Post CS/Hysterectomy for ruptured 86 uterus, obstetric indication
Total 181
PRIOR LAPAROTOMY
l CS once 20 l CS twice 4 l CS thrice 3 l Others 4 Total 31 (17,1%)
OPERATOR l Specialist 48 (26,4%) l Registrar 8 l Medical Officer 95 (52,5%) l AMO/CO 30
Total 181
VESICO-UTERO/CERVICO- VAGINAL FISTULAS(VCVF)
PATHOPHYSIOLOGY This fistula is an accidental bladder injury (cut or suture) during a Caesarean Section, which is less than 3 cm
VCVF
Dr. Kees Waaldijk
VCVF 351
l Obstetric Origin 349
l Gynecological 2 Total 351
VCVF 349
Obstetric l Live birth 210(60%) l Stillbirth 139(40%)
Total 349
PRIOR LAPAROTOMY
Alive Stillborn Total l CS once 76 32 108 l CS twice 23 7 30 l CS thrice 3 3
Total 102 39 141(40,2%) l (48,6%) (28,1%)
OPERATOR
l Specialist 4 l Registrar 5 l Medical Officer 234 (66,7%) l AMO/CO 108 (30,8%)
Total 351
IATROGENIC FISTULAS
3 TYPES l Uretero-CVF 273 l Vault Fistulas 181 l Vesico-CVF 351
Total 805
CONCLUSIONS RECOMMENDATIONS
l In my series 13,2% of the women have iatrogenic fistulas
l Iatrogenic fistulas are a separate group l All cadres of service providers are involved l Women with previous CS are at an increased
risk of iatrogenic fistula
l Most operations are performed by Med. Off.
and AMO’s/CO’s
CONCLUSIONS RECOMMENDATIONS
l Training needs to be better. MO’s/AMO’s must perform CS under supervision, before they are posted to hospitals
l Prevention: Do not use blunt, but sharp dissection between bladder and uterus (Tancer, Hilton)
CONCLUSIONS RECOMMENDATIONS
l Alternatives for CS need to be used, like
Vac. Extr., Destructive Delivery for dead babies and Symphysiotomy
l Early Detection and Catheter Treatment l Access: Improve the accessibility for
pregnant women to free maternity services
Thank you