case ppt VVF fistula formation in obg .pptx

Vvf fistula case ppt

1. CASE PRESENTATION Dr. Ashita Aggarwal Fellow Urogynaecology and Pelvic Reconstructive Surgery AIIMS, New Delhi Moderator – Dr(Prof.) J.B Sharma

2. HISTORY Mrs ‘X’, 49 years, P5L5, resident of New Delhi, home maker, presented with complaints of- Dribbling of urine per vaginum since last 8 months

3. HISTORY OF PRESENTING ILLNESS Underwent Total Abdominal Hysterectomy with bilateral salpingo -oophorectomy i /v/o AUB-A in December 2023, 1 month later of surgery developed complain of watery discharge p/v continuous, transparent, associated with ammoniacal odour. persistently soaking undergarments and was using diapers. Patient was having bladder sensation and was passing voiding normally 5-6/day. Associated with vulval itching and persistent wetness in the vulval region.

4. HISTORY OF PRESENTING ILLNESS Patient complained of urgency associated with urge urinary incontinence. No complain of fever No complain of abdominal pain No complain of involuntary leakage of urine on straining, coughing, laughing etc. No complain of burning micturition, dysuria. No complain of urinary hesitancy, intermittency No complain of sensation of incomplete emptying of bladder.

5. HISTORY OF PRESENTING ILLNESS No c/o constipation or diarrhoea. No sexual complains, as patient had maintained abstinence since post TAH. No c/o mass in abdomen No c/o mass descending per vaginum

6. HISTORY OF PRESENTING ILLNESS Consulted private hospital in Gwalior with above complaints where she had undergone hysterectomy. Advised antibiotics and was offered surgical management for the same Self-referred to AIIMS, New Delhi for further management.

7. MENSTRUAL HISTORY Menarche- 14 years of age Cycles were regular, heavy flow, 9-10 days/25-30 days cycle , associated with dysmenorrhoea for 4-5 months. She was diagnosed with AUB-A. OBSTETRIC HISTORY Married for 36 years P5L5. All FTNVD at home, last childbirth 18 years back. Minilap ligation done 17 years back. PAST HISTORY No H/O DM, HTN, TB, thyroid disorders, allergies, asthma No H/O of malignancies in past, No H/O of any chemotherapy or radiotherapy

8. SURGICAL HISTORY Patient was diagnosed with AUB-A for which she underwent Total Abdominal Hysterectomy with Bilateral Salpingo -oophorectomy at a private hospital in Gwalior in December 2023. Pre-surgery USG – Bulky uterus, polyp in endometrial cavity with adenomyotic changes. 13X7 mm echogenic lesions present in endometrial cavity . I/O- Uterus enlarged to 8-10 weeks size, Bladder congested Cervix hypertrophied and congested. Post operatively Foley’s catheter was kept for 10 days. Histopathology report- not available

9. PERSONAL HISTORY Education- 5th standard Occupation – Unskilled labourer Patient consumes vegetarian diet Bowel habits are normal Sleep disturbed due to continuous dribbling of urine No addictions SOCIO-ECONOMIC STATUS Lower class according to modified kuppuswamy scale. FAMILY HISTORY No h/o similar complaints in any other family member. No h/o any other chronic illness or malignancy in past.

10. EXAMINATION Patient is conscious, co-operative and well oriented to time, place and person GC- fair Hydration- adequate Pallor – nil No icterus, cyanosis, clubbing, lymphadenopathy, edema Breast , Thyroid- NAD Gait/ Spine- Normal PR- 70/min, BP- 120/76 mm Hg CVS/ Chest- NAD

11. EXAMINATION Thyroid- NAD Breast – Bilateral soft, no palpable mass, lump, discharge ANTHROPOMETRY Height- 140 cm Weight – 40 kg BMI- 20.4 kg/m 2

12. Per Abdomen Examination Inspection- Contour normal No Distension Umbilicus – central, inverted Mini-lap ligation scar + Pfannesteil scar + No dilated veins, sinus All hernial sites intact

13. Per Abdomen Examination Palpation Soft No guarding/ tenderness/ rigidity No organomegaly Percussion Tympanic note + No free fluid Auscultation Bowel sounds present

14. Examination Local Examination External Genitalia appears normal Soddening of skin + Diaper Rash + Vulva moist No local lesion present

15. Examination Per speculum examination Ammoniacal odour + Pooling of urine noted in vagina 1 cm fistula opening seen at the level of vault in the midline Per vaginal examination Same fistulous opening felt at the level of vault in midline No growth/mass felt Bilateral adnexa- non tender Vagina- mobile Fibrosis + around the margins of fistula

16. INVESTIGATIONS All routine blood investigations – W/N/L Urine routine microscopy- NAD Urine culture- sterile Pre surgery(TAH) PAP Smear – NILM Mammography – Bilateral BIRADS 1

17. CYSTOSCOPY 1 cm fistula noted in the supra-trigonal area. Away from both the ureteric orifices. Ureteric orifices – Normal Trigone – Normal Bladder wall – Normal

18. CECT UROGRAPHY Abnormal communication between posterior wall of bladder and vagina with extension of contrast from vagina into the urinary bladder lumen, s/o VVF formation. Fistulous tract– 6.7X4 mm. Bilateral kidney normal Bilateral ureter normal No obvious enlarged lymph node Impression – VVF

19. CECT UROGRAPHY

20. SUMMARY 49 years, P5L5, post TAH with BSO with complain of constant dribbling of urine from vagina since last 8 months (1 month post surgery) with 7-8 mm vesico -vaginal fistula at the level of vault in the midline, planned for VVF repair (vaginal route)- flap splitting technique.

21. MANAGEMENT Patient planned for VVF repair- vaginal route. Patient underwent VVF repair by Flap splitting technique with an indwelling catheter inserted for 2 weeks. Post operative phase was uneventful and patient was discharged on POD 3 with an indwelling catheter.

22. Classification of VVF by Kees Waaldijk Type I : Fistulae ≥5 cm from the EUO and therefore not involving the closing mechanism, urethra and bladder neck are intact. - Waaldijk K. Int J Gynaecol Obstet 1995

23. Type II : Fistulae that involve the closing mechanism (<5cm from the EUO): A. Without (sub)total involvement of the urethra: (a) without a circumferential defect (b) with a circumferential defect B. With (sub)total involvement of the urethra: (Urethral remnant of less than 1.5cm) (a) without a circumferential defect (b) with a circumferential defect. Type III : Miscellaneous fistulae, e.g. uretero-vaginal and other exceptional fistulae. *Sub-classification by size Small <2cm Medium 2-3cm Large 4-5cm Extensive 6 or more cm

24. Kees Waaldijk’s classification IIAa IIBa IIBb IIAb

25. Judith Goh’s Classification - Based on three variables Urethral length Type 1: Distal edge of fistula >3.5 cm from the external urethral orifice orifice (EUO), i.e. the urethra is not involved Type 2: Distal edge 2.5–3.5 cm from the EUO Type 3: Distal edge 1.5–<2.5 cm from the EUO Type 4: Distal edge <1.5 cm from the EUO. Fistula Size (a) Size <1.5 cm (b) Size 1.5–3 cm (c) Size >3 cm. Scarring I. No or mild fibrosis around fistula/vagina, and/or vagina length >6 cm or normal capacity II. Moderate or severe fibrosis around fistula and/or vagina, and/or reduced vaginal length and/or capacity III. Special considerations, e.g. circumferential fistula, involvement of ureteric orifices, Post radiation, previous repair - Goh JT. Aust N Z J Obstet Gynecol , 2004

26. VVF can also be classified as either simple or complex. Any fistula which is solitary and is ≤0.5 cm in size in a nonirradiated and nonmalignant situation is termed as a simple fistula. Fistulas that are large in size (≥2.5 cm), multiple, have history of failed previous fistula repair, are associated with chronic infection and disease, are postradiation induced, or are associated with malignancy are termed as complex fistulas . Stamatakos M, Sargedi C, Stasinou T, Kontzoglou K. Vesicovaginal f istula: Diagnosis and management. Indian J Surg 2014;76:131‐6.

27. Classification based on degree of anticipated difficulty of repair : - WHO Manual on Obstetric fistula 2006

28. Chinthakanan O, Sirisreetreerux P, Saraluck A. Vesicovaginal Fistulas: Prevalence, Impact, and Management Challenges.  Medicina . 2023; 59(11):1947. https:// doi.org /10.3390/medicina59111947

29. Chapter 129, Campbell-Walsh-Wein Urology 12 th edition

30. Angioli R, Penalver M, Muzii L, Mendez L, Mirhashemi R, Bellati F, Crocè C, Panici PB. Guidelines of how to manage vesicovaginal fistula. Crit Rev Oncol Hematol . 2003 Dec;48(3):295-304. doi : 10.1016/s1040-8428(03)00123-9. PMID: 14693342.

31. Rajaian S, Pragatheeswarane M, Panda A. Vesicovaginal fistula: Review and recent trends. Indian J Urol. 2019 Oct-Dec;35(4):250-258. doi : 10.4103/iju.IJU_147_19. PMID: 31619862; PMCID: PMC6792412

32. Chapter 129, Campbell-Walsh-Wein Urology 12 th edition

33. . Total 124 patients were included in the study. 30 patients underwent VVF repair by transabdominal technique and 66 through transvaginal technique. The length of hospital stay and mean operating time was longer in the abdominal group. The number of both first and second recurrent cases was higher in the transvaginal route . No significant difference in terms of blood loss.

34. CONSERVATIVE METHODS- NEWER TRENDS Continuous bladder drainage (CBD) Catherisation with fulguration of the fistula tract Fibrin Glue injection Injection with Platelet Rich Plasma Anticholinergics For intractable and recurrent VVF – Percutaneous nephrostomy (PCN), PCN with bilateral ureteric occlusion, isobutyl-2-cyanoacrylate injection, ballons, nylon plugs, coils, gelatin sponges, fulguration Rajaian S, Pragatheeswarane M, Panda A. Vesicovaginal fistula: Review and recent trends. Indian J Urol. 2019 Oct-Dec;35(4):250-258. doi : 10.4103/iju.IJU_147_19. PMID: 31619862; PMCID: PMC6792412

35. . Effectiveness of fibrin glue to omental flap was compared in reducing the failure of laparoscopic VVF repair of large size. 40 patients with VVF were enrolled and divided in two groups of 20 each. Of 20 patients in fibrin glue group no failure was seen, while 5 patients out of 20 in omental flap group had failure. The result was statistically significant and therefore, use of fibrin glue was considered during laparoscopic repair of VVF.

36. . Platelet rich plasma and platelet rich fibrin glue were prepared from 12 patients’ own blood. <5mm fistula size patients were taken. De-epithelization was performed around the fistula until a small hemorrhage occurred. Platelet rich plasma was injected around the fistula into the tissue and platelet rich fibrin glue was interpositioned in the tract. ICIQ-UI and ICIQ-QOL showed remarkable improvement in 11 patients. Hence, this technique offered a safe, effective and novel minimally invasive approach.

37. TIMING OF SURGERY- EARLY OR LATE ? Usually, the repair is performed at 12 weeks duration after the diagnosis. Timing of the repair is influenced by factors such as: Nature of injury leading to fistula Nutritional status of the patient Presence of infection and foreign body. Immunocompromised status Rajaian S, Pragatheeswarane M, Panda A. Vesicovaginal fistula: Review and recent trends. Indian J Urol. 2019 Oct-Dec;35(4):250-258. doi : 10.4103/iju.IJU_147_19. PMID: 31619862; PMCID: PMC6792412

38. There is no definite data regarding the most appropriate timing for VVF repair. Both the timing and route of repair are best tailored to the individual patient. Blaivas , J.G.; Heritz , D.M.; Romanzi , L.J. Early versus late repair of vesicovaginal fistulas: Vaginal and abdominal approaches. J. Urol. 1995 , 153 , 1110–1113. G eneral consideration is the presence of healthy surrounding tissue. The healing of inflammation, infection, and tissue necrosis takes 2 to 3 months. Therefore, delayed VVF repair increases the chance of success Ghoniem , G.M.; Warda, H.A. The management of genitourinary fistula in the third millennium. Arab. J. Urol. 2014 , 12 , 97–105. However, delayed treatment of a VVF impacts the patient's quality of life and has detrimental social consequences Ahmed, S.; Holtz, S.A. Social and economic consequences of obstetric fistula: Life changed forever? Int. J. Gynecol. Obstet. 2007 , 99 (Suppl. 1), S10–S15.

39. The timing of VVF repair can be categorized into early and late repair. Early repair is performed immediately after to 4 months after detection of the VVF. The most common cut-off is 6 weeks The success rate does not significantly differ between early and late repair (86-100% and 67-100%, respectively) Blaivas , J.G.; Heritz , D.M.; Romanzi , L.J. Early versus late repair of vesicovaginal fistulas: Vaginal and abdominal approaches. J. Urol. 1995 , 153 , 1110–1113. Experts generally recommend a 4- to 6-week interval from the onset of the fistula to surgical treatment. Angioli , R.; Penalver , M.; Muzii , L.; Mendez, L.; Mirhashemi , R.; Bellati , F.; Crocè, C.; Panici , P.B. Guidelines of how to manage vesicovaginal fistula. Crit. Rev. Oncol. / Hematol . 2003 , 48 , 295–304.

40. This interval should be 2 to 3 weeks for the transvaginal approach and 3 to 6 months for the abdominal approach. With respect to the cause of the VVF, uncomplicated postgynecologic fistulas should be repaired immediately. The interval should be 3 to 6 months after obstructed labor and 6 to 12 months after radiotherapy.

41. 41 Laparoscopic and Robotic-assisted Vesicovaginal Fistula Repair: A Systematic Review of the Literature J Minim Invasive Gynecol,2015 Eligible studies, published between 1994 & 2014 included Both laparoscopic & robotic can be done trans-vesically(O’Conor) or extra-vesically Results: Success rate of transvesical and extravesical techniques were 95.89% & 98.04% (relative risk, .98; 95% confidence interval, .94-1.02). Conclusion: Transperitoneal extravesical VVF repair has cure rates similar to the transvesical approach

42. CURRENT TRENDS IN SURGICAL MANAGEMENT AND SURGICAL TECHNIQUES In the hands of experienced surgeons, laparoscopic and robotic-assisted extravesical VVF repair is a safe, effective, and minimally invasive technique with outstanding cure rates comparable to those of the conventional transvesical approach [ 17 ]. 2023- Vaginal- Laparoscopic Repair (VLR) of primary and persistent VVF Natural Orifice Transurethral Endoscopic Vesicovaginal Fistula (NOTE-VVF) for treatment of early and small fistulas . Chinthakanan O, Sirisreetreerux P, Saraluck A. Vesicovaginal Fistulas: Prevalence, Impact, and Management Challenges.  Medicina . 2023; 59(11):1947. https:// doi.org /10.3390/medicina59111947

43. POST OPERATIVE CARE Simple fistulas – 10 to 14 days Complex fistulas- 14 to 21 days Placement of suprapubic cystostomy drainage tube is an option Encourage ambulation Prophylactic antibiotics Anticholinergics A retrograde cystogram may be obtained before catheter removal to ensure fistula closure. Patients are advised to avoid the use of tampons and refrain from sexual activity for 2 months after the procedure. Chinthakanan O, Sirisreetreerux P, Saraluck A. Vesicovaginal Fistulas: Prevalence, Impact, and Management Challenges.  Medicina . 2023; 59(11):1947. https:// doi.org /10.3390/medicina59111947

44. Rajaian S, Pragatheeswarane M, Panda A. Vesicovaginal fistula: Review and recent trends. Indian J Urol. 2019 Oct-Dec;35(4):250-258. doi : 10.4103/iju.IJU_147_19. PMID: 31619862; PMCID: PMC6792412

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