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HOLES WHERE THEY SHOULDN’T BE

Fistula Review for the General Gynecologist

Definition:

Obstetric Fistulas Worldwide

Perineal Breakdown

Making the diagnosis

Treatment Preferences

Key Points

• Majority of gynecologic fistulas in the US are our fault😷

• Early recognition is key🔎

• Even better – prevention! 🚧

• Accompanied by major social/emotional distress😪

1845 encountered his first fistula case

Took 30 operations to close

1855 opened world’s first fistula hospital in New York – modern day “Waldorf Astoria Hotel”

Dr. J. Marion Sims – the “father of American gynecology”

VVF: vesicovaginal

UVF: Ureterovaginal Fistula

VUF: vesicouterine

RVF: rectovaginal

OF: Obstetric fistula (RF and VF)

Overview of Fistula Types

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Etiology of Fistulas

Obstetric

8%

Pelvic

Surgery

90%

Other

2%

Developed

Obstetric

95%

Other

5%

Developing

Other Etiologies

90%occur during surgery for benign conditions

70% TAH

Vesicovaginal Fistula

Childbirth

Inflammatory Bowel Disease

Radiation

Prior Surgery

Infection

Rectovaginal Fistula

10-15% of VVF also have ureteral involvement

Ureterovaginal fistula

Vesicouterine Fistula

Cause: surgical injury during c-section• Rarely: uterine rupture, supracervical

hyst, operative vaginal del, d&cPresentation: urine leak through cervix or cyclical hematuria

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Complications from Obstetric Lacerations

Infection Breakdown

Secondary Repair

Vascular compromise

RV Fistula in

5-10% of women with 3-4th degree repair

Risk factors High BMI

Operative vaginal delivery

4th deg lac

DM/smoker

Present: pain, anal incontinence, fever, malodorous discharge

Management Early vs Delayed repair

Perineal Breakdown

Identify entirety of tear

Rectal exam on all

Irrigation

Interrupted delayed absorbable suture

One dose antibiotic?

2nd gen ceph or clinda if allergy

Keep clean and closely monitor those with risk factors

Perineal breakdown:

Prevention

To give or not The data for

Antibiotics

Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized controlled trial. AU Duggal N, Mercado C, Daniels

K, Bujor A, Caughey AB, El-Sayed YY SO Obstet Gynecol. 2008;111(6):1268.

147 women with 3rd or 4th

degree lac randomized to placeebo vs single dose of cefotetan or cefoxitan2 weeks later: Breakdown of wound 24% vs 8% (without vs with antibiotics)

Cochrane 27% lost to follow-up, therefore not great evidence and interpret as you wish.

Early vs Delayed

Perineal Breakdown: Management

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Detection in a clinical settingCC: Continuous leakage

History

Remember risk factors?

Physical

Thorough exam to detect source of leak

Scopes

Vaginoscopy

Hysteroscopy

Cystoscopy

Diagnostic eval

10-15% of VVF have concomitant ureteral involvement. Must evaluate!

Look further

Intravenous Pyelogram

Bladder Fill Test

Risk factors: prior CS, distorted anatomy

Signs

Gas in Foley bag

Bloody urine in Foley bag

Urinary drainage from secondary trocar site

Fluid pooling in abdomen

Cystoscopy

Undiagnosed: evident days to weeks after, months and even years later

Intraoperative Detection:

Bladder trauma

Cystoscopy

Cystoscopy

471 patients enrolled, 23 (5 percent) had a lower

urinary tract injury. 30 percent (one ureteral

and six bladder injuries) were detected prior to cystoscopic survey.

Detection of injury without routine cysto is 18% for ureteric injury and 79% for bladder injury.

With routine cystoscopy, intraoperative detection was 95%

Routine Cysto?

All types of hysterectomy

Intraoperatively detected rates of ureteric and bladder injury were markedly higher with routine intraoperative cystoscopy. 1.6 vs 0.7 per 1,000 surgeries

To do an adequate RCT 25,500 patients in each arm to detect difference

Routine Cysto? Green Journal Dec 2015 Systematic Review of 79 studies

Pro Cysto (Academic) Anti Cysto (Private Practive)

Improved detection of intraoprateive injury

Varied cost per facility

Timely referral saves $$$ and stress for patient

Added OR time

Difficult to predict, need for systematic approach

Incidental findings unneccessary modifications

Not 100% sensitive – miss delayeddamage (heat, suture)

Routine Cysto?

Patient selection

Higher risk if: prior pelvic surgery, endometriosis, riary tract abnormalities, hx radiation, obesity, large pelvic mass, fibroids

Foley catheter bladder decompressed

Triple lumen to inject contrast if needed

During hyst

constant upward traction on uterus

Dissect pubovesical fascia anterior to cervix

Sharp >> blunt dissection

Ureteral catheters?

Direct visualization during insertion of ports – ensure empty bladder

If difficult visualization inject 5cc of methylene blue or sterile milk to visualize the bladder

Intraoperative Prevention

Catheter

Spontaneous closure with cath placement: 1-8%,

O% after 10 weeks

Size dependent

Treatment Basics= catheter and counseling

(and phone a friend)

So you’ve detected an injury – now what?

Counseling

Timing

Technique

Perioperative management

Surgical repair

Early repair (within 4 weeks)

72% success

Delayed repair (3-5 months)

94% success

Timing

Vaginal

Abdominal

Laprascopic

Interpositional flaps

Technique

Vaginal-Latzko Technique

Martius BulbocavernosusFat Pad Flap

Abdominal

{ “Fistula Belt” northern

half of sub-Saharan Africa into Middle East Asia

Estimated 1-2/1000 deliveries

About 2 million women waiting for treatment

~100,000 new cases annually

Obstetric Fistulas Worldwide

Average walk of 12 hours + avg bus ride 34 hours

Average age ~22, 84% <20yo

Average age of marriage ~14.7

50% with no formal education

56% with no prenatal care

86% delivered at home

Aerage height: 4 ft 10 inches

Average labor duration: 3.8 days

93% stillbirth

Of those seeking care for Obstetric Fistulas…

Learn More…

Similar rates until 1940s

In the US

Majority of gynecologic fistulas in

the US are our fault😷Early recognition is key

🔎

Even better – prevention! 🚧

VVF are associated with major social/emotional distress😪

Key points

Always keep in mind during gynsurgery

Intraoperative vs at time of delivery

Avoid obstructed labor, wound breakdown, bladder damage

Counseling and support should be a part of every treatment regimen

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Williams Gynecology

“Rectovaginal Fistula” Journal of Pelvic Medicine and Surgery. Fellows Lecture Survey. Vol 11:6. Nov/Dec 2005

“Modern Management of Fistula” JPMS. Fellows Lecture Series. Vol 11:6. Nov/Dec 2005.

The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy.

AU Vakili B, Chesson RR, Kyle BL, Shobeiri SA, Echols KT, Gist R, Zheng YT, Nolan TE SO Am J Obstet Gynecol. 2005;192(5):1599.

References