11 th Dynasty- Egyptian mummies : Queen Henhenit circa 2050 BC wife of King Mentuhotep II VVF 550 BC- Ancient Egyptian documents (papyri)

Transcription

1 February 2019

2 11 th Dynasty- Egyptian mummies : Queen Henhenit circa 2050 BC wife of King Mentuhotep II VVF 550 BC- Ancient Egyptian documents (papyri) Prescription for a woman whose urine is in an irksome place: if the urine keeps coming and she distinguishes it, she will be like this forever AD- Al Kanoun text by Avicenna In cases in which women are married too young, and in patients who have weak bladders, the physician should instruct the patient in the ways of prevention of pregnancy. In these patients the bulk of foetus may cause a tear in the bladder which results in incontinence of urine. The condition is incurable and remains so till death.

3 1663- Van Roonhuyze- Dutch textbook describing principles of repair (use of sharpened Swan s quills) John P. Mettauer of Virginia first to describe VVF repair in U.S.A J. Marion Sims- published surgical technique for successful VVF 1854-Gustave Simon- transverse colpocleisis (Latzko technique 1942) Colis of Dublin- split thickness layered closure Mackenrodt- recommends separating bladder from fistula and closing in separate layers.

4 First in U.S. to describe principles of VVF surgical repairs in 1852 Montgomery, Alabama First fistula hospital New York City.

5 Reg & Catherine Hamlin

6 Obstruction & Trauma Social Factors Immaturity (young girls) Tribal customs (more prevalent in W. Africa) Male Factor Education Political Factors Corrupt governments / policies Geography Isolation Transportation Communications Zacharin 1994 Hamlin 2001

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8 Prolonged obstructed labor Site of fistula determined by level of obstruction (pelvic brim or outlet) Failure to drain the bladder in second stage Pressure necrosis Mechanical and hydrostatic Sloughing of tissue and prolonged healing (12 weeks) Intense scar formation Uterine rupture deformation of cervix

9 Obstetrical Rare in U.S. Africa = 3-4 million Hysterectomy 1/1,300 hysterectomies 1/455 TLH 1/958 TAH 1/>5,000 vag hyst

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11 Risk Factors / Causes Hysterectomy Cesarean Delivery (multiple) Urethral diverticulum Synthetic urethral slings Retained sex toys Neglected Pessaries Prolonged Foley catheter Radiation Malignancy Inflammatory Bowel Disease (Crohn, Ulcerative Colitis)

12 Rare occurs at hysterectomy (0.1-1 %) U.S. VVF (1988 Mayo) 82% gynecololgic 8% obstetric 6% rads 4% trauma

13 Risk Factors continued Medical conditions that impair healing Diabetes Chronic steroid use Malignancy Tobacco use Vasculopathy Peri-operative hematoma / abscess Endometriosis PID

14 Risk factors Blunt dissection (Abd) Partial bladder wall /ureter clamp trauma (Abd) Thermal injury (TLH, RTLH) Bladder clamp crush, incised, sutured to vaginal cuff

15 Cystoscopy at time of hysterectomy Improved diagnosis of intraop bladder injury from 52% to 80%, and 12% to 90% for ureteral injury Sharp dissection Minimize energy use

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17 History- continuous leakage, intermittent with small fistulas, false SUI Symptoms occur 7-21 days post op Cyclic hematuria, amenorrhea (vesico-uterine fistula) Physical examination -Inspection -Palpation- scar tissue, defect, mass Dye test Cystourethroscopy number (15% multiple fistulas), size, location (ureters, trigone, urethra), mature?

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19 Fistula Type VVF VVF, Ureterovaginal fistula Urethrovaginal fistula Test Dye test, back fill Double dye tampon Oral phenazopyridine, tampon, backfill methylene blue Cystourethroscopy

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27 Simple Complex >1 cm diameter Post radiation Previous failed repair Juxtacervical Urethral, ureter, rectal involvement

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31 Within 72 hrs of causation 8-12 weeks 3-6 months large complicated fistula 6-12 months- radiation history Mature fistula tract Tissue healed without inflammation

32 Antibiotics prophylaxis Continuous bladder drainage (1-2 weeks) Transurethral Foley Suprapubic Post drainage cystogram (not required) Vaginal rest up to 8 weeks

33 Maintain Foley for prolonged period (small fistula <3mm) Ureteral stenting (may allow fistula healing and avoid stricture)

34 Transvaginal-(most) less invasive, same day surgery, improved access Transabdominal - Open Laparoscopic Robotic Transvesicle- no omental graft Supravesicle- omental graft

35 Identify the source of urine loss Adequate light Adequate exposure Wide mobilization of tissues around fistula tract Use tissue mobility to surgeon s advantage Tension free suture closure Multiple layer closure (2 + epithelium) Water tight closure Avoid devascularization Healthy tissue (non radiated) Adequate drainage

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39 Martius fat pad graft, Omentum Used for: New blood supply Extra layer of tissue Obliterate dead space Use on radiated field, large defects bladder trigone urethra, and redo operations

40 Ureteroneocystostomy (ureteral reimplant)

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43 Obstetrical- 88% Associated with 4 th degree lacerations Diverticulitis Radiation Colon CA Inflammatory bowel disease Perianal abscess Retained pessary

44 Stool from vagina Fecal soiling Vaginal gas Pain

45 Colonoscopy (for high fistula) biopsy fistula Tampon/rectal methylene blue Vaginal water / rectal air MRI

46 Low- transvaginal approach, if not obstetrical, could still be Crohn disease Mid High- more likely enterovaginal, colovaginal, diverticulitis, CA, may need diversion- not approached transvaginally

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53 What is your differential diagnosis?

54 Vesicovaginal fistula Cuff dehiscence Stress incontinence Urinary retention/overflow incontinence Ureterovaginal fistula Lymphocyst drainage

55 Your evaluation will be?

56 Examination Amber fluid is seen seeping from upper vagina

57 Tests Backfill bladder with dye /water Oral pyridium / tampon test Blue dye is seen coming into the vagina on back fill but a clear fistula cannot be seen or palpated. WHAT NEXT?

58 1. return to OR for robotic repair of fistula 2. CT urogram and refer for second opinion 3. Place a Foley catheter and recheck in 2 weeks

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61 Zacharin, Robert F. : Obstetric Fistula 1988 Springer- Verlag Wien-New York Hamlin, E. Catherine with John Little : The Hospital by the River 2001 Monarch Books, Grand Rapids, MI Elkins, T.E. 5 th International Vaginal Surgery Conference, St. Louis, MO 1994 Zacharin, R.F. 5 th International Vaginal Surgery Conference, St. Louis, MO 1994 Thompson, J.D. Chapter 41 TeLinde s Operative Gynecology 8 th Ed Rogers, RG and Jeppson, PC. Current Diagnosis and Management of Pelvic Fistulae in Women, Obstet Gynecol Vol 128, NO. 3, Sept 2016 Wong MJ, Wong K, Rezvan A, et al Urogenital Fistula Female Pelvic Medicine and Reconstructive Surgery Vol 18 No.2 March / April 2012