Management of genitourinary fistula


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Management of genitourinary fistula

  1. 1. UROGENITAL FISTULAS Prof.M.C.Bansal. MBBS., MS. MICOG.FICOG. Founder Principal & Controller ; Jhalawar Medical College And Hospital , Jhalawar. Ex. Principal & Controller; Mahatma Gandhi Medical College And Hospital,Sitapura , Jaipur Dr Jaya Patel (PG Student,NIMS Medical College Jaipur
  2. 2. Introduction • Fistula represents an extra-anatomic( Pathological) communication between two or more body cavities covered by Their own epithelia; the communicating tract Is also epithelized. This tract may also open at skin surface. • Classification of urinary fistula is generally based on organ of origin in urinary tract and termination point of fistula.
  3. 3. Types Of Urinary Fistula • Congenital---Ectopic Vesicae ,Ureterovaginal Fistula. • Acquired--- 1.Vascical Visio Uterine / cervical. Visio vaginal, 2. Urethra Vaginal. 3. Urethra Vaginal 4. Combined— two or more types of fistula present in same patient.
  4. 4. Vesicovaginal fistula • Most common acquired fistula of urinary tract. • Vesicovaginal fistula has been reported in a mummy found in pyramids of Egypt ;and many more have been described by Sims who is claimed to Have repaired maximum vesicovaginal fistula using his technique of “Sims triad “ Quoting That he was requested by number of women to repair their fistula as they do not want to go in grave with their wet bottom; they have suffered since their child’s birth.
  5. 5. ETIOLOGY • Obstetrical TRAUMA ( 95 %) • GYNAECOLOGICAL-----(0.5 -1 %) - Prolonged and obstructed labour---pressure necrosis of bladder neck or trig one leads to delayed onset of urinary fistula during second week of puerperal due to constant and prolonged compression of bladder neck by jammed up presenting part against syphilis pubis as in cases of obstructed and prolonged labour . Till mid 6th decade of last century; this was the commonest cause of obstetrical urinary fistula . Change in the management of CPD , Contracted pelvis , malpresentation ,Uterine inertia has made it a remote complication. - Introital stenosis secondary to female circumcision , cephalopelvic disproportion, an android pelvis , malnutrition , orthopaedic disorder contribute to dystosia . - Operative(Iatrogenic)--- forceps (Killend’s /High forceps application ,destructive instruments used to deliver stillborn infants and criminal abortion. Gishiri cuts(Nigra)
  7. 7. POST SURGICAL : - Abdominal hysterectomy(1/1300patients)Simple / redical(Werthem’s.) - Vaginal hysterectomy. Myomectommy—cervical and broad ligament fibroids. Laparoscpic --- fulgeration, too much heat near by bladder or ureter - Caesarean section - Sling operation for-incontinence of urine. - Repair of Anterior vaginal wall prolapse -- (e.g.colporrhaphy) - Manchester Repair. - Circullage operation with separation of bladder at the level of internal so. - Vaginal cystectomy. - cystoscopic---Bladder biopsy , endoscopic resection , laser procedure
  8. 8. • Radiation induced fistula (associated with Rx for Cancer Cervix or other pelvic malignancies) • Vaginal foreign bodies • Forgotten passeri • Direct trauma from masturbation or automobile accidents • Miscellaneous- Late stage of malignancy of genital tract involving urinary tract or visa versa. Tuberculosis , Schistosomiasis , Perforating bladder calculi , Endometriosis , Syphilis , Lymphogrannuloma venerum and ideopathic and congenital cause.
  9. 9. Clinical features • Constant urine drainage peer vagina. • Most commonly recognized in first 10 days after operation and less commonly between 10th to 20th postoperative day. • constant wetness of vulva-- excoriation of Skin leads to fungal infection , irritation , dermatitis. • Recurrent cystitis or UTI. • Unexplained fever ,hematuria ; discomfort in flank and suprapubic region .
  10. 10. • As urea is split by vaginal flora, the vaginal pH becomes alkaline, which precipitates greenish-gray phosphate crystals in the vagina and on the vulva. • Constant leakage of urine may make the patient a social recluse; disrupt sexual relations; and lead to depression, low self-esteem, and insomnia.
  11. 11. Physical examination • External genitalia(Leakage of urine and excoriation of vulva ) • Per speculum examination (Pool of urine in vagina and fistulous opening may be visible) • Location, number and size of fistula is to be noted. • In case of bladder neck fistula involvement of internal sphincter may also be associated . • There may be associated or combined fistulas e-g vesico vaginal , vesicocervical and ureteric fistula.
  12. 12. DIAGNOSTIC OFFICE TECHNIQUES • 1.Three swab test • 2.OfficeUrethroscopy and cystoscopy using gas as a distension media.
  13. 13. INVESTIGATIONS • CBC and Urine analysis • Blood chemistry for serum creatinine , blood urea and fasting blood sugar. • Urine for culture and sensitivity. • Intravenous pyelography (Ureteric fistula ,ureteric stricture and hydronephrotic changes) • Ascending pyelography to fortify the findings of IVP. • Modern imaging technique CT and MRI have limited value as Cystoscopy ( performed)gives maximum and to the point information about size ,shape , number and location of fistulas. • Biopsy from the edge of fistula cystoscope guided when it is suspected to be – malignant/post radiation/tubercular /schistosomiasis
  14. 14. Fistula opening in Bladder Cystoscpy
  15. 15. Transurethral catheter is visible through fistulous opening in vagina Catheter Per urethra
  16. 16. Cystogram-----Fistulous tract
  17. 17. Prevention • OBSTETRICAL- • Avoiding use of high forceps ,rotational forceps ,ventouse on undilated cervix , neglected shoulder,persistant occipito posterior position ,prolonged trial in CPD/mild contracted pelvis ,destructive operation (excepting craniotomy in cases of hydrocephalous) • LSCS-proper separation of bladder avoiding lateral and downward vertical extension of tears of lower segment • Proper identification of ureter and bladder before applying any clamp or ligature at the time of massive traumatic haemorrage or repair of rupture uterus/emergency obstetrical hysterectomy. • GYNAECOLOGICAL – • Immediate detection of bladder injury/ Ureter. • Watertight closure of bladder. • Extra-vesical drain placement. • Avoidance of vaginal incision if possible after recognition of bladder injury • Prolonged uninterrupted bladder drainage in postoperative period
  18. 18. • An intrafascial technique for hysterectomy also may protect the bladder and ureter injury . • The use of a two-way indwelling catheter, sharp dissection to isolate the bladder, an extraperitoneal cystostomy when the dissection is difficult, retrograde filling of the bladder when injury is suspected, and repair of an overt bladder injury only after mobilization of the injured area. • Retrograde filling of the bladder also may help define the border of a bladder otherwise distorted or displaced by prior surgery or a lower uterine segment fibroid.
  19. 19. PREOPERATIVE CARE • Cystitis, vaginitis, and perineal dermatitis should be treated with the appropriate antibiotic. • Perineal care is important and makes the patient more comfortable and tolerant of delayed closure. • Frequent pad changes are required to minimize inflammation, edema, and vulvar irritation. • Zinc oxide ointment or a cream containing lanolin may be especially helpful in the treatment of perineal and vulvar dermatitis. • Indweling catheter and nursing of patient in sim’s position or in prone position----the fistula in trigone area will be at higher level , catheter will drain each drop of urine coming down in bladder ;so fistulous tract will remain relatively dry . • Keeping so –the vulva will be dry, Even small tiny fistula may close.
  20. 20. TIMING OF REPAIR • Success rate for immediate repair is 98.4%. • The traditional belief is to wait a minimum of 3 to 6 months after the inciting event or the last attempt at repair. • If the gynaecological fistula is recognized within the first 48 hours postoperatively , It can be repaired immediately as the tissue is more mobile, have less inflammation and amenable to early repair.
  21. 21. • Large fistulae may be easier to repair once the tract is allowed to heal and edema resolves. • Fistulae arising later usually are complicated by significant edema, inflammation, and induration. An interval of 3 months from injury to repair in obstetric and surgical fistulae allows inflammation and edema to resolve and better chances of good healing.
  23. 23. General Principles of fistula repair • Good exposure , spot less bright light . • Selection of route of fistula repair depends on surgeons experience with best route as well as location of fistula size ,number or associated uretric fistula. • Mobilization of bladder. • Excision of scar tissue. • Tension free suturing. • Closure in layers. • Interposition of flaps or grafts—omentum , muscle etc. • Postoperative continuous bladder drainage for 2-3 weeks.
  24. 24. PRINCIPLE OF FISTULA REPAIR • Adequate exposure of fistula tract with debridement of devitalised and ischaemic tissues . • Removal of involved foreign bodies or synthetic materials from region of fistula(if possible). • Careful dissection and anatomic separation of the involved organ cavities. • Water tight closure. • Use of well vascularized ,healthy tissues flaps of repair(traumatic handling of tissue). • Multiple layer closure. • Tension free, non-overlapping suture lines
  25. 25. • Adequate urinary tract drainage and stinting urethra after repair. • Treatment and prevention of infection(Appropriate use of antimicrobials). • Maintenance of haemostasis. • Wide mobilization of the vaginal epithelium to expose the bladder • Excision of all scar tissue, even at the risk of increasing the size of the fistula in an attempt to create a fresh bladder injury• (this recommendation is not universally acceptable)
  26. 26. Surgical repair VAGINAL TECHNIQUES vaginal flap or flap splitting technique
  27. 27. A: Ureters have been catheterized. An incision through the vaginal epithelium is made circumferentially around the fistula. B: The vaginal epithelium is widely mobilized from the bladder. The scarred fistula tract should be excised.
  28. 28. C: A continuous (or interrupted) delayed-absorbable suture inverts the mucosa into the bladder. D: A second suture line is placed in the musculofascial layer to reinforce the first. Vaginal epithelium is trimmed and
  29. 29. Latzko technique for a closure of a simple posthysterectomy vesicovaginal fistula. (A)A circumferential incision is made around the fistula. The fistula is not excised. B: The vaginal epithelium is mobilized approximately 2 cm from the fistula.
  30. 30. C: Delayed-absorbable interrupted mattress sutures are placed parallel to the edge of the fistula tract to invert it into the bladder. D: One or two additional rows of suture approximate the musculofascial layer of the bladder.
  31. 31. The vaginal epithelium is closed transversely with interrupted delayed-absorbable sutures.
  32. 32. A: The lateral margin of the labia majora is incised vertically) The fat pad adjacent to the bulbocavernosus muscle is mobilized, leaving a broad pedicle attached at the inferior pole.
  33. 33. C: The fat pad is drawn through a tunnel beneath the labia minor and vaginal mucosa and sutured with delayed-absorbable sutures to the fascia of the urethra and bladder. D: The vaginal mucosa is mobilized widely to permit closure over the pedicle without tension. The vulvar incision is closed with interrupted delayed-absorbable sutures.
  34. 34. Abdominal Approach for Vesicovaginal Fistula Repair
  35. 35. A: A longitudinal incision is placed in the bladder dome. B: The incision is extended around the fistula. The fistulous tract and its vaginal orifice are completely excised. C: Interrupted delayed-absorbable sutures are used to close the vagina in one or two layers.
  36. 36. D: Continuous delayed-absorbable suture closes the bladder mucosa longitudinally. E: A suprapubic catheter is placed into the bladder in an extra peritoneal location.
  37. 37. F: The bladder muscularis is closed with delayed-absorbable continuous or interrupted sutures. G: An omental “J― flap can be interposed between the bladder closure and the vaginal closure.
  39. 39. • It is uncommon. • Most common cause is surgical injury to distal ureter(division , clamping or ligation), while performing gynecologic procedures by abdominal or vaginal route. • Laparoscpic surgery – injury with electric current, heat , laser, ligation ( avascular injury) • LSCS, rupture uterus repair and emergency obstetrical hysterectomy.
  40. 40. Presentation • Urinary incontinence which is constant 1 to 4 weeks after surgery • Normal voiding habits
  41. 41. Diagnosis Dye test --Vaginal swabs will be soaked with urine but no staining with dye. • Cysto urethoscopy(uretric catheterization, dilatation of stricture part or caliectasis) • IVP • RGP(Retrograde pylogram) • Cystography • CT
  42. 42. Hydrourte ureter opening in vagina Hydronephrosis
  43. 43. Hydro ureter Spillage of dye in vagina
  44. 44. Treatment • Urethral stenting or PCN decompression • Conservative management • Open surgical repair ureteroneocystostomy + psoas hitch Boari’s flap transureterouretrostomy ileal substitution of ureter renal autotransplantation nephrectomy
  45. 45. Repair of urethro vaginal fistula
  46. 46. A: A U-shaped incision is made through the vaginal epithelium. B: The flap is mobilized and rotated over the fistula. C: Three interrupted sutures of delayed-absorbable suture are placed in the sphincter region, and the tissue inverted. D: The mucosal flap is pulled downward, and the incision is extended on both sides.
  47. 47. E: The flap is rotated anteriorly and the incision edges approximated to form a tube. F: A layer of paraurethral fascia is plicated beneath the urethra. The vagina is approximated over the neourethra with interrupted delayed-absorbable sutures:
  48. 48. G: Completion of the reconstruction, showing interrupted suture closure of suburethral mucosa.
  49. 49. reconstruction of total or partial loss of the urethral floor
  50. 50. A: A line of incision is made along the margins of the roof of the urethra and extended to the bladder base. B: The urethral margins and fascia are mobilized from the vagina to permit tension-free approximation of the urethral mucosa. C: Urethral edges are approximated over a 12F catheter with interrupted delayed-absorbable sutures. Mobilized urethral fascia is sutured on each side of the total length of the urethra. D: The lower strand of each suture is tied beneath the urethral floor, and the upper strands of the two sutures are used to pull the fascia
  51. 51. E: The vaginal mucosa is closed without tension. F: For additional reinforcement, a U-shaped labial fat pad can be developed along the labia, leaving a broad pedicle superiorly. The vaginal mucosa between the urethral operative site and the labial graft is resected. G: The skin margins of the labial graft are sutured to the vaginal margins. The labial defect is closed.
  52. 52. POSTOPERATIVE CARE • The bladder should be drained for 10-14 days. • Excellent hydration will ensure irrigation of the bladder and help to prevent clots that could obstruct the bladder. • Catheter blockage should be prevented so that there is no bladder distension and tension on the suture lines. • Supra-pubic catheter may be used for fistula. • Cystogram is to evaluate the integrity of the bladder before discontinuing the bladder drainage.
  53. 53. INSTRUCTION ON DISCHARGE • Contraceptive advice for spacing for 2 years. • Abstenence for 3 month. • Maintain hygeine. • If pregnancy occurs elective caesarean section is indicated as and when foetus attains maturity. • Woman who had repair of obstetrical fistula may develop urinary tract infection , DUB and other gynaecological problems like general population in their life ,should go for medical Rx and when pelvic surgery is indicated ; It should be done by experienced surgeon.
  54. 54. • Uncommon and usually occur after surgery for urethral diverticulum, anterior vaginal wall prolapse, or urinary incontinence, and after radiation therapy. • The most common causes include tissue ischemia, problems related to healing, or radiation necrosis. URETHROVAGINAL FISTULAE
  55. 55. • Risk factor – Operative vaginal delivery. • Pressure necrosis, resulting in a urethrovaginal fistula, can occur with a prolonged indwelling transurethral catheter. • Urethrovaginal fistulae also may be congenital(extremely rare).
  56. 56. • They are rare. They are usually complications of caesarean section. • The clinical presentation may be similar to VVF, with urine egressing through the vagina. VESICOUTERINE AND VESICOCERVICAL FISTULAE
  57. 57. • The examination fails to reveal a vaginal fistula, however, and rarely urine trickles down through the os. • Cyclic haematuria (menouria) is common. • An abdominal approach with interposition of graft is for repair, using the techniques for VVF.
  58. 58. Ectopia vesicae • The posterior wall of the urinary bladder is exposed to the exterior. • It is caused by the failure of the anterior abdominal wall and anterior wall of the bladder to develop. • It is due to inability of the mesoderm of the primitive streak to migrate around the cloacal membrane
  59. 59. • Obstructed labor injury complex urethral loss stress incontinence hydroureteronephrosis renal failure rectovaginal fistula rectal atresia anal sphincteric incompetence cervical destruction amenorrhoea PID secondary infertility vaginal stenosis osteitis pubis foot drop
  60. 60. Treatment • Indwelling catheterization and anticholinergic medication for at least 2 to 3 weeks • Spontaneous healing is more likely when patient is seen within 3 weeks of initial injury • Small fistulas benefit from disruption of epithelial layer of the fistula track electrocoagulation fibrin sealant + bovine collagen
  61. 61. Surgical repair contd.. • Postoperative cystography • Anticholinergics • Abstinence from sexual intercourse • Complications bleeding ureteral injury vaginal shortening and stenosis recurrence
  62. 62. Surgical repair contd.. • Other transvaginal techniques • Latzko high partial colpocleisis advantages disadvantages • Webster vaginal cuff excision advantages
  63. 63. Surgical repair contd.. • Abdominal techniques • Suprapubic intraperitoneal-extraperitoneal approach
  64. 64. Surgical repair contd.. • Transvesical vertical cystotomy excision of VVF track transvesically • Laparoscopic • Laser tissue welding with Nd:YAG • Transurethral endoscopic suturing
  65. 65. Surgical repair contd.. • Adjuvant techniques tissue interposition • Martius flap consists of adipose and connective tissue fistula involving trigone, bladder neck and urethra blood supply