Each year between 50 000 to 100 000 women worldwide are affected by obstetric fistula. I share here practical aspects of my personal experiences dealing with this complex issue mainly affecting the weak and the poor. During the last two decades huge international interest towards this problem has been raised up in the global medical arena. One might think anyone equipped with abilities to adjust to resource poor settings, armed with comprehensive surgical skills fulfill essentials to learn how to repair fistulas. This is definitely not enough to be a part of the solution! Regardless surgeons must understand both their own limitations as well as the limitations given by the environment in place as precondition to deal with this problem. Sharing my experiences I hope to contribute to make this understood.

1. Practical Aspects about Urogenital
Fistula Repair
Dr Dirk Grothuesmann, MScHI, MDMa
http://dg-maternalhealth.de/

3. ‘One surgeon in the vagina is already a
crowd’
Kees Waaldijk a fistula surgeon who has performed
more than 23,000 repair surgeries over the last 30 years

4. Preface
“Anyone equipped with abilities to adjust to resource poor settings,
armed with comprehensive surgical skills might fulfill essentials to learn
how to repair fistulas. Regardless surgeons must understand both their
own limitations as well as the limitations given by the environment in
place.
Most suitable to tackle this tale of suffer are well trained doctors with
in-depth understanding of the context from which these individual
tragedies originate.”
Dr Dirk Grothuesmann

5. Code of Ethics for Fistula Surgery
• Dedication to provide the best possible care for women based on
circumstances in place
• The surgeon must recognize the vulnerable nature of this population
of patients
• Personal responsibility for the perioperative care
• No hubris, accept own and infrastructural limitations and select
patients accordingly
• Collect/review data on treatment outcomes
• Help to reduce root causes of fistula genesis
Wall LL et al, 2008

6. THE OBSTETRIC FISTULA
COMPLEX

7. Primary/Anatomical Damage
• Predominant Lesion (vagina and urinary tract/urethra)
• Recto-vaginal fistulae
• Ureteric fistulae
• Renal damage
• Genital tract injuries
• Nerve damage
• Muscle and fascial damage
• Bone damage

8. Secondary Consequences
• Social consequences
• Mental health
• Urine dermatitis
• Bladder stones
• Contractures
• Malnutrition
• Infertility

9. Other Causes of Incontinence
In war-torn countries sexual violence is another tragic cause of genital
tract injuries with possible fistula development
The principles of management are the same
as for obstetric fistulae

10. Genitourinary Fistula Classification
Goh Classification System (2004)
• depending on the distance of the distal edge of the fistula from the
external urinary meatus
Goh, 2004

11. Genito-anorectal Fistula Classification
Goh Classification System (2004)
• depending on the distance of the distal edge of the fistula from the
external urinary meatus

12. Fistula Site
Simple juxta-urethral Fistula Small circumferential
juxta-urethral Fistula

13. Fistula Site
Circumferential juxta-urethral Fistula
pulled up and stuck to the back
of the pubic symphysis, making it
relatively inaccessible
The term ‘circumferential fistula’ is used when the bladder has been completely
separated from the urethra

14. Fistula Site
Simple juxta-cervical Fistula Juxta-cervical/intra-cervical Fistula

15. Fistula Site
Circumferential Fistulae
Small Gap Massive Gap
Fistula size
• tiny (admitting only
a small probe)
• small (0.5–1.5 cm)
• medium (1.5–3 cm)
• large (>3 cm
• extensive, i.e.
involving major loss of
bladder and urethra

16. Degrees of circumferential Tissue loss
(a) stenosed proximal urethra
but negligible separation
(b) complete separation with a
small gap
(c) more separation with pubic
bone exposed
(d) major separation with
significant loss of bladder volume

17. Degrees of circumferential Tissue loss
There are two important things to consider:
• To what extent is there circumferential tissue loss (i.e. separation of
bladder and urethra)?
• How much urethra has been destroyed?
(a) one-quarter loss
(b) three-quarters loss
(c) (c) complete detachment.
Urethral length is the major prognostic factor for stress Incontinence

18. Scarring
Scar is the big enemy of fistula surgery
(a) sagittal section (b) intra-vaginal view

20. History taking
• Symptoms
• Age
• Parity
• How long has patient been wet?
• Mode of delivery
• How long in labor
• Where did delivery take place
• Did the child survive
• Neurological symptoms
• Menstruation pattern

21. History taking
• Symptoms
• Age
• Parity
• How long has patient been wet?
• Mode of delivery
• How long in labor
• Where did delivery take place
• Did the child survive
• Neurological symptoms
• Menstruation pattern
• History of repair attempts
• Social history
Get the story behind right

23. Closing procedure of circumferential Fistulas
Incomplete Mobilization
• historically, been the method used to repair circumferential fistulae in the
Addis Ababa Fistula Hospital
(a) Mobilization is only
done postero-laterally
(b) The mobilized bladder margin is sutured
to the periostium/para-urethral area
(c) The urethral sutures are
inserted last, using the
center of the posterior
mobilized bladder
Catheterize the Ureters

24. Incomplete Mobilization
Advantages of incomplete Mobilization
• The operation may be easier to
perform than a complete detachment
and anastomosis
• A high rate of closure can be obtained
Disadvantages of incomplete
Mobilization
• Stress incontinence may be
unacceptably high.
• There is no muscle between the
urethra and bladder on the anterior
aspect
• the urethra remains short.
• If the fistula breaks down in the
corners (the most common place), an
almost impossible situation to re-
repair occurs
• Secondary operations for stress are
often needed, and may be hazardous

25. Complete Mobilization
The retro-pubic space is entered, and the anterior bladder wall is freed
(b) The three
methods of matching the
bladder to the
urethra. Note that the anterior
and lateral
sutures are inserted before
dealing with
the excess posterior bladder.

26. Incomplete versus complete Mobilization
• Restore muscular continuity between bladder and urethra front and
back MAKES SENSE
• BUT persisting Stress Continence problem with both techniques
Never forget to explain explicitly about this scenario
post fistula surgery

27. Fistula Closure with Urethra Reconstruction

28. Prognostic Factors associated with
Incontinence after Fistula Surgery
• If the urethra is involed up to 63% of cases (unpublished series,
Browning, Barhirdar, Ethiopia)
• If there is significant vaginal scarring, such that a small Sims speculum
cannot be inserted into the vagina without relaxing incisions
• The larger the fistula
• If there is a reduced bladder volume, more so if less than 100ml

31. Ureteric Involvement
The larger the fistula and the closer it is to the cervix, the greater is the
chance of ureter involvement
Ureter

32. Massive mid-vaginal fistula

33. Ureter Catheterization

34. Successful Closure

37. Operative steps to reduce the incidence of
Stress Incontinence
• Urethra Lengthening procedures
• Repair of the pubo-cervical fascia
• Urethral support with a fibro-muscular sling (pubo-coccygeal sling)
• The pubo-cervical fascia is brought together to support the urethro-vesical
anastomosis.
(a) a cut is made below with scissors so as to elevate a
broad rectangular block of tissue attached anteriorly
under the pubic arch

38. URETERIC FISTULAE
• Mainly related to iatrogenic injuries to the ureter
• Caesarean section
• Emergency hysterectomy
• Injury to a ureter at the time of a vesico-vaginal fistula repair
Mostly repaired by abdominal approach, Psoas Hitch and Boari
procedures might be utilized
Discuss simultaneous tube ligation

39. Psoas Hitch
Ureteroneocystostomy
Stein R et al, 2013

40. Boari Flap
Ureteroneocystostomy

42. Literatur
Browning A, 2012, The problem of continuing urinary incontinence after obstetric vesicovaginal surgery, Royal College of Obstetricians and Gynaecologists, from
https://www.rcog.org.uk/en/global-network/global-health-news/international-news/international-news-september-2012/the-problem-of-continuing-urinary-
incontinence-after-obstetric-vesicovaginal-surgery
De Ridder D, 2009, Vesicovaginal fistula: a major healthcare problem, Curr Opin Urol, 19 (4), 358-61, from http://www.ncbi.nlm.nih.gov/pubmed/19440154
De Ridder D et al, 2008, Fistulas in the Developing World, ICI Committee 18, from http://www.ics.org/publications/ici_4/files-book/comite-18.pdf
Goh, J T W, 2004, Australian and New Zealand Journal of Obstetrics and Gynaecology; 44: 502 – 504, from http://worldwidefistulafund.org/docs/resources/goh-new-
classification-system-2004.aspx
Hancock B, 2009, Practical Obstetric Fistula, The Royal Society Medicine Press, from http://www.glowm.com/resources/glowm/pdf/POFS/POFS_full.pdf
Wall LL et al, 2008, A code of ethics for the fistula surgeon, Int. J Gynaecol Obstet, 101(1):84-7 from http://www.ncbi.nlm.nih.gov/pubmed/18068168
Stein R et al, 2013, BJU International, 112, 137–155 from http://onlinelibrary.wiley.com/doi/10.1111/bju.12103/pdf

43. Aim of my Project
Dr. Dirk Grothuesmann Consultancy
Improving Maternal Health and Gynecology Services by Training Health
Care Providers: Relaying on standardized training modules I teach
evidence-based obstetrical procedures, gynaecology surgery and
related evaluation tools to local personnel in developed and developing
countries. Completing the programs offered, skills gained enable to
serve women in need in any requested setting.
http://dg-maternalhealth.de/index2.html

45. http://dg-maternalhealth.de/
Dr Dirk Grothuesmann
Consultancy