An introduction to Obstetric Fistula surgery Brian Hancock MD.FRCS.FRCOG
Obstructed LabourProlonged pressure of the babies headcrushes the base of the bladder againstthe back of the pubis
Causes of wetness post delivery• Ischaemic necrosis to the bladder and vagina due to prolonged labour ( 90%)• Accidental damage to the Bladder or Ureter at Caesarean section or hysterectomy for ruptured uterus (10%)
The Vesico Vaginal Fistula1-2 million in AfricaWet for life.High skillLow tech surgeryDramatic results
The Cause. Unrelieved obstructed labourUrban poverty. Lack of Remote dwellings.Nofree medical care. Transport. No hospitals
Three stages of delay for Caesarean section.• Delay deciding to get help• Delay getting to hospital• Delay in Hospital
ResultA hole between the Vagina and Bladder (VVF)
Effect of a VVFShe will be incontinent ofurine for lifeShe will become a socialoutcast unless she can find askilled surgeon
Vesico-Vaginal Fistula isMore than a hole in the bladder The whole body is damaged
Can all patients with VVF be cured? easy 25% intermediate 50% difficult 25%One quarter are easy with near 100% successOne half are intermediate in difficultly, 80% success foran expertOne quarter are very difficult, 50% success rate for anexpert.
Results of VVF surgery1100 cases in Uganda in 10 years Inoperable Fail 3% 10% Stress 17% Dry70%
Why are so few repairs done?Surgery thought to be difficult but 25% are quite easyResults thought to be poor. but 100% success for easy casesNo teaching in post graduate curriculum but simple books are availableLack of special instruments but they are not needed for easy casesNo specialist nursing care but nursing care is very easy
Many cases can be repaired under basic conditions Lira. Uganda Kamuli. Uganda
Further progress is best made by apprenticeship with one of the master surgeons. Kees Waaldijk Dr Mulu Katsina Addis Ababa Nigeria Ethiopia
Understanding the nature of VVFThe commonest site for ischaemicinjury is the junction of the bladder andurethra. In severe cases the whole ofthe anterior vaginal wall and bladderbase are lost and the urethra isseparated from the bladder.
Diagnosis is made by,• History taking• Examination• No special investigations required
History takingWet all the time?Leaking faeces as well? ( 5-10%)How long wet?Which delivery caused the problem?Did the baby survive?How born? CS or Vaginal Delivery?Has repair been attempted before?Social history.
Some demographic facts from 1000 cases in Uganda• Mean age was 26 years• Mean duration of fistula was 6 years• 50% were primiparous• Only 33% of patients with a fistula delivered vaginally, the rest had acaesarean section.• 12% of women who developed a fistula after LSCS had a live babyIn contrast to 4% in those delivering vaginally.• 13% had already had at least one attempt at repair.
ExaminationInspection. For signs of wetness.Palpation by VE. ( don’t forget abdo exam first)Is there any vaginal stenosis?Can a defect be felt in the anterior vaginal wall.? Ifso, what is its site, size and mobility.Can the cervix be felt? Is the vagina shortened?If in doubt expose the anterior wall with aspeculum.
The reality• Nurses will be in short supply• Post op care must be kept as simple as possible.• Patients and their carers must often take responsibility for their own care.
The essentials. The patient must be Dry Drinking Draining
Ensure free drainage at all times• Options. • Closed drainage into a bag. • Free drainage into a basin or bucket
A practical method of drainageThe patient is nursed flatFor 24 hours post spinalAllow oral fluids freelyWatch the dripping into the bucket.
Closed drainageThis is a very high tech system.
Problems with closed drainageWhat happens to thisbag in the night?
A BLOCKED CATHETER is an emergencySigns Urine flow stops. Patients feels a full bladder Wet Bed due to leak through the urethra or repairAction Look to exclude kinked catheter Irrigate to clear obstruction Change Catheter.
Kinked Catheters big trouble ahead.The patient is lying on thecatheterThe catheter is kinkedThe urine is concentrated.
Further reading•Practical Obstetric Fistula Surgery . Brian Hancock and Andrew Browning•Step by Step Surgery of Vesico Vaginal Fistula. Kees WaaldijkBoth obtainable from Teaching Aids at Low Cost. (TALC)Box 49,St Albans, Herts, AL1 5TX, UK. (firstname.lastname@example.org)