- Email: [email protected]
Complex obstetric fistulas
International Journal of Gynecology and Obstetrics (2007) 99, S51–S56
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
w w w. e l s e v i e r. c o m / l o c a t e / i j g o
ISSUES IN CLINICAL MANAGEMENT
Complex obstetric fistulas R.R. Genadry a,⁎, A.A. Creanga b , M.L. Roenneburg c , C.R. Wheeless a a
Department of Gynecology and Obstetrics, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA Population, Family and Reproductive Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA c Weinburg Center for Women's Health and Medicine, Mercy Medical Center, Baltimore, Maryland, USA b
KEYWORDS Abdominal repair; Complex obstetric fistulas; Fistula repair; Urinary augmentation; Urinary diversion; Urinary reconstruction
Abstract 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. © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Obstetric fistulas are rarely simple. Vesico-vaginal fistulas (VVFs) are caused by a broad injury resulting in extensive scarring and the breakdown of the more severely affected areas, and involve the urogenital barrier [1]. The recto-genital barrier can also be involved, causing the formation of a rectovaginal fistula (RVF) or a combined VVF and RVF. The combination is reported in 5% to 10% of surgically treated patients [1,2]. Lucky is the patient who presents with a small
⁎ Corresponding author. Department of Gyn/Ob, JHU School of Medicine, 10755 Falls Road, Suite 330, Lutherville, MD 21093, USA. Tel.: +1 410 583 2991. E-mail address: [email protected] (R.R. Genadry).
communication, less than 2 cm in diameter, above the vesical trigone and far from the urinary continence mechanism, because her fistula is easily accessible and has minimal scarring. Most likely, in both the developed and developing world, such a fistula is iatrogenic and follows a cesarean section or hysterectomy. In sub-Saharan Africa and parts of Asia, most patients who present with obstetric fistulas are not so fortunate. Theirs are the consequence of obstructed labor away from a medical facility where a cesarean section could have been performed in time [2,3]. These patients are often carriers of complex and/or complicated (N 6 cm) fistulas requiring expert skills for evaluation and management. Although the data on the true distribution of simple and complex VVFs are inadequate, more than 70% of obstetric VVFs are reported as complicated [4]. This high percentage may reflect a significant reporting bias by
0020-7292/$ - see front matter © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2007.06.026
S52 experts interested in solving the more difficult cases. In the absence of a universally accepted classification, the degree of complexity reported for a VVF is inversely related to the surgeon's experience and remains subjective. This article reviews the anatomical and clinical characteristics of complex obstetric fistulas; the existing evaluation methods applicable in developing countries; and the main surgical techniques currently used for the management of this category of fistulas. Although we focus on complex obstetric fistulas, certain aspects of the discussion may be applicable to all obstetric and gynecologic fistulas.
R.R. Genadry et al. of fistula closure is limited when the intervention results in a noncompliant bladder or a nonfunctioning bladder outlet. It is often difficult to report data on recognized complex fistulas in the absence of standardized definitions and the ensuing absence of a universal classification system. Standardized definitions and a universal classification system are urgently needed because they would assist in evaluating and treating fistulas, and in predicting treatment outcome. When they exist, the overall care management will certainly be improved.
3. Evaluation of complex fistulas 2. Characteristics of complex fistulas The factors defining the complexity of a fistula revolve around its site, particularly in relation to the bladder neck and ureteral orifices; its size, particularly as it affects the residual bladder and urethra; and the severity of scarring, as it determines the fistula's accessibility and mobility as well as the vagina's residual capacity and function. In addition, the degree of the fistula's interference with the integrity of the sphincteric mechanism determines the functional results of its repair, i.e., the degree of continence of the patient. A simple fistula may become complex when repair fails. When the repair was optimally performed in every respect, the damage was perhaps extended beyond the obvious, with surrounding tissues of poor quality, perhaps devascularized. A pinhole fistula is often the subtle sign of a broader underlying area of severely traumatized and scarred tissue. The breakdown of a surface larger than originally estimated may also occur because the repair was not optimally timed and/or the circumstances were not optimal-surgical errors or technical difficulties can be caused by the patient's anatomical configuration or her bad general health. In any case, it is critical to adhere scrupulously to the basic surgical principles of asepsis, hemostasis, and delicate dissection. Moreover, it is important to proceed at the most propitious time, when no infectious or inflammatory processes, local or general, would prevent proper healing. Particular attention should also be paid to bladder drainage, which must be unimpeded following fistula repair, and to good recovery. A fistula is predictably complex when it is greater than 4 cm and involves the continence mechanism (whether the urethra is partially absent or the bladder capacity is reduced, or both); is associated with moderately severe scarring of the trigone and urethro-vesical junction; and/or has multiple openings. When these conditions are present, the patients often require ureteral catheterization to assess and protect the ureters, and they will be prone to persistent incontinence even when the fistula is surgically closed. The urethro-vesical junction requires particular attention in urethral reconstruction, and a sling procedure is at times necessary to support the urethral function [5]. A VVF fistula is even more complicated when it is greater than 6 cm, particularly if the urethra is absent, there is severe scarring, and/or it is combined with a RVF. In such cases, 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. These alterations will usually affect the functional outcome of a surgically successful fistula repair. Clearly, the usefulness
The examination of women with complex fistulas needs to be comprehensive. It should assess their general health as well as the status of their urogenital tissues. Nutritional status, general physical and psychological health, and whether systemic or local infections are present should be noted, as well as the size of lesions, number of fistulous tracts, degree of scarring of the vagina and urethral sphincter, length of residual urethra (which determines the degree of urethral reconstruction to be performed and the patient's future continence), residual bladder capacity, and status of the ureters. A vesico-cervical or vesico-uterine communication should be ruled out. The presence of such a communication is ascertained when water colored with methylene blue instilled in the bladder is seen draining through the cervix. The size and status of the vagina dictate the need for vaginal augmentation and/or reconstruction. The degree of mobility or fixation of the bladder and urethrovesical junction against the pubic bone predicts the difficulty of the dissection and the likelihood of a successful surgical closure. The bladder and its sphincter may be nonfunctional or dysfunctional even before the mobilization is completed. After packing the vagina, a simple cystometrogram, when possible, might be useful to assess detrusor stability and urethral leak pressure. As the bladder is filled with water, using 50-mL aliquots through an asepto syringe placed at the level of the symphysis pubis, the water level is monitored. Unless a Valsalva maneuver is being performed, any rise in the water level suggests a bladder contraction; on the other hand, leakage through the urethral meatus during a Valsalva maneuver suggests sphincter insufficiency. Pressures are easily recorded with simple recording equipment. Once completed, the elements of a patient evaluation thus performed guide the selection of the best procedure. The process of choosing the most appropriate technique for each case is based on a number of factors including lesion accessibility and mobility; degree of scarring; vaginal length; size, site, and number of fistulas; and the condition of the residual bladder and urethral sphincter. In any event, the fixity of the vaginal structures and the ability to achieve adequate mobilization for a proper closure without tension remain the most important factors in selecting the surgical technique, which is also informed by the number of previous attempts at closure and the experience and skills of the surgeon.
4. Management of complex fistulas Any intercurrent infection should be treated and adequate nutritional and psychological status should be ensured for each patient before surgery. The debate is still open on whether the
Complex obstetric fistulas abdominal or vaginal route is the most appropriate for the repair of complex fistulas. The surgical options include a vaginal approach with or without urethral reconstruction; a combined abdomino-vaginal approach with or without bladder augmentation; and a urinary diversion procedure. The surgeon's skills and preference as well as the clinical circumstances of the case guide the choice of the approach. The abdominal and vaginal approaches both offer an excellent chance of successfully closing a VVF if general surgical principles are respected. The vaginal approach minimizes the risk of operative and postoperative complications but may be associated with vaginal scarring and shortening. The abdominal route is more frequently preferred when bladder augmentation or ureteral reimplantation is needed, or in the presence of associated pelvic pathology. A combined approach is indicated when the first approach chosen did not provide good exposure or did not lead to successful repair, or when a single route does not permit the complex treatment necessary. In general, complex fistulas are treated vaginally using a myocutaneous flap or through an abdominal approach (Fig. 1). Circumstances difficult to manage include vaginal stenosis or the presence of severely indurated vaginal epithelium around the fistula; a small-capacity or poorly compliant bladder; lesions involving other pelvic structures; the necessity of ureteral implantation; and when proper exposure cannot be obtained [6–8].
4.1. Vaginal repair 4.1.1. Description of a standard repair Most fistulas of the genital tract can be closed vaginally. Access to the fistula, rather than its size, causes difficulty, as the lesion can be encased in dense scar tissue. Lateral relaxing incisions in the scar tissue, however, will permit to view the fistula. Depending on the fistula's location, the patient is either positioned in the exaggerated lithotomy position or placed prone in the reverse lithotomy position. Then a U-shaped incision is made with the fistula at the base of the U, the vaginal wall is mobilized as much as possible, and the fistula is circumscribed. The ureteric orifices are identified and catheterized for protection against possible injury and the catheters are brought out through the urethra. The fistula is then closed transversely, starting at either end. The fistula is closed
Figure 1
S53 transversely starting at either end in order to avoid missing its most lateral portion—interrupted absorbable sutures are preferred. The sutures are placed such as not to penetrate the mucosa of the bladder, resulting in its inversion. The second layer strengthens the repair by suturing the bladder wall and the third layer of sutures closes the vaginal wall [9]. 4.1.2. When ancillary vascular supplies are needed When the vaginal route is used for the management of a complex fistula, an ancillary vascular supply to the area is usually required in the form of a Martius bulbocavernosus flap or a gracilis myocutaneous flap. A Martius flap involves the use of a vascular fat pad, 5 to 6 cm long and 2 to 3 cm wide, diverted from the length of the labium majus. The fat pad is elevated and tunneled subcutaneously into the vagina, then placed over the vesical site of the repair. After vaginal closure the pad becomes interposed between bladder and vagina, providing the repaired area with blood from the perineal branch of the internal pudendal artery and the external pudendal artery and collaterals. When the blood supply provided by the Martius flap would be insufficient, the bulbocavernosus muscle (modified Martius flap) can be utilized, along with the subcutaneous muscle and cutaneous tissue (myocutaneous flap). The flap can be unilateral or bilateral, according to the anatomy of the fistula. The benefits of grafting include covering minor defects in the suture line, bringing a fresh blood supply to an area of injured tissues, and keeping the healing of the bladder and vaginal wall apart [9]. Elkins [10] suggest that the anatomical proximity of labial fatty tissue and obstetric fistulas make the Martius flap an ideal adjunct in the repair of difficult fistulas such as large fistulas, fistulas that recur after repair, and those associated with underlying problems that hinder tissue healing. Rangnekar and colleagues [11] studied retrospectively 46 patients with urinaryvaginal fistulas, most of them due to obstetric trauma. When the Martius procedure was used the success rate was around 95%, compared with 72% with anatomic repair only (P b 0.05). Postoperative stress incontinence occurred in 1 patient who underwent anatomic repair only, and in none of the patients who also underwent the Martius procedure. Furthermore, none of the patients among the 20 cured with the Martius procedure experienced dyspareunia, compared with 6 of the 18 cured patients who underwent anatomic repair only (P b 0.05) [11].
Clinical circumstances and corresponding management options in complex obstetric fistulas.
S54 Conventional dissection and repair in layers is appropriate for most midvaginal fistulas, but modifications may be necessary in specific circumstances. For example, juxtacervical fistulas may be repaired if the cervix can be drawn down to provide access to the lesion, and distortion of the ureteric orifices may be prevented if the underlying trigone is reconstructed transversally. Moreover, when the anterior lip of the cervix is involved in the lesion and a tension-free repair would be difficult to achieve, the posterior lip of the cervix may be used to close juxtacervical fistulas. This procedure is easier and less time-consuming than repair via the abdominal route, less blood is lost, and vaginal capacity is still preserved [12]. Vault fistulas can be managed vaginally with a transverse incision of the vault, followed by a wide mobilization of the fistula aided by an intentional opening of the pouch of Douglas. The peritoneal opening is then incorporated into the vaginal closure. Tissue loss may be extensive with subsymphysial fistulas involving the bladder neck and proximal urethra, and adherence to underlying bone is a common problem. An extension of the incision facilitates the exposure of the proximal urethra. The extensive dissection required with fistulas extending from the bladder neck to the vault might produce considerable bleeding. A defect in the bladder wall should be closed in 2 layers, avoiding placing the suture through the mucosa of the bladder. To add additional protection to the repair, the anterior peritoneal flap may be interposed over the 2-layered closure and sutured to the back wall of the bladder. Repairing the bladder in this manner, followed by continuous postoperative bladder drainage, can virtually eliminate the chances of a recurrent fistula. Eilber and colleagues [13] consider that the use of a peritoneal flap for transvaginal repair of VVFs is associated with minimal morbidity, results in a success rate comparable to that of the Martius flap, and is especially useful for proximal fistulas when previous repair has failed.
4.2. Urethral reconstruction Several techniques can be used in patients with substantial urethral loss. To create a neourethra, a strip taken from the anterior vaginal wall may be placed over a catheter and configured into a tube, and a graft made of labial fat or muscle can be interposed to fill the dead space and provide additional bladder neck support. This procedure may improve continence by reducing scarring between bladder neck and vagina. Neourethras can also be constructed from vaginal or vesical flaps [14]. To strengthen the neourethra, tubulization of a labial graft obtained from one or both labia majora can be effective in addition to extending the neourethra to the urethral floor [15]. A thick muscular and fatty pedicle, cut from the fibers of the bulbocavernosus muscle, is at times necessary when there is extensive loss of substance. Such a pedicle may be useful in cases of combined VVF and RVF. A suburethral sling procedure is often also needed to insure continence. Periurethral injections are particularly appropriate in cases of urethral insufficiency in a fixed urethra [15].
4.3. Abdominal repair The indications for abdominal repair include a vagina of insufficient size, often because of scarring; inadequate vaginal exposure; an inaccessible ureteral fistula; the need
R.R. Genadry et al. for an omental graft; low compliance in a bladder requiring augmentation; and concomitant abdominal pathology. The patient is positioned in the low lithotomy position, which permits bimanual examination and facilitates a combined abdominal/vaginal approach, if necessary. When omental interposition is required, a midline abdominal wall incision allows for the mobilization of the full length of the omentum's vascular pedicle from the stomach. A lower midline incision or a suprapubic V incision provides good access [9], but a short additional midline epigastric skin incision may be required if an upper abdominal access is needed to mobilize the vascular pedicle of a short apron omentum (in 30%–40% of cases) [9]. Abdominal approaches may be extraperitoneal or intraperitoneal, the former precluding the use of an omental flap and the latter requiring opening the bladder at the dome. The incision is carried down to the fistulous opening and a wide mobilization of the bladder from the vagina is performed. After excision of the fistulous tract, the vagina and the bladder are closed separately. With the intraperitoneal technique, an omental flap secures the separation and provides fresh blood supply; with the extraperitoneal technique, a bladder mucosal flap may be used to cover the large defect. A mucosal segment from the unaffected portion of the bladder, about one-third larger than the defect to be covered, is dissected and attached with interrupted absorbable sutures, its luminal side facing the bladder lumen. Alternatively, human dura mater has been used successfully for the same purpose [16].
4.4. Bladder augmentation and urinary diversion Repairing complicated VVFs or multiple fistulas is often difficult, especially when the anatomy is distorted and the tissue fibrotic. The rate of successful surgical closures in these conditions is poor, and a urinary diversion is sometimes indicated. However, permanent urinary diversion is seldom socially acceptable in developing countries, and proper follow-up is seldom possible. Therefore, the procedure is infrequently performed. In a series of cases reported from southeast Nigeria, urinary diversion was performed in only 0.6% of 2484 patients [17]. Four criteria are to be satisfied in patients undergoing urinary tract reconstruction: a compliant bladder of adequate capacity; adequate bladder outlet resistance; adequate bladder emptying; and maintenance of a sterile, nonobstructed, nonrefluxing upper urinary tract [18]. Gastrointestinal segments are commonly used in patients who require augmentation cystoplasty, but a procedure preserving the urothelium should be favored when possible. A variety of demucozalized bowel segments have been used and tissue engineering promises a wider choice. A continent urinary diversion can be stoma based (the Mitrofanoff procedure) or non-stoma based. The Mitrofanoff procedure requires placing a narrow tube, usually constructed from the appendix, between the patient's bladder and the skin, with antireflux implantation in the bladder. A successful operation provides continence by virtue of reliable bladder emptying. The ureter, bladder, ileum, and colon can also be used to construct the tube. Adjunctive procedures such as ureteric reimplantation and bladder neck tubularization or division may be needed.
Complex obstetric fistulas
S55 Key issues in the management of complex obstetric fistulas are outlined in the Fig. 2. Newer techniques of bladder augmentation, including those involving biological material and/or engineered tissue, might find their optimal indications in these situations.
5. Postoperative care
Figure 2 fistulas.
Key issues in the management of complex obstetric
The use of detubularized ileum, ileocecum, or sigmoid colon is associated with excessive mucus production, hyperchloremic acidosis, and recurrent urinary tract infection. And although gastric segments protect against metabolic acidosis, their use increases the risk of hypochloremic alkalosis and severe fluid and electrolyte disequilibrium; and if the bladder neck is incompetent, gastrocystoplasty may also cause the hematuria-dysuria syndrome. Common surgical complications of gastrointestinal interventions are urinary tract infection, stone formation, catheter blockage, spontaneous bladder perforation, and increased risk of malignancy. When a large bladder diverticulum or a megaureter is available, “autoaugmentation” may be considered [18].
4.5. Ureterosigmoidostomy In this surgical procedure the ureters are diverted into the sigmoid colon. The incidence of adenocarcinomas associated with ureterosigmoidostomy has been estimated to be between 2% and 15% following this procedure, however [19], the lesions usually developing close to the anastomoses. Moreover, the risk of recurrent urinary infection is very high following ureterosigmoidostomy, and there is discomfort. Anal leakage is also frequent at night. In the modified ureteroenterosigmoidostomy procedure (the hemi-Koch pouch), the ureters are implanted the ileum, which is turned into a pouch draining into the rectosigmoid [20]. Any patient considered for a hemi-Koch pouch to the rectosigmoid colon must have an intact and functioning anal sphincter. If there is any doubt about the patient's sphincter tonus, she should be able to hold a 1-pint enema for at least 30 min [20]. The use of nonrefluxing nipples theoretically protects the upper urinary tract and prevents urine reflux up the descending colon. Protective catheters are threaded up the ureters into the renal pelvis bilaterally. A rectal tube is guided up the rectum into the rectosigmoid colon, and double J ureteral stents are sutured to the rectal tube. The rectal tube is sutured to the skin outside the anus and connected to a drainage bag. The rectal and ureteral stents are removed on the 10th postoperative day. A broadspectrum antibiotic agent should be given preoperatively and for 2 weeks postoperatively [20].
Recovery after surgery generally takes 2 weeks, during which the patient needs continuous bladder drainage. Most patients can leave the hospital after 14 to 21 days. Women with successfully repaired fistulas are usually advised not to resume sexual activity for 3 to 4 months to give tissues the time to heal [21], but the time needed to recover varies with the extent of the damage repaired [22]. Moreover, excessive activity should be avoided for 4 to 6 weeks [23]. Good postoperative drainage of the bladder is the most critical feature of postoperative care. The Foley catheter must be secured in proper position, whether suprapubic or transurethral. If the fistula involves the bladder neck, the balloon should not be inflated but the catheter should be sutured in place. As a rule the bladder should be continuously drained for at least 10 days, but sometimes the catheter should remain in place for up to 3 weeks. Anticholinergic drugs may be administered if bladder spasm occurs, and a high fluid input and output should be maintained until the urine is blood free. Postoperatively, antibiotic prophylaxis is indicated [23,24] and proper perineal hygiene is imperative.
6. Conclusion This article reviewed the characteristics, evaluation, and management of complex obstetric fistulas. However, there are no standardized or widely accepted definitions and classification systems for obstetric fistulas. Moreover, a lack of commonly accepted definition for cure hinders proper assessment of fistula repair. Authors have reported their successes and failures according to customized definitions and subjective outcome measures, the most common being fistula status at discharge from the hospital—without further evaluation of the effect of the procedure's outcome on quality of life, continence, and societal integration. Such results should be evaluated askance. Conflict of interest None. Role of the funding source None.
References [1] Wall LL, Karshima JA, Kirschner C, Arrowsmith SD. The obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004;109:1011–6. [2] Gassessew A, Mesfin M. Genitourinary and rectovaginal fistulae in Adigrat Zonal Hospital, Tigray, North Ethiopia. Ethiop Med J 2003;41(2):123–30.
S56 [3] Danso KA, Martey JO, Wall LL, Elkins TE. The epidemiology of genitourinary fistulae in Kumasi, Ghana, 1977–1992. Int Urogynecol J Pelvic Floor Dysfunct 1996;7(3):117–20. [4] Kelly J, Kwast BE. Epidemiologic study of vesico-vaginal fistulas in Ethiopia. Int Urogynecol J 1993;4:278–81. [5] Roenneburg ML, Wheeless CR. Traumatic absence of the proximal urethra. Am J Obstet Gynecol 2005;193(6):2169–72. [6] Blaivas JG, Heritz DM, Romanzi LJ. Early versus late repair of vesicovaginal fistulas: vaginal and abdominal approaches. J Urol 1995;153:1110–3. [7] Carr LK, Webster GD. Abdominal repair of vesicovaginal fistula. Urology 1996;48(1):10–1. [8] Angioli R, Penalver M, Muzii L, Mendez L, Mirhashemi R, Bellati F, et al. Guidelines of how to manage vesicovaginal fistula. Crit Rev Oncol Hematol 2003;48(3):295–304. [9] Smith GL, Williams G. Vesicovaginal fistula. BJU Int 1999;83 (5):564–9. [10] Elkins TE, DeLancey JO, McGuire EJ. The use of modified Martius graft as an adjunctive technique in vesicovaginal and rectovaginal fistula repair. Obstet Gynecol 1990;75(4): 727–33. [11] Rangnekar NP, Imdad Ali N, Kaul SA, Pathak HR. Role of the Martius procedure in the management of urinary-vaginal fistulas. J Am Coll Surg 2000;191(3):259–63. [12] Ijaiya MD. Posterior cervical lip for juxtacervical vesicovaginal fistula closure (M. Ijaiya's technique). Int Urogynecol J Pelvic Floor Dysfunct 2004;15(3):216–8. [13] Eilber KS, Kavaler E, Rodriguez LV, Rosenblum N, Raz S. Tenyear experience with transvaginal vesicovaginal fistula repair using tissue interposition. J Urol 2003;169(3):1033–6.
R.R. Genadry et al. [14] Elkins TE, Ghosh TS, Tagoe GA, Stocker R. Transvaginal mobilization and utilization of the anterior bladder wall to repair vesicovaginal fistulas involving the urethra. Obstet Gynecol 1992;79(3):455–60. [15] Falandry L, Illo A, Guelina G, Durasnel P, Alphonsi R, Madougou M. Pediculated labial ureteroplasty: an original treatment procedure for ureteral lesions of obstetric origin. Med Trop 1997;57(3):273–9. [16] Alagol B, Gozen AS, Kaya E, Inci O. The use of human dura mater as an interposition graft in the treatment of vesicovaginal fistula. Int Urol Nephrol 2004;36(1):35–40. [17] Hilton P, Ward A. Epidemiological and surgical aspects of urogenital fistulae: a review of 25 years' experience in southeast Nigeria. Int Urogynecol J Pelvic Floor Dysfunct 1998;9(4):189–94. [18] Ahmed S. Urinary tract reconstruction augmentation cystoplasty. Saudi Med J 2003;24(5 suppl):S45–6. [19] Azimuddin K, Khubchandani IT, Stasik JJ, Rosen L, Riether RD. Neoplasia after ureterosigmoidostomy. Dis Colon Rectum 1999;42(12):1632–8. [20] Husain A, Johnson K, Glowacki CA, Osias J, Wheeless Jr CR, Asrat K, et al. Surgical management of complex obstetric fistula in Eritrea. J Womens Health (Larchmt) 2005;14(9):839–44. [21] Kelly J. Ethiopia: an epidemiological study of vesico-vaginal fistula in Addis Ababa. World Health Stat Q 1995;48(1):15–7. [22] Dupont MC, Raz S. Vaginal approach to vesicovaginal fistula repair. Urology 1996;48(1):7–9. [23] Chapple C, Turner-Warwick R. Vesico-vaginal fistula. BJU Int 2005;95(1):193–214. [24] Kelly J. Fistulae of obstetric origin. Midwifery 1991;7(2):71–3.
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
w w w. e l s e v i e r. c o m / l o c a t e / i j g o
ISSUES IN CLINICAL MANAGEMENT
Complex obstetric fistulas R.R. Genadry a,⁎, A.A. Creanga b , M.L. Roenneburg c , C.R. Wheeless a a
Department of Gynecology and Obstetrics, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA Population, Family and Reproductive Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA c Weinburg Center for Women's Health and Medicine, Mercy Medical Center, Baltimore, Maryland, USA b
KEYWORDS Abdominal repair; Complex obstetric fistulas; Fistula repair; Urinary augmentation; Urinary diversion; Urinary reconstruction
Abstract 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. © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Obstetric fistulas are rarely simple. Vesico-vaginal fistulas (VVFs) are caused by a broad injury resulting in extensive scarring and the breakdown of the more severely affected areas, and involve the urogenital barrier [1]. The recto-genital barrier can also be involved, causing the formation of a rectovaginal fistula (RVF) or a combined VVF and RVF. The combination is reported in 5% to 10% of surgically treated patients [1,2]. Lucky is the patient who presents with a small
⁎ Corresponding author. Department of Gyn/Ob, JHU School of Medicine, 10755 Falls Road, Suite 330, Lutherville, MD 21093, USA. Tel.: +1 410 583 2991. E-mail address: [email protected] (R.R. Genadry).
communication, less than 2 cm in diameter, above the vesical trigone and far from the urinary continence mechanism, because her fistula is easily accessible and has minimal scarring. Most likely, in both the developed and developing world, such a fistula is iatrogenic and follows a cesarean section or hysterectomy. In sub-Saharan Africa and parts of Asia, most patients who present with obstetric fistulas are not so fortunate. Theirs are the consequence of obstructed labor away from a medical facility where a cesarean section could have been performed in time [2,3]. These patients are often carriers of complex and/or complicated (N 6 cm) fistulas requiring expert skills for evaluation and management. Although the data on the true distribution of simple and complex VVFs are inadequate, more than 70% of obstetric VVFs are reported as complicated [4]. This high percentage may reflect a significant reporting bias by
0020-7292/$ - see front matter © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2007.06.026
S52 experts interested in solving the more difficult cases. In the absence of a universally accepted classification, the degree of complexity reported for a VVF is inversely related to the surgeon's experience and remains subjective. This article reviews the anatomical and clinical characteristics of complex obstetric fistulas; the existing evaluation methods applicable in developing countries; and the main surgical techniques currently used for the management of this category of fistulas. Although we focus on complex obstetric fistulas, certain aspects of the discussion may be applicable to all obstetric and gynecologic fistulas.
R.R. Genadry et al. of fistula closure is limited when the intervention results in a noncompliant bladder or a nonfunctioning bladder outlet. It is often difficult to report data on recognized complex fistulas in the absence of standardized definitions and the ensuing absence of a universal classification system. Standardized definitions and a universal classification system are urgently needed because they would assist in evaluating and treating fistulas, and in predicting treatment outcome. When they exist, the overall care management will certainly be improved.
3. Evaluation of complex fistulas 2. Characteristics of complex fistulas The factors defining the complexity of a fistula revolve around its site, particularly in relation to the bladder neck and ureteral orifices; its size, particularly as it affects the residual bladder and urethra; and the severity of scarring, as it determines the fistula's accessibility and mobility as well as the vagina's residual capacity and function. In addition, the degree of the fistula's interference with the integrity of the sphincteric mechanism determines the functional results of its repair, i.e., the degree of continence of the patient. A simple fistula may become complex when repair fails. When the repair was optimally performed in every respect, the damage was perhaps extended beyond the obvious, with surrounding tissues of poor quality, perhaps devascularized. A pinhole fistula is often the subtle sign of a broader underlying area of severely traumatized and scarred tissue. The breakdown of a surface larger than originally estimated may also occur because the repair was not optimally timed and/or the circumstances were not optimal-surgical errors or technical difficulties can be caused by the patient's anatomical configuration or her bad general health. In any case, it is critical to adhere scrupulously to the basic surgical principles of asepsis, hemostasis, and delicate dissection. Moreover, it is important to proceed at the most propitious time, when no infectious or inflammatory processes, local or general, would prevent proper healing. Particular attention should also be paid to bladder drainage, which must be unimpeded following fistula repair, and to good recovery. A fistula is predictably complex when it is greater than 4 cm and involves the continence mechanism (whether the urethra is partially absent or the bladder capacity is reduced, or both); is associated with moderately severe scarring of the trigone and urethro-vesical junction; and/or has multiple openings. When these conditions are present, the patients often require ureteral catheterization to assess and protect the ureters, and they will be prone to persistent incontinence even when the fistula is surgically closed. The urethro-vesical junction requires particular attention in urethral reconstruction, and a sling procedure is at times necessary to support the urethral function [5]. A VVF fistula is even more complicated when it is greater than 6 cm, particularly if the urethra is absent, there is severe scarring, and/or it is combined with a RVF. In such cases, 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. These alterations will usually affect the functional outcome of a surgically successful fistula repair. Clearly, the usefulness
The examination of women with complex fistulas needs to be comprehensive. It should assess their general health as well as the status of their urogenital tissues. Nutritional status, general physical and psychological health, and whether systemic or local infections are present should be noted, as well as the size of lesions, number of fistulous tracts, degree of scarring of the vagina and urethral sphincter, length of residual urethra (which determines the degree of urethral reconstruction to be performed and the patient's future continence), residual bladder capacity, and status of the ureters. A vesico-cervical or vesico-uterine communication should be ruled out. The presence of such a communication is ascertained when water colored with methylene blue instilled in the bladder is seen draining through the cervix. The size and status of the vagina dictate the need for vaginal augmentation and/or reconstruction. The degree of mobility or fixation of the bladder and urethrovesical junction against the pubic bone predicts the difficulty of the dissection and the likelihood of a successful surgical closure. The bladder and its sphincter may be nonfunctional or dysfunctional even before the mobilization is completed. After packing the vagina, a simple cystometrogram, when possible, might be useful to assess detrusor stability and urethral leak pressure. As the bladder is filled with water, using 50-mL aliquots through an asepto syringe placed at the level of the symphysis pubis, the water level is monitored. Unless a Valsalva maneuver is being performed, any rise in the water level suggests a bladder contraction; on the other hand, leakage through the urethral meatus during a Valsalva maneuver suggests sphincter insufficiency. Pressures are easily recorded with simple recording equipment. Once completed, the elements of a patient evaluation thus performed guide the selection of the best procedure. The process of choosing the most appropriate technique for each case is based on a number of factors including lesion accessibility and mobility; degree of scarring; vaginal length; size, site, and number of fistulas; and the condition of the residual bladder and urethral sphincter. In any event, the fixity of the vaginal structures and the ability to achieve adequate mobilization for a proper closure without tension remain the most important factors in selecting the surgical technique, which is also informed by the number of previous attempts at closure and the experience and skills of the surgeon.
4. Management of complex fistulas Any intercurrent infection should be treated and adequate nutritional and psychological status should be ensured for each patient before surgery. The debate is still open on whether the
Complex obstetric fistulas abdominal or vaginal route is the most appropriate for the repair of complex fistulas. The surgical options include a vaginal approach with or without urethral reconstruction; a combined abdomino-vaginal approach with or without bladder augmentation; and a urinary diversion procedure. The surgeon's skills and preference as well as the clinical circumstances of the case guide the choice of the approach. The abdominal and vaginal approaches both offer an excellent chance of successfully closing a VVF if general surgical principles are respected. The vaginal approach minimizes the risk of operative and postoperative complications but may be associated with vaginal scarring and shortening. The abdominal route is more frequently preferred when bladder augmentation or ureteral reimplantation is needed, or in the presence of associated pelvic pathology. A combined approach is indicated when the first approach chosen did not provide good exposure or did not lead to successful repair, or when a single route does not permit the complex treatment necessary. In general, complex fistulas are treated vaginally using a myocutaneous flap or through an abdominal approach (Fig. 1). Circumstances difficult to manage include vaginal stenosis or the presence of severely indurated vaginal epithelium around the fistula; a small-capacity or poorly compliant bladder; lesions involving other pelvic structures; the necessity of ureteral implantation; and when proper exposure cannot be obtained [6–8].
4.1. Vaginal repair 4.1.1. Description of a standard repair Most fistulas of the genital tract can be closed vaginally. Access to the fistula, rather than its size, causes difficulty, as the lesion can be encased in dense scar tissue. Lateral relaxing incisions in the scar tissue, however, will permit to view the fistula. Depending on the fistula's location, the patient is either positioned in the exaggerated lithotomy position or placed prone in the reverse lithotomy position. Then a U-shaped incision is made with the fistula at the base of the U, the vaginal wall is mobilized as much as possible, and the fistula is circumscribed. The ureteric orifices are identified and catheterized for protection against possible injury and the catheters are brought out through the urethra. The fistula is then closed transversely, starting at either end. The fistula is closed
Figure 1
S53 transversely starting at either end in order to avoid missing its most lateral portion—interrupted absorbable sutures are preferred. The sutures are placed such as not to penetrate the mucosa of the bladder, resulting in its inversion. The second layer strengthens the repair by suturing the bladder wall and the third layer of sutures closes the vaginal wall [9]. 4.1.2. When ancillary vascular supplies are needed When the vaginal route is used for the management of a complex fistula, an ancillary vascular supply to the area is usually required in the form of a Martius bulbocavernosus flap or a gracilis myocutaneous flap. A Martius flap involves the use of a vascular fat pad, 5 to 6 cm long and 2 to 3 cm wide, diverted from the length of the labium majus. The fat pad is elevated and tunneled subcutaneously into the vagina, then placed over the vesical site of the repair. After vaginal closure the pad becomes interposed between bladder and vagina, providing the repaired area with blood from the perineal branch of the internal pudendal artery and the external pudendal artery and collaterals. When the blood supply provided by the Martius flap would be insufficient, the bulbocavernosus muscle (modified Martius flap) can be utilized, along with the subcutaneous muscle and cutaneous tissue (myocutaneous flap). The flap can be unilateral or bilateral, according to the anatomy of the fistula. The benefits of grafting include covering minor defects in the suture line, bringing a fresh blood supply to an area of injured tissues, and keeping the healing of the bladder and vaginal wall apart [9]. Elkins [10] suggest that the anatomical proximity of labial fatty tissue and obstetric fistulas make the Martius flap an ideal adjunct in the repair of difficult fistulas such as large fistulas, fistulas that recur after repair, and those associated with underlying problems that hinder tissue healing. Rangnekar and colleagues [11] studied retrospectively 46 patients with urinaryvaginal fistulas, most of them due to obstetric trauma. When the Martius procedure was used the success rate was around 95%, compared with 72% with anatomic repair only (P b 0.05). Postoperative stress incontinence occurred in 1 patient who underwent anatomic repair only, and in none of the patients who also underwent the Martius procedure. Furthermore, none of the patients among the 20 cured with the Martius procedure experienced dyspareunia, compared with 6 of the 18 cured patients who underwent anatomic repair only (P b 0.05) [11].
Clinical circumstances and corresponding management options in complex obstetric fistulas.
S54 Conventional dissection and repair in layers is appropriate for most midvaginal fistulas, but modifications may be necessary in specific circumstances. For example, juxtacervical fistulas may be repaired if the cervix can be drawn down to provide access to the lesion, and distortion of the ureteric orifices may be prevented if the underlying trigone is reconstructed transversally. Moreover, when the anterior lip of the cervix is involved in the lesion and a tension-free repair would be difficult to achieve, the posterior lip of the cervix may be used to close juxtacervical fistulas. This procedure is easier and less time-consuming than repair via the abdominal route, less blood is lost, and vaginal capacity is still preserved [12]. Vault fistulas can be managed vaginally with a transverse incision of the vault, followed by a wide mobilization of the fistula aided by an intentional opening of the pouch of Douglas. The peritoneal opening is then incorporated into the vaginal closure. Tissue loss may be extensive with subsymphysial fistulas involving the bladder neck and proximal urethra, and adherence to underlying bone is a common problem. An extension of the incision facilitates the exposure of the proximal urethra. The extensive dissection required with fistulas extending from the bladder neck to the vault might produce considerable bleeding. A defect in the bladder wall should be closed in 2 layers, avoiding placing the suture through the mucosa of the bladder. To add additional protection to the repair, the anterior peritoneal flap may be interposed over the 2-layered closure and sutured to the back wall of the bladder. Repairing the bladder in this manner, followed by continuous postoperative bladder drainage, can virtually eliminate the chances of a recurrent fistula. Eilber and colleagues [13] consider that the use of a peritoneal flap for transvaginal repair of VVFs is associated with minimal morbidity, results in a success rate comparable to that of the Martius flap, and is especially useful for proximal fistulas when previous repair has failed.
4.2. Urethral reconstruction Several techniques can be used in patients with substantial urethral loss. To create a neourethra, a strip taken from the anterior vaginal wall may be placed over a catheter and configured into a tube, and a graft made of labial fat or muscle can be interposed to fill the dead space and provide additional bladder neck support. This procedure may improve continence by reducing scarring between bladder neck and vagina. Neourethras can also be constructed from vaginal or vesical flaps [14]. To strengthen the neourethra, tubulization of a labial graft obtained from one or both labia majora can be effective in addition to extending the neourethra to the urethral floor [15]. A thick muscular and fatty pedicle, cut from the fibers of the bulbocavernosus muscle, is at times necessary when there is extensive loss of substance. Such a pedicle may be useful in cases of combined VVF and RVF. A suburethral sling procedure is often also needed to insure continence. Periurethral injections are particularly appropriate in cases of urethral insufficiency in a fixed urethra [15].
4.3. Abdominal repair The indications for abdominal repair include a vagina of insufficient size, often because of scarring; inadequate vaginal exposure; an inaccessible ureteral fistula; the need
R.R. Genadry et al. for an omental graft; low compliance in a bladder requiring augmentation; and concomitant abdominal pathology. The patient is positioned in the low lithotomy position, which permits bimanual examination and facilitates a combined abdominal/vaginal approach, if necessary. When omental interposition is required, a midline abdominal wall incision allows for the mobilization of the full length of the omentum's vascular pedicle from the stomach. A lower midline incision or a suprapubic V incision provides good access [9], but a short additional midline epigastric skin incision may be required if an upper abdominal access is needed to mobilize the vascular pedicle of a short apron omentum (in 30%–40% of cases) [9]. Abdominal approaches may be extraperitoneal or intraperitoneal, the former precluding the use of an omental flap and the latter requiring opening the bladder at the dome. The incision is carried down to the fistulous opening and a wide mobilization of the bladder from the vagina is performed. After excision of the fistulous tract, the vagina and the bladder are closed separately. With the intraperitoneal technique, an omental flap secures the separation and provides fresh blood supply; with the extraperitoneal technique, a bladder mucosal flap may be used to cover the large defect. A mucosal segment from the unaffected portion of the bladder, about one-third larger than the defect to be covered, is dissected and attached with interrupted absorbable sutures, its luminal side facing the bladder lumen. Alternatively, human dura mater has been used successfully for the same purpose [16].
4.4. Bladder augmentation and urinary diversion Repairing complicated VVFs or multiple fistulas is often difficult, especially when the anatomy is distorted and the tissue fibrotic. The rate of successful surgical closures in these conditions is poor, and a urinary diversion is sometimes indicated. However, permanent urinary diversion is seldom socially acceptable in developing countries, and proper follow-up is seldom possible. Therefore, the procedure is infrequently performed. In a series of cases reported from southeast Nigeria, urinary diversion was performed in only 0.6% of 2484 patients [17]. Four criteria are to be satisfied in patients undergoing urinary tract reconstruction: a compliant bladder of adequate capacity; adequate bladder outlet resistance; adequate bladder emptying; and maintenance of a sterile, nonobstructed, nonrefluxing upper urinary tract [18]. Gastrointestinal segments are commonly used in patients who require augmentation cystoplasty, but a procedure preserving the urothelium should be favored when possible. A variety of demucozalized bowel segments have been used and tissue engineering promises a wider choice. A continent urinary diversion can be stoma based (the Mitrofanoff procedure) or non-stoma based. The Mitrofanoff procedure requires placing a narrow tube, usually constructed from the appendix, between the patient's bladder and the skin, with antireflux implantation in the bladder. A successful operation provides continence by virtue of reliable bladder emptying. The ureter, bladder, ileum, and colon can also be used to construct the tube. Adjunctive procedures such as ureteric reimplantation and bladder neck tubularization or division may be needed.
Complex obstetric fistulas
S55 Key issues in the management of complex obstetric fistulas are outlined in the Fig. 2. Newer techniques of bladder augmentation, including those involving biological material and/or engineered tissue, might find their optimal indications in these situations.
5. Postoperative care
Figure 2 fistulas.
Key issues in the management of complex obstetric
The use of detubularized ileum, ileocecum, or sigmoid colon is associated with excessive mucus production, hyperchloremic acidosis, and recurrent urinary tract infection. And although gastric segments protect against metabolic acidosis, their use increases the risk of hypochloremic alkalosis and severe fluid and electrolyte disequilibrium; and if the bladder neck is incompetent, gastrocystoplasty may also cause the hematuria-dysuria syndrome. Common surgical complications of gastrointestinal interventions are urinary tract infection, stone formation, catheter blockage, spontaneous bladder perforation, and increased risk of malignancy. When a large bladder diverticulum or a megaureter is available, “autoaugmentation” may be considered [18].
4.5. Ureterosigmoidostomy In this surgical procedure the ureters are diverted into the sigmoid colon. The incidence of adenocarcinomas associated with ureterosigmoidostomy has been estimated to be between 2% and 15% following this procedure, however [19], the lesions usually developing close to the anastomoses. Moreover, the risk of recurrent urinary infection is very high following ureterosigmoidostomy, and there is discomfort. Anal leakage is also frequent at night. In the modified ureteroenterosigmoidostomy procedure (the hemi-Koch pouch), the ureters are implanted the ileum, which is turned into a pouch draining into the rectosigmoid [20]. Any patient considered for a hemi-Koch pouch to the rectosigmoid colon must have an intact and functioning anal sphincter. If there is any doubt about the patient's sphincter tonus, she should be able to hold a 1-pint enema for at least 30 min [20]. The use of nonrefluxing nipples theoretically protects the upper urinary tract and prevents urine reflux up the descending colon. Protective catheters are threaded up the ureters into the renal pelvis bilaterally. A rectal tube is guided up the rectum into the rectosigmoid colon, and double J ureteral stents are sutured to the rectal tube. The rectal tube is sutured to the skin outside the anus and connected to a drainage bag. The rectal and ureteral stents are removed on the 10th postoperative day. A broadspectrum antibiotic agent should be given preoperatively and for 2 weeks postoperatively [20].
Recovery after surgery generally takes 2 weeks, during which the patient needs continuous bladder drainage. Most patients can leave the hospital after 14 to 21 days. Women with successfully repaired fistulas are usually advised not to resume sexual activity for 3 to 4 months to give tissues the time to heal [21], but the time needed to recover varies with the extent of the damage repaired [22]. Moreover, excessive activity should be avoided for 4 to 6 weeks [23]. Good postoperative drainage of the bladder is the most critical feature of postoperative care. The Foley catheter must be secured in proper position, whether suprapubic or transurethral. If the fistula involves the bladder neck, the balloon should not be inflated but the catheter should be sutured in place. As a rule the bladder should be continuously drained for at least 10 days, but sometimes the catheter should remain in place for up to 3 weeks. Anticholinergic drugs may be administered if bladder spasm occurs, and a high fluid input and output should be maintained until the urine is blood free. Postoperatively, antibiotic prophylaxis is indicated [23,24] and proper perineal hygiene is imperative.
6. Conclusion This article reviewed the characteristics, evaluation, and management of complex obstetric fistulas. However, there are no standardized or widely accepted definitions and classification systems for obstetric fistulas. Moreover, a lack of commonly accepted definition for cure hinders proper assessment of fistula repair. Authors have reported their successes and failures according to customized definitions and subjective outcome measures, the most common being fistula status at discharge from the hospital—without further evaluation of the effect of the procedure's outcome on quality of life, continence, and societal integration. Such results should be evaluated askance. Conflict of interest None. Role of the funding source None.
References [1] Wall LL, Karshima JA, Kirschner C, Arrowsmith SD. The obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004;109:1011–6. [2] Gassessew A, Mesfin M. Genitourinary and rectovaginal fistulae in Adigrat Zonal Hospital, Tigray, North Ethiopia. Ethiop Med J 2003;41(2):123–30.
S56 [3] Danso KA, Martey JO, Wall LL, Elkins TE. The epidemiology of genitourinary fistulae in Kumasi, Ghana, 1977–1992. Int Urogynecol J Pelvic Floor Dysfunct 1996;7(3):117–20. [4] Kelly J, Kwast BE. Epidemiologic study of vesico-vaginal fistulas in Ethiopia. Int Urogynecol J 1993;4:278–81. [5] Roenneburg ML, Wheeless CR. Traumatic absence of the proximal urethra. Am J Obstet Gynecol 2005;193(6):2169–72. [6] Blaivas JG, Heritz DM, Romanzi LJ. Early versus late repair of vesicovaginal fistulas: vaginal and abdominal approaches. J Urol 1995;153:1110–3. [7] Carr LK, Webster GD. Abdominal repair of vesicovaginal fistula. Urology 1996;48(1):10–1. [8] Angioli R, Penalver M, Muzii L, Mendez L, Mirhashemi R, Bellati F, et al. Guidelines of how to manage vesicovaginal fistula. Crit Rev Oncol Hematol 2003;48(3):295–304. [9] Smith GL, Williams G. Vesicovaginal fistula. BJU Int 1999;83 (5):564–9. [10] Elkins TE, DeLancey JO, McGuire EJ. The use of modified Martius graft as an adjunctive technique in vesicovaginal and rectovaginal fistula repair. Obstet Gynecol 1990;75(4): 727–33. [11] Rangnekar NP, Imdad Ali N, Kaul SA, Pathak HR. Role of the Martius procedure in the management of urinary-vaginal fistulas. J Am Coll Surg 2000;191(3):259–63. [12] Ijaiya MD. Posterior cervical lip for juxtacervical vesicovaginal fistula closure (M. Ijaiya's technique). Int Urogynecol J Pelvic Floor Dysfunct 2004;15(3):216–8. [13] Eilber KS, Kavaler E, Rodriguez LV, Rosenblum N, Raz S. Tenyear experience with transvaginal vesicovaginal fistula repair using tissue interposition. J Urol 2003;169(3):1033–6.
R.R. Genadry et al. [14] Elkins TE, Ghosh TS, Tagoe GA, Stocker R. Transvaginal mobilization and utilization of the anterior bladder wall to repair vesicovaginal fistulas involving the urethra. Obstet Gynecol 1992;79(3):455–60. [15] Falandry L, Illo A, Guelina G, Durasnel P, Alphonsi R, Madougou M. Pediculated labial ureteroplasty: an original treatment procedure for ureteral lesions of obstetric origin. Med Trop 1997;57(3):273–9. [16] Alagol B, Gozen AS, Kaya E, Inci O. The use of human dura mater as an interposition graft in the treatment of vesicovaginal fistula. Int Urol Nephrol 2004;36(1):35–40. [17] Hilton P, Ward A. Epidemiological and surgical aspects of urogenital fistulae: a review of 25 years' experience in southeast Nigeria. Int Urogynecol J Pelvic Floor Dysfunct 1998;9(4):189–94. [18] Ahmed S. Urinary tract reconstruction augmentation cystoplasty. Saudi Med J 2003;24(5 suppl):S45–6. [19] Azimuddin K, Khubchandani IT, Stasik JJ, Rosen L, Riether RD. Neoplasia after ureterosigmoidostomy. Dis Colon Rectum 1999;42(12):1632–8. [20] Husain A, Johnson K, Glowacki CA, Osias J, Wheeless Jr CR, Asrat K, et al. Surgical management of complex obstetric fistula in Eritrea. J Womens Health (Larchmt) 2005;14(9):839–44. [21] Kelly J. Ethiopia: an epidemiological study of vesico-vaginal fistula in Addis Ababa. World Health Stat Q 1995;48(1):15–7. [22] Dupont MC, Raz S. Vaginal approach to vesicovaginal fistula repair. Urology 1996;48(1):7–9. [23] Chapple C, Turner-Warwick R. Vesico-vaginal fistula. BJU Int 2005;95(1):193–214. [24] Kelly J. Fistulae of obstetric origin. Midwifery 1991;7(2):71–3.