Recurrence rates after RVF repair are high and did not differ by fistula etiology. Abdominal repair of RVF had significantly fewer recurrences.

A wide variety of fistulae occur in the female pelvis, most of which cause significant morbidity. Diagnosis, characterization, and treatment planning may be difficult using traditional imaging modalities such as fluoroscopy and computed tomography. To date, there is no comprehensive literature review of the radiologic findings associated with various types of female pelvic fistulae, and furthermore, none dedicated to magnetic resonance imaging (MRI). In this article, we seek to provide a broad overview of the MRI characteristics of female pelvic fistulizing disease in combination with epidemiologic and clinical characteristics. MRI is often considered the imaging modality of choice for evaluation of fistulae owing to its superior soft‐tissue contrast and ability to provide surgeons with the highest quality information derived from just one study, including anatomic location of fistulae and associated pelvic pathology. In other instances, MRI can be complementary to the more traditional imaging techniques. This review will describe the etiology, anatomy, MRI findings, and treatment pearls for several of the more common pelvic fistulae found in female patients, including anovaginal, rectovaginal, colovaginal, vesicovaginal, colovesical, and other complex fistulae. Level of Evidence: 5 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:1172–1184

No abstract

OBJECTIVES: The American College of Obstetricians and Gynecologists supports vaginal hysterectomy as the safest and most costeffective route. While the cost-benefit ratio is favorable, there are still opportunities to optimize efficiency and contain cost. Several studies have highlighted the low instrument utilization within surgical trays, which leading to increased processing costs and surgical case setup time. Other risks related to excess surgical instruments include a reduction in instrument longevity from preventable wear-and-tear, increased risk for tray assembly errors, and strain placed on operating suite staff from tray weight. A previous study in gynecologic surgery reported as few as 13% of surgical instruments on a vaginal surgery tray were used. We aimed to evaluate the instrument usage within our vaginal hysterectomy trays to reduce unnecessary instruments without compromising high quality, safe patient care. Further, we estimated cost savings from the development of a "minor gynecology" tray that could replace the vaginal hysterectomy tray previously used for benign outpatient vaginal cases. MATERIALS AND METHODS: The Female Pelvic Medicine and Reconstructive Surgeons (FPRMS) and operating suite staff first eliminated extraneous instruments based on clinical experience. Following that initial reduction, the Surgical Quality Committee initiated a formal audit of surgical instrument usage. The vaginal hysterectomy tray was used for major benign gynecology cases, including vaginal hysterectomy with and without pelvic reconstruction, urogenital and rectovaginal fistulas approached vaginally, and vaginal mesh removal. Minor gynecology cases included isolated anterior or posterior repairs, Bartholin cyst/labial lesions, urethral diverticulum, and midurethral sling placement or revision. Cost of sterile processing and packaging was estimated to be $0.51/instrument based on published data. RESULTS: The standard vaginal hysterectomy tray contains 67 instruments. This was reduced to 48 instruments in the minor gynecology tray. Processing costs were estimated to be $34.17/vaginal hysterectomy tray and $24.48/minor gynecology tray. Instrument usage for the vaginal hysterectomy tray averaged 66%, which is higher than what has been reported by other studies in gynecology. In 2015, four FPRMS specialists at our institution performed 844 cases. The cost to process the instruments for those cases would have been $28,839.48 prior to the development of the minor gynecology tray. Estimating that the minor gynecology tray could be used for 20% of those cases, we achieved a cost savings of 5.7% ($1637.61). CONCLUSION: Healthcare costs related to set-up, processing and packaging of unused surgical instruments can be reduced when surgeons and operating suite staff work together to identify opportunities to reduce inefficiencies. Cost savings are likely underestimated due to the surgeon-and operating suite staffdriven initiative to reduce the number of instruments in each tray prior to the formal audit. The development of...