Fistula.pptx it is a comon disease which require treatment

it is a complecated case and treatment is mondatory

1. VESICO VAGINAL FISTULA PRESENTER: Dr. Krishan Suyal 1

2. VESICO-VAGINAL FISTULA Vesicovaginal fistula (VVF) is an abnormal opening between bladder and vagina that results in continuous and unremitting urinary incontinence. 2

3. congenital or acquired Congenital are very rare and associated with other urogenital malformations Obstetric =developing world over 90 % of fistulas are of obstetric etiology Surgical/gynaecological =industrialized world, the most common cause (>75 %) gynaecologic and pelvic surgeries Radiation Malignancy miscellaneous causes CAUSES/ETIOLOGY 3

4. CLASSIFICATION OF VVF SIMPLE VVF <5cm size No h/o of pelvic malignancy or radiation Vaginal length normal Healthy tissue COMPLEX VVF >5cm H/o pelvic malignancy or radiation Vaginal length shortened or scarred Involving urethra, vesical neck, ureter, intestine Previous unsuccessful attempt of repair 4

5. PRESENTATION Continuous leak of urine per vagina - “CLASSIC SYMPTOM” - Immediate (post op) - Delayed (post pelvic radiations i.e months upto years) Surgical injury - first post op day Obstetric injury – 7 to14 days Small fistula : only in certain positions; pass urine normally Large fistula : not void at all but leak Menouria : cyclic heamaturia at time of menstruation Recurrent cystitis, perineal skin irritation, vaginal fungal infection 5

6. EVALUATION AND DIAGNOSIS History: - Etiology, attempts of repair, comorbidities General & genital examination: - Examination with speculum “always to be performed” ; Precise assessment - location, size, number of fistulae , tissue mobility, accessibility of fistula to vaginal repair, determination of degree of tissue inflammation, edema and infection. 6

7. EVALUATION AND DIAGNOSIS 3 SWAB TEST ( Vaginal Gauze test): Three separate sponge swabs placed into vagina one above another Bladder filled with methylene blue through rubber catheter Following some exertional manuevers , swabs removed after 10 mins 7

8. EVALUATION AND DIAGNOSIS 3 SWAB TEST (Results): Discolouration of topmost or middle swab - VVF Uppermost wet but not discoloured- Ureterovaginal fistula Lower most discoloured with upper two dry- Urethrovaginal fistula 8

9. EVALUATION AND DIAGNOSIS Double Dye test: Oral phenazopyridine, fill bladder with blue tinted solution, insert tampon. Blue stain- VVF or urethrovaginal fistula Yellow orange stain ( pyridium ) – ureterovaginal fistula 9

10. EVALUATION AND DIAGNOSIS CBC, Urine analysis, Sr.creatinine Urine for culture and sensitivity Intravenous urogram (IVU) - to exclude ureter injury or fistula ( 10% VVFs associated ureter fistula) Cystoscopy - Gold standard to asses size , shape , number and location of fistulas Biopsy of fistula - Prior h/o pelvic malignancy 10

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12. EVALUATION OF VVF 12

13. Conservative management Medical therapy Surgical therapy MANAGEMENT Conservative management Surgical management 13

14. PRINCIPLES OF MANAGEMENT Ensure adequate nutrition Eliminate infection Achieve unobstructed urinary drainage Beware of malignant cause of fistula 14

15. CONSERVATIVE MANAGEMENT Indications - Newly diagnosed - <2 -3m m - Simple injuries - No devascularization or thermal injury spread Trial of indwelling catheterization and anticholinergic medication for at least 2 to 3 weeks. Failure: persistently open even after 3 weeks 15

16. PRINCIPLES OF SURGICAL REPAIR Adequate exposure of fistula tract with debridement of devitalized and ischemic tissue Removal of involved foreign bodies or synthetic materials from region of fistula, if applicable Careful dissection and/or anatomic separation of involved organ cavities Watertight closure Use of well-vascularized, healthy tissue flaps for repair (atraumatic handling of tissue) Multiple-layer closure, tension-free, nonoverlapping suture lines Adequate urinary tract drainage Maintenance of haemostasis 16

17. TIME TO REPAIR Controversial Obstetric - 3 months after delivery Surgical/ gynaecolgical - repair immediately - Otherwise after 10-12 weeks Radiation fistula after 6-12 months If repair fails reattempt after 3 months

18. Vaginal ap p roach Vaginal Flap splitting Latzko technique Abdominal approach Tansperitoneal Combined 18 Transvesical SURGICAL APPROACHES

19. Vaginal approach for VVF Repair Vaginal flap technique/Flap splitting technique 19

20. Vaginal approach: Flap splitting technique Dorsal lithotomy position Rectal packing and cystoscopy done Ureteral catheters placed if needed Fistula tract cannulation: Foley (10 to 12 Fr), gentle downward traction maintained to pull VVF toward introitus Fistula tract is carefully circumscribed Vaginal wall flaps: Dissect in a proximal, distal, and lateral direction away from fistula tract. Each mobilized 2 to 4 cm from fistula tract, exposing underlying perivesical fascia. First layer repair: Interrupted 3-0 or 4-0 absorbable sutures in a transverse or vertical fashion, incorporates bladder wall and fistulous tract

21. Vaginal approach: Flap splitting technique Second layer repair: Interrupted 2-0 or 3-0 absorbable sutures, to invert previous layer by imbricating perivesical fascia and deep musculature of bladder Third layer repair: vaginal wall flaps closure Vaginal wall closure: Running, locking, absorbable 2-0 suture Antibiotic impregnated vaginal packing placed Urethral Foley and suprapubic catheters placed for 10 to 14 days. 21

22. Vaginal approach: Flap splitting technique 22

23. Vaginal approach: Flap splitting technique 23

24. Vaginal approach for VVF Repair Latzko procedure 24

25. Vaginal approach: Latzko technique Denuding vaginal epithelium around fistula tract: Fistula tract isolated Vaginal epithelium surrounding VVF tract denuded circumferentially - 1 to 2 cm. First layer repair: Denuded areas reapproximated over fistula tract with interrupted absorbable sutures but not placed into bladder wall or vesical mucosa. Second layer repair: Edges of vaginal wall reapproximated creating a partial colpocleisis

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28. Vaginal approach: Latzko technique Advantages: Minimal blood loss No need for ureteral reimplantation (even for a fistula adjacent to ureter, because sutures are not placed through the bladder) Short convalescence Disadvantages: Possibility of vaginal shortening Creation of directly overlapping suture lines 28

29. VAGINAL V/S ABDOMINAL APPROACHS Avoids laparotomy and splitting of bladder Recovery is shorter with less morbidity Less blood loss Procedure can be done in an outpatient setting Postoperative pain is minimal Results comparable Vaginal shortening may be an issue in Latzko operation 29

30. ABDOMINAL APPROACH INDICATIONS High inaccessible fistula Multiple fistula Involvement of uterus or bowel Need for ureter re-implantation Complex fistula Associated pelvic pathology Surgeon preference 30

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32. Abdominal Approaches for VVF Repair Suprapubic intraperitoneal or Extraperitoneal Approach 32

33. Abdominal approach : Suprapubic intraperitoneal or Extraperitoneal Approach Position: Low lithotomy position with access to vagina Ureteral catheters may be placed Incision and Dissection: Lower midline ( O’Conor and colleagues) Bladder approached extraperitoneally In some cases, peritoneum entered Bladder opened vertically(bivalved), extended down to the opening of VVF and distally, stay sutures placed on bladder edges to assist in retraction. VVF tract excised and vesicovaginal space created. Vagina dissected 2 to 3 cm beyond VVF

34. Abdominal approach : Suprapubic intraperitoneal or Extraperitoneal Approach key to the operation is mobilization of bladder from vagina caudal to (beyond) VVF tract. Repair: Vagina closed with running absorbable suture. Interpositional flap of greater omentum is mobilized and secured 1 to 2 cm distally beyond excised VVF tract. Bladder closed in several layers. Suprapubic tube and urethral catheter left for postoperative drainage. 34

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36. Abdominal Approaches for VVF Repair Transvesical Approach 36

37. Abdominal approach: Transvesical approach Incision, Dissection & Repair: Bladder opened through a vertical cystotomy but not bivalved VVF tract circumscribed and excised transvesically Vaginal edges mobilized from bladder Vagina and bladder closed sequentially A V-shaped flap of adjacent posterior bladder wall may be brought down as a flap to close a large gap or to minimize overlapping suture lines 37

38. Adjuvant Procedures in the Repair of Vesicovaginal Fistula: Tissue Interposition Martius Flap Peritoneal Flap Greater omental flap Other flaps and grafts - Gracilis flap - Bladder mucosa as free graft - Rectus abdominis 38

39. Tissue Interposition: Martius Flap Reliable source of tissue - low or distal fistulae Preferential tissue for fistula involving the trigone, bladder neck and urethra. Consisting of: Adipose tissue, connective tissue Blood supply - inferiorly from posterior labial vessels, superiorly from external pudendal artery and laterally from obturator artery. Lateral blood supply is sacrificed during mobilization of the flap 39

40. Tissue Interposition: Martius Flap Division of flap: Either its most superior or inferior margin (basing the blood supply on the inferior or superior vascular pedicle, respectively), depending on where flap will be transferred Procedure: Flap harvested after first two layers of closure of VVF but before advancing final vaginal wall flap over repair Vertical incision made over labia majora 40

41. Tissue Interposition: Martius Flap Procedure: Borders of dissection include labiocrural fold laterally, labia minora and bulbocavernosus muscle medially and Colles fascia covering urogenital diaphragm posteriorly Flap harvest is accomplished in a lateral to medial fashion For a posterior-based flap, main vascular supply to flap is located at base of labia majora. Anterior segment is clamped and transected anterior to pubic symphysis 41

42. Tissue Interposition: Martius Flap Procedure: With flap having been mobilized, a tunnel created from labial incision to the site of fistula repair A hemostat used to transfer flap from harvest site Flap placed over the fistula repair and secured with interrupted absorbable sutures Vaginal wall flap advanced over Martius flap and closed Labial incision closed Pressure dressing may be applied to labial skin incision “ Eilber and colleagues (2003) reported that 33 of 34 (97%) patients undergoing repair of a distal VVF with a Martius flap were cured after the first operation” 42

43. Tissue Interposition: Martius Flap 43

44. Tissue Interposition: Martius Flap 44

45. Tissue interposition: Peritoneal Flap Uses: In conjunction with repair of a high-lying posthysterectomy VVF Procedure: Peritoneum and preperitoneal fat identified, isolated and mobilized from caudal origin of vaginal wall flap using sharp dissection Peritoneum not opened but mobilized and advanced over fistula repair and secured with interrupted absorbable sutures 45

46. Tissue interposition: Peritoneal Flap “ success reported in 9 of 11 patients with high VVF undergoing peritoneal flap placement (Raz et al, 1993)”. “Later study from the same institution reported on use of peritoneal flaps in 83 patients, of whom 80 were cured after first operation ( Eilber et al, 2003)”. 46

47. Tissue interposition: Peritoneal Flap 47

48. Tissue interposition: Greater Omentum Uses: Adjunct during transabdominal VVF repair (most common) Favorable properties of omentum : Ability to be mobilized on a well-vascularized pedicle into deep pelvis without tension Inherent lymphatic properties Healing even in presence of infection Ease with which epithelialization occurs on its surface 48

49. Tissue interposition: Greater Omentum Blood supply: Principally from right and left gastroepiploic arteries Distal branches of gastroduodenal and splenic arteries Procedure: Omental flap secured with absorbable suture to healthy tissue at a location distal to and beyond closed VVF tract, between the vagina and bladder “ Orford and Theron (1985) reported a 93% cure rate with use of an omental pedicle graft in 52 patients undergoing VVF” 49

50. Tissue interposition: Other Flap and Graft Techniques ( Gracilis muscle flaps) Procedure: Muscle is mobilized through a thigh incision from its distal attachment on tibial condyle Tunneled cephalad into vagina subcutaneously and secured over fistula. Bilateral gracilis muscle flaps can be used for total vaginal reconstruction. 50

51. Tissue interposition: Other Flap and Graft Techniques (Bladder mucosa as a free graft ) Procedure: Bladder approached extraperitoneally and a small cystotomy performed Fistula tract identified and denuded of mucosa circumferentially for approximately 1 cm Free graft of bladder mucosa harvested from edge of cystotomy and placed over denuded VVF tract and secured in place with absorbable suture 51

52. Tissue interposition: Other Flap and Graft Techniques ( Rectus abdominis flaps) Procedure: Subcutaneous tissue elevated off anterior rectus sheath. Anterior rectus sheath superior to the arcuate line elevated off the rectus abdominus muscle. Rectus muscle elevated off the posterior rectus sheath. RAM flap divided superiorly at its tendon insertion to the rib. Posterior sheath incised, so the RAM flap could be passed through into abdominal cavity. Rectus muscle completely transected from its attachment , keeping attached only by its inferior blood supply. Flap transposed to lie between the bladder and vagina. 52

53. Tissue interposition: Other Flap and Graft Techniques ( Rectus abdominis flaps) 53

54. Robotic-Assisted Laparoscopic Repair of Vesicovaginal Fistula Procedure: Peritoneum between bladder and vagina incised Posterior bladder wall incised vertically and dissection continued until catheter going across fistula seen Incision carried downward as far as fistula tract 54

55. Robotic-Assisted Laparoscopic Repair of Vesicovaginal Fistula Repair: Vaginal closure initiated at apex of incision in one layer using continuous transverse 2-0 absorbable suture Interposition of omentum or pericolic or mesenteric fat over vaginal suture line A suture is then placed at anterior vaginal wall, distal to vaginal closure. This suture is used to anchor part of omental flap Bladder closure is subsequently performed in two layers: first, mucosal closure with continuous 3-0 absorbable suture, seromuscular closure with interrupted 2-0 absorbable suture 55

56. Robotic-Assisted Laparoscopic Repair of Vesicovaginal Fistula “Gupta and colleagues evaluated robotic-assisted laparoscopic versus open repair for recurrent VVF without any significant statistical difference in success rate (100% vs. 90%), mean operative time, complication rate, use of interpositional flap (omental vs. peritoneum), or complications ”. “The most significant difference between two groups was shorter average hospitalization (3.1 vs. 5 days) favoring robotic-assisted group, with decreased morbidity as opposed to open surgery”. 56

57. POSTOPERATIVE CARE Bladder should be drained for 14-21 days Excellent hydration to ensure irrigation of bladder and to prevent clots that could obstruct bladder Catheter blockage should be prevented Cystogram is to evaluate integrity of bladder before discontinuing bladder drainage 57

58. INSTRUCTION ON DISCHARGE Contraceptive advice - spacing for 1-2 years Abstinence for 3 months Maintain hygiene If pregnancy occurs elective C/section is indicated as when fetus attains maturity 58

59. CONCLUSION Optimal approach for VVF repair depends on surgeon expertise The surgeon’s experience and skill set guide the selection of surgical approach, taking into account cause, localization, size, time of presentation, and complexity of fistula. 59