Uro gynacology- vvf

Uro gynacology- vvf

1. GENITO URINARY FISTULAE

VESICO VAGINAL FISTULA
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

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2. Moderators:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,

Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH, Chennai
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3. GENITO-URINARY FISTULAE
An extra-anatomic communication between two or more
epithelial or mesothelial-lined body cavities or the skin surface.


Wein, Alan J. et al., Campbell-Walsh Urology, 10
th
Ed., Vol 3, 2012

Dept Of Urology, KMC and GRH, Chennai 3

4. VVF- Etiology
 Two main causes:
Obstetric – Developing countries
Iatrogenic – Developed countries
Surgical, mainly.

Other etiologies:
Malignancy
Radiation
Infection (including TB)
Foreign body (i.e. retained pessary, eroded mesh, calculi)
Sexual assualt (traumatic- rape or under-aged marriages most common
setting)

Smith GL, Williams G. BJU Int. 1999 Mar;83(5):564-9

Dept Of Urology, KMC and GRH, Chennai
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5. Etiology
Developed countries - Gynecological surgery

Incidence rate of VVF after total abdominal
hysterectomy (TAH) of 0.5-2%

TAH - Incidental unrecognized iatrogenic
bladder injury near the vaginal cuff(benign cause)

Other causes –
 malignant disease,
 pelvic irradiation, and
 obstetric trauma
Dept Of Urology, KMC and GRH, Chennai
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6. Obstructed labour

 7 million cases worldwide annually
6.5 million occur in developing nations

2-7 million affected cases of VVF- world wide

Obstetric fistula – 50,000 to 1,00,000 cases/year

100 fold disparity in maternal mortality exists between industrialized nations and
developing countries.


Early age of marriage, CPD, illiteracy and malnutrition



Wall LL. Lancet. 2006 Sep 30;368(9542):1201-9

Dept Of Urology, KMC and GRH, Chennai
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7. BLADDER INJURY
Incidence
10/10,000 deliveries
14/10,000 caesarean
100/10000 Gynaec surgeries
250/10000 Cystocele Repair

Dept Of Urology, KMC and GRH, Chennai
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8. Prolonged obstructed labour
widespread tissue
edema, hypoxia,
necrosis, and sloughing
resulting from prolonged
pressure on the soft
tissues of the vagina,
bladder base, and
urethra.
Dept Of Urology, KMC and GRH, Chennai
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9. RISK FACTORS
Intraoperative bladder injury
Prior uterine surgery
Endometriosis
Infection
Diabetes
Arteriosclerosis
Pelvic inflammatory disease
Prior radiotherapy
Dept Of Urology, KMC and GRH, Chennai
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10. PROBLEMS
Delayed diagnosis

Abandoned from their families(60 – 70% in india)

Co –Morbidity
Infection
Bladder stones
Infertility
malignancy
Dept Of Urology, KMC and GRH, Chennai
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11. Factors in prevention (Hutch)
Immediate detection of bladder injury
Water tight closure of bladder injury
Extravesical drain placement
Avoidance of vaginal incision if possible
Prolonged uninterrupted post op bladder drainage
Dept Of Urology, KMC and GRH, Chennai
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12. Clinical features
The uncontrolled leakage of urine into the vagina is
the hallmark symptom
The drainage may be continuous; however, in the
presence of a very small VVF, it may be intermittent
Recurrent cystitis or pyelonephritis, abnormal urinary
stream, and hematuria

Dept Of Urology, KMC and GRH, Chennai
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13. Clinical features
Pain is an uncommon unless associated with skin irritation or
prior radiation therapy

VVF following surgical procedures may present on catheter
removal or 1 to 3 weeks later

VVF from radiation therapy can present months to years after
completion of therapy

Dept Of Urology, KMC and GRH, Chennai
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14. DD post hysterectomy clear vaginal
discharge
VVF
Fallopian tube fluid drainage
Lymphatic fistula
Urinary loss detrusor instability or poor compliance
Ectopic ureteral discharge
Ureterovaginal fistula
Spontaneous vaginal secretions

Dept Of Urology, KMC and GRH, Chennai
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15. Evaluation
Any fluid collection tested for urea, creatinine to
diagnose VVF

Urine culture and sensitivity

In patients with a h/o local malignancy, a biopsy of
the fistula tract

Dept Of Urology, KMC and GRH, Chennai
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16. DOUBLE DYE or TAMPOON TEST
For diagnosing vesicovaginal or ureterovaginal fistulae. oral
phenazopyridine (Pyridium),methylene blue is filled in to the
empty bladder via a urethral catheter.


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17. Imaging Studies
USG ( in ureterovaginal fistula - HUN +,collection)

IVU (R/o ureteral injury or fistula 10%)

MCU (CYSTOGRAM)

RGP ROLE

CT UROGRAM / MRU - ? Invest. Of choice




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18. Cystogram in VVF
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19. IVU
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20. Fistula
Bladder
Vagina
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21. MR UROGRAM
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22. Cystoscopy
To assure bilateral ureteral patency

To determine the location, number and proximity to
ureteric orifices,

 To look for suture placement in the bladder or
urethra


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23. Cystoscopy
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24. Cystoscopy
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25. Complex Fistulae
Primary fistula greater than 4 cm in size
Recurrent fistula greater than 2cm in size
Fistula involving urethra and/or bladder neck
Fistula requiring ureteric reimplantation/ augmentation
cystoplasty,
Fistula with large bladder stone
Fistula with scarred and non capacious vagina
Post radiotherapy fistula
Multiple fistulae
Malignant fistulae
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26. FISTULA
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27. Dept Of Urology, KMC and GRH, Chennai
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28. Conservative Management
 VVF diagnosed within the first few days of surgery,
a transurethral or suprapubic catheter should be
placed and maintained for up to 30 days.

 Small fistulae (<0.3 cm) may resolve or decrease

if no improvement is observed after 30 days, a VVF
is not likely to resolve spontaneously
Dept Of Urology, KMC and GRH, Chennai
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29. MANAGEMENT
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30. Medications
Estrogen replacement therapy
Corticosteroid and NSAIDS
Acidification of urine
parasympatholytics
Sitz baths and barrier ointments, such as zinc oxide
preparations, can provide needed relief from local
ammoniacal dermatitis.

Dept Of Urology, KMC and GRH, Chennai
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31. Principles Of Fistula Management
Adequate nutrition
Elimination of infection
Unobstructed urinary tract drainage or stenting
Removal or bypass of distal urinary tract obstruction
Beware of malignant etiology
Dept Of Urology, KMC and GRH, Chennai
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32. Timing Of Repair
Longer intervals are universally accepted as the
standard care in infected or irradiated tissue

Primary fistulae were repaired once local vaginal
tissue was healthy and infection-free

recurrent or obstetric fistulae repair was delayed for
at least three months or unless infection-free.
Dept Of Urology, KMC and GRH, Chennai
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33. Surgical Principles
Adequate exposure,
Removal of foreign bodies
Careful dissection
haemostasis
watertight closure
Use vascularised healthy
tissue flaps

Multiple layer closure
Tension free non overlapping
suture
Adequate urinary tract
drainage or stenting
Treat infections

Dept Of Urology, KMC and GRH, Chennai
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34. Techniques Of Repair
1.Vaginal approach,
2.Abdominal approach,
3.Electrocautery
4.Fibrin glue(petersson etal..)
5.Endoscopic closure using fibrin glue with or without adding
bovine collagen,
6.Laparoscopic approach(nazler-1994)
7.Interposition flaps or grafts.
Dept Of Urology, KMC and GRH, Chennai
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35. Vaginal approach
MERITS
Minimal blood loss,
Low postoperative morbidity,
 Shorter operative time,
Shorter postoperative recovery time
Obviates bowel manipulation, reducing operative morbidity,
particularly in radiation-associated fistulas.
Easier & safer, success rate 98 to 100%
Dept Of Urology, KMC and GRH, Chennai
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36. Ring retractor & traction on catheter placed through fistula to enhance exposure
fistula
VAGINAL FLAP TECHNIQUE





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37. LATZKO REPAIR
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38. Tissue interposition
Helpul in complex fistulas
Recurrent fistulas
Post radiotherapy
Ischemic or obstetric fistulas
Large fistulas
Difficult or tenuous closure due to poor tissue quality
Dept Of Urology, KMC and GRH, Chennai
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39. Interposition flaps or grafts
Granulation Tissue Formation,
Neovascularity
Obliterating Dead Space.
A Barrier Layer
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40. Vaginal approach interposition grafts or
flaps
Martius flap
Gracilis muscle flap
Peritoneal flap

Dept Of Urology, KMC and GRH, Chennai
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41. Martius flap

The fibroadipose tissue in
the labium majus isolated.

Blood supply -(cranial via
internal pudendal artery
,caudal via external
pudendal artery laterally
via obturator artery)

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42. MARTIUS FLAP
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43. Fibrin glue
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44. Abdominal Approach
Absolute indications

The need for concomitant abdominal surgery, such as
augmentation cystoplasty and ureteral reimplantation;

Inability to adequately expose the fistula vaginally;

A complex presentation of VVF involving the ureters, bowel,
or other intraabdominal structures;

Involvement of the VVF with ureteric orifices
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45. Abdominal Approach

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46. LAPAROSCOPIC
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47. ROBOTIC VVF REPAIR
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48. URINARY CONDUIT
Multiple fistulae/ Recurrent
Complete urethral defect
Fibrosed atrophic bladder
Unrelenting urinary incontinence

Procedures
Conduits- ileal bladder
Orthotopic diversion
Dept Of Urology, KMC and GRH, Chennai
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49. Postoperative
Bladder drainage – 2 to 3 weeks

Acidification of urine

Estrogen replacement therapy

Control of postoperative bladder spasms

Antibiotic therapy

 Minimizing Valsalva maneuvers
Pelvic rest -3 months

Avoid sex or tampoon for 3 months
Dept Of Urology, KMC and GRH, Chennai
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50. Prognosis
The success rate of fistula surgery is high overall
95%
 vesico-vaginal fistulas that were associated with
recto-vaginal fistulas or uretero-vaginal fistulas had
even lower rates of successful closure
Dept Of Urology, KMC and GRH, Chennai
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51. Prognosis

The success rate declined with increasing attempts
at closure.

First attempt 70/82 (85%)
Second attempt 6/12 (50%)
Third attempt 2/6 (33%)

Dept Of Urology, KMC and GRH, Chennai
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52. Take home …
Vesicovaginal Fistula(post-op)
 obstructed labour / TAH- most common causes
Identification of proper plane between bladder and cervix, sharp
dissection of bladder, care in clamping suturing vaginal cuff (0.2 %)
 postoperative vesicovaginal fistula ; watery vaginal discharge 10
to 14 days after surgery (1
st
48 to 72 hours after surgery)
Dept Of Urology, KMC and GRH, Chennai
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53. Take home …
Vesicovaginal fistula: foley catheter inserted for prolonged drainage
Up to 15% of fistulas close spontaneously with 4 to 6 weeks of
continuous bladder drainage
Closure not occurred by 6 weeks operative correction
3 to 4 monthes from time of diagnosis  reduction of
inflammation and improve vascular supply
Three-layered closure:
Bladder mucosa
Endopelvic fascia
Vaginal epithelium

Dept Of Urology, KMC and GRH, Chennai
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54. Take home …
Incidental cystotomy at time of hysterectomy: more
common( than vesicovaginal fistula)
Repaired correctly, rarely development of fistula
Now,the trend more towards trans-vaginal (Foley pull) and also
not to excise fistulous tract or vaginal cuff.
Laparoscopy evolving technique
Robotic !!
Individualized treatment.
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55. Thank You
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