Complex obstetric fistulas

Abstract

Obstetric fistulas are rarely simple. Most patients in sub-Saharan Africa and parts of Asia are carriers of complex fistulas or complicated fistulas requiring expert skills for evaluation and management. A fistula is predictably complex when it is greater than 4 cm and involves the continence mechanism (the urethra is partially absent, the bladder capacity is reduced, or both); is associated with moderately severe scarring of the trigone and urethrovesical junction; and/or has multiple openings. A fistula is even more complicated when it is more than 6 cm in its largest dimension, particularly when it is associated with severe scarring and the absence of the urethra, and/or when it is combined with a recto-vaginal fistula. The present article reviews the evaluation methods and main surgical techniques used in the management of complex fistulas. The severity of the neurovascular alterations associated with these lesions, as well as inescapable limitations in staff, health facilities, and supplies, make their optimal management very challenging.

Outcome of using a modified surgical technique for the repair of complex vesicovaginal fistulas in Nigeria

“…12,18 Conversely, repeated failed attempts at repair aggravates the condition and decreases the chances of successful repair for any given patient.…”

Repair of vesicovaginal fistula by the transabdominal route: outcome at a north Indian tertiary hospital

“…Urinary diversion is advocated in patients with multiple failed repairs [2,3,14]. Hilton and Ward reported urinary diversion in 0.6% of 2,484 patients of VVF [24].…”

“…It creates high psychological morbidity and causes social embarrassment to the patient [1]. The abdominal route of VVF repair is indicated in patients with high-up supratrigonal fistulae, VVF associated with ureterovaginal fistula, VVF with lower ureteric stricture, ureteric orifice at the margin of fistula, multiple failed vaginal repair with vaginal shortening and stenosis, radiation fistula, small-capacity bladder requiring augmentation, inability to place the patient in lithotomy position, or surgeon's preference [1][2][3][4][5][6]. The advantages of abdominal repair are simultaneous ureteric reconstruction or bladder augmentation and/or placement of interposition flap such as omentum, peritoneal flap, or tinea epiploicae of sigmoid colon [7][8][9][10].…”

S3-Leitlinie: Rektovaginale Fisteln (ohne M. Crohn)

“…Sie sind Folge des Dehnungstraumas sub partum mit Zerreißung des Damms und des rektovaginalen Septums [92]. Insgesamt 5% aller vaginalen Entbindungen führen zu einem dritt-oder viertgradigen Dammriss.…”