Genitourinary Fistula Research Articles

MP41-12 SIGMOID EPIPLOICA SAVES THE DAY: A STEP FORWARD IN ROBOT ASSISTED LAPAROSCOPIC GENITOURINARY FISTULA REPAIR WITH ITS USE AS TISSUE INTERPOSITION GRAFT

INTRODUCTION AND OBJECTIVE:Genitourinary fistula, an abnormal communication of the genital and urinary tract, demands a precise surgical reconstruction to treat this pathological morbidity and caus...

02: The effect of music listening on preoperative anxiety in female pelvic medicine and reconstructive surgery: A randomized controlled trial

Preoperative anxiety has been associated with increased postoperative pain and lower patient satisfaction. The purpose of this study was to evaluate the effect of listening to music just prior to surgery on preoperative anxiety compared to usual care in patients undergoing reconstructive pelvic surgery. Patients scheduled for reconstructive pelvic surgery at our tertiary care center were enrolled on the day of their surgery approximately 45 minutes prior to the anticipated surgery start time. Following consent, all participants completed the Spielberg State Trait Anxiety Inventory Y1 (STAI-Y1) to measure baseline state anxiety levels prior to surgery. Demographic information, past surgical history, and a questionnaire regarding musical background and preferences were collected. Participants were then randomized to either the usual care (control group) or listening to music on headphones (music intervention group). Those in the music group could choose between several genres of prerecorded music. After 30 minutes, the STAI-Y1 questionnaire was re-administered. The primary outcome was the change in anxiety score as measured by the STAI-Y1. Descriptive statistics, T-tests, and Fisher's Exact Test were used to analyze the data. Sixty-six women completed the study; 34 participants in the control group and 32 participants in the music group. Racial/ethnic distribution, age, prior history of surgery, and music background and preferences were similar amongst those in the control group and the music group. Surgical indications included one or more of the following diagnosis: pelvic organ prolapse (44%), stress urinary incontinence (34%), urge urinary incontinence (6%), mesh exposure (5%), vaginal mass/diverticula (5%), genitourinary fistula (4%), and sling revision (2%). Participants reported that they found classical music (26%), soft rock (26%), country (17%), jazz (11%), and gospel music (10%) most relaxing. Baseline STAI-Y1 scores on the day of surgery were similar between the two groups (37.29 ± 11.57 in control group vs. 37.25 ± 9.02 in music group). STAI-Y1 scores significantly improved in the music group after 30 minutes of music listening compared to the control group (-6.81 vs. -1.59, P = 0.006). Patients undergoing reconstructive pelvic surgery present with moderate anxiety on the day of surgery. Allowing patients to listen to their preferred music is a simple intervention that may lower preoperative anxiety in this patient population.

Vesicovaginal fistula following pelvic surgery: Our experiences and recommendations for diagnosis and prompt referral.

Vesicovaginal fistula (VVF) is an uncommon but known complication of pelvic surgery. Post-operative urine leakage should generate a high index of clinical suspicion for early diagnosis of VVF. This study aims to identify areas for improvement and provide recommendations for timely and accurate diagnosis of VVF to minimise patient morbidity. A retrospective observational study of all patients who underwent VVF repairs unrelated to malignancies in a ten-year period at two primary referral centres in Brisbane was performed to review the aetiology, performance of investigative tests and management of these cases. A total of 56 patients were studied with the identification of significant delays to diagnosis and referral, the performance of multiple unnecessary tests and low rates of primary surgeon referral. Early recognition of VVF and assessment by outpatient methylene blue dye test can provide quick same-day diagnosis and minimise patient suffering. We hope this will alert gynaecologists and provide guidelines for diagnosis and improved management to allow for prompt referral and repair of genitourinary fistula.

Management of Genitourinary Fistulas Following Benign Gynecological and Obstetric Procedures: A Single Surgeon Experience.

Background:Genitourinary fistula results in lot of anxiety in the suffering females. Scant literature regarding the comprehensive management of genitourinary fistula i.e. VVF and UVF is available.Objective:The aim of the study was to review a single surgeon experience in dealing with these complex situations.Material and Methods:We conducted a retrospective, institutional review board approved chart review of patients who underwent genitourinary fistula repair from Jan 2014 till Dec 2019. Of all the fistulas VVF accounted for 18 and UVF for 12 cases. Pre-operative diagnosis in these patients was based predominantly on the history, local examination and cystoscopy. Of the 18 VVF 12 were managed laparoscopically and 6 by open O'Connor's repair. Of the 12 UVF, 8 were managed laparoscopically and 4 by open ureteric reimplants. All were followed up for three months post operatively.Results:A total of 30 patients were treated since 2014 till December 2019. Average age for the VVF was 54.72 ≤ 10.9 years and that for UVF repair was 59.9 ≤ 7.6 years. Hysterectomies for benign diseases accounted for 66.66% of VVF and 91.6% of UVF. Of the VVF patients one required a ureteric reimplantation, remaining were managed with O'Connors' repair. We had one failure which was successfully repaired after 6 weeks. None of our patients with UVF repairs had a failure at three months follow-up.Conclusion:Genitourinary fistulas are a debilitating problem in females but a comprehensive approach regarding diagnosis and treatment can cure these patients.

Iatrogenic Genitourinary Fistula: Changing Trends

Aims: To study the frequency of iatrogenic cause amongst the surgery done for genitourinary fistula and to study the type and cause of iatrogenic genitourinary fistula.
 Methods: This is retrospective study of women undergoing surgery for genitourinary fistula repair from year 2013 to 2018. The analysis considers frequency and characteristics of type of fistula.
 Results: Out of 223 genitourinary fistula 75 (33.6%) were iatrogenic. Vaginal vault fistula were 25% followed by uretero-vaginal fistula (32.9%), vesico-vaginal fistula (32.9%) and there were 4 iatrogenic recto-vaginal fistula; 81.6% of the iatrogenic fistula had preceding history of hysterectomy followed by emergency caesarean section (17.1%). There is annual increasing trend in iatrogenic fistula repair from 3 to 23.
 Conclusions: Women undergoing hysterectomy were under risk for iatrogenic fistula. Optimum work environment is important to reduce surgical error during procedures. Operating training should be emphasised on optimal surgical skills, decision making.
 Keywords: genitourinary fistula, ureteric fistula, vault fistula

Repair of Vesicovaginal Fistula: Experience of 30 Cases and Analysis of Outcome Predictors

Female genital fistula is a serious medical condition in which a perforation develops most commonly between bladder and vagina (VVF). Although the majority of genitourinary fistulas can be closed surgically, the successful closure depends on many factors. In this retrospective study, the records of 30 women with a mean age of 23.8 years were assessed; 13% of the VVF occurred after abdominal hysterectomy, 67% after Caesarean section, and 20% after difficult vaginal delivery. Six (20%) women had previous repair. The median duration of the VVF was 5.9 months. Of the 30 patients of VVF, 24 were high and 6 were low. Twenty seven had single fistula opening and 3 had two fistulous openings. An abdominal approach was used in 24 patients and vaginal approach in 6 patients. At a mean follow up of 24 months, the VVF was cured in 90% patients. In conclusion, surgical correction of the VVF is more successful when done earlier, probably in the first 6 months. Abdominal approach seems to be more successful technique and recurrent VVF being associated with lower success rates than primary repair. High variety also has good result. Faridpur Med. Coll. J. Jul 2018;13(2): 85-88

3012 Lessons Learned from Ten Litigated Cases of Genitourinary and Gastrointestinal Fistulas Post Benign Gynecological Surgeries: A Multi-Center Case Series

Study Objective We aim to summarize all litigated cases of vesicovaginal, colovaginal and ureteric-vaginal fistulas from benign gynecological surgeries in Canada between 1997 to 2017. We outline the initial post-operative presentation, course of treatment and recovery, clinical and legal outcomes associated with each case. Design Retrospective case series of 10 genitourinary, gastrointestinal and enterocutaneous fistulas occurring post gynecological surgeries for benign indications. Setting Eight secondary and tertiary hospitals across Canada. Patients or Participants Ten women aged 18 years or older receiving laparoscopic, vaginal or open surgeries to treat benign gynecological conditions. Interventions Benign gynecological procedures including laparoscopic-assisted vaginal (1 case), vaginal (1 case) and open abdominal hysterectomies (3 cases), laparoscopic ovarian cystectomy (2 cases), laparoscopic cautery of endometriosis (2 cases) and operative hysteroscopy (1 case). Measurements and Main Results Median age at time of initial operation was 43 (range 39-55). The most common post-op presentation was fever, abdominal pain and tachycardia between post-op days (POD) 4-10. A bladder, small bowel or rectal injury was found on imaging at the time of presentation for 9 out of 10 cases, with one case diagnosed five weeks post op on outpatient serial CT scans. All patients required a laparotomy with involvement from a general surgeon or urologist, and five patients received second and third look laparotomies and bowel resections. 7 patients required ICU observation post-op. In all cases, the fistulas manifested as delayed presentations for unrecognized intra-operative bladder, bowel or ureteric injuries. One patient had ongoing fistulous drainage per vaginal at the time of case settlement. Most litigated cases were dismissed. Conclusion GU and GI fistulas are rare but morbid entities, which most often manifest after missed bladder or bowel injuries, post benign gynecological surgeries. Early detection and recognition of GI and GU injuries may be key for secondary prevention of fistula formation.

1053P - Primary results from CECILIA, a global single-arm phase II study evaluating bevacizumab (BEV), carboplatin (C) and paclitaxel (P) for advanced cervical cancer (aCC)

BackgroundAdding BEV to P + cisplatin/topotecan for aCC significantly improved overall survival (OS) and progression-free survival (PFS) in the phase 3 GOG240 trial. CECILIA (NCT02467907) evaluated BEV with a more widely used CP backbone. MethodsThe primary objective was to determine the safety of BEV + CP for aCC, defined by the frequency and severity of gastrointestinal (GI) perforation/fistula, GI-vaginal fistula and genitourinary (GU) fistula. Eligible patients (pts) had metastatic/recurrent/persistent CC not amenable to curative surgery and/or radiotherapy (RT). Pts with ongoing bladder/rectal involvement, prior cobalt RT, history of fistula/GI perforation, or bowel resection ≤6 wk or chemoRT ≤3mo before first dose were excluded. Pts received BEV 15mg/kg, P 175mg/m2 and C AUC 5 q3w until disease progression (PD), unacceptable toxicity or consent withdrawal. If BEV, C or P was stopped for adverse events (AEs), the remaining drug(s) could be continued alone. ResultsFrom Jul 2015 to Dec 2016, 150 pts began treatment. Disease status at study entry was persistent in 20%, recurrent in 53% and metastatic at diagnosis in 27%; 71% had received prior RT (chemoRT in 58%) and 59% prior platinum. At data cutoff (31 Dec 2018), median follow-up was 27.8mo. The most common reasons for stopping treatment were PD (39%) and AEs (34%). Median BEV duration was 6.7 (range <1–39) mo; 57% received BEV alone after stopping CP. 17 pts (11.3%, 95% CI 6.7–17.5%) had ≥1 perforation/fistula event: GI perforation/fistula in 4.7% (1.9–9.4%), GI-vaginal fistula in 4.0% (1.5–8.5%) and GU fistula in 4.7% (1.9–9.4%). All but 1pt with fistula/GI perforation had received prior RT; several had ongoing radiation effects. The most common grade 3/4 AEs were neutropenia (21%), anaemia (19%) and hypertension (14%). 5 pts (3%) had fatal AEs. Objective response rate was 61% (95% CI 52–69%), including complete responses in 14%. Median PFS was 10.9 (95% CI 10.1–13.7) mo and median OS 25.0 (20.9–30.4) mo. ConclusionsThese results show that BEV can be combined with CP in the CECILIA study population. The fistula/GI perforation incidence is in line with GOG240 and efficacy results are encouraging. Clinical trial identificationNCT02467907. Editorial acknowledgementJennifer Kelly (Medi-Kelsey Ltd), funded by F. Hoffmann-La Roche. Legal entity responsible for the studyF. Hoffmann-La Roche. FundingF. Hoffmann-La Roche. DisclosureA. Redondo: Honoraria (self), Advisory / Consultancy, Travel / Accommodation / Expenses: AstraZeneca; Honoraria (self), Advisory / Consultancy, Research grant / Funding (institution), Travel / Accommodation / Expenses: Roche Farma; Honoraria (self), Advisory / Consultancy, Travel / Accommodation / Expenses: Tesaro; Honoraria (self), Advisory / Consultancy: Clovis; Honoraria (self), Advisory / Consultancy, Research grant / Funding (institution), Travel / Accommodation / Expenses: PharmaMar; Honoraria (self), Advisory / Consultancy: Lilly; Honoraria (self), Research grant / Funding (institution): Eisai. N. Colombo: Advisory / Consultancy, Travel / Accommodation / Expenses: Roche; Advisory / Consultancy, Travel / Accommodation / Expenses: PharmaMar; Advisory / Consultancy: AstraZeneca; Advisory / Consultancy, Travel / Accommodation / Expenses: Tesaro; Advisory / Consultancy: Clovis; Advisory / Consultancy: Pfizer; Advisory / Consultancy: MSD; Advisory / Consultancy: BIOCAD; Advisory / Consultancy: Takeda; Advisory / Consultancy: Lilly; Non-remunerated activity/ies, ESMO Clinical Guidelines: ESMO; Non-remunerated activity/ies, Scientific Committee Chair: ACTO Onlus. L.M. Dreosti: Honoraria (self), Advisory / Consultancy: Eli Lilly; Honoraria (self), Advisory / Consultancy: MSD; Travel / Accommodation / Expenses: Janssen; Travel / Accommodation / Expenses: Merck. M. McCormack: Honoraria (self): AstraZeneca; Honoraria (self): Roche. A. Nogueira Rodrigues: Honoraria (self), Advisory / Consultancy, Research grant / Funding (institution): Roche; Honoraria (self), Advisory / Consultancy: AstraZeneca; Honoraria (self), Advisory / Consultancy, Research grant / Funding (institution): MSD. M. Donica: Shareholder / Stockholder / Stock options: Novartis; Full / Part-time employment: Roche. B. Ulker: Full / Part-time employment: F. Hoffmann-La Roche AG. A. González Martín: Advisory / Consultancy, Speaker Bureau / Expert testimony, Research grant / Funding (institution): Roche; Advisory / Consultancy, Speaker Bureau / Expert testimony: AstraZeneca; Advisory / Consultancy, Speaker Bureau / Expert testimony, Research grant / Funding (institution), Non-remunerated activity/ies, PI of PRIMA: Tesaro; Advisory / Consultancy: Clovis; Advisory / Consultancy: Pfizer; Advisory / Consultancy: ImmunoGen; Advisory / Consultancy, Speaker Bureau / Expert testimony: PharmaMar; Advisory / Consultancy: MSD; Advisory / Consultancy: Genmad. All other authors have declared no conflicts of interest. Scientific clarification

Urologic Injury and Fistula After Hysterectomy for Benign Indications.

To explore the rates and risk factors for sustaining a genitourinary injury during hysterectomy for benign indications. In this population-based cohort study, all women who underwent hysterectomy for benign indications were identified from the Office of Statewide Health Planning and Development databases in California (2005-2011). Genitourinary injuries were further classified as identified at the time of hysterectomy, identified after the date of hysterectomy; or unidentified until a fistula developed. Of the 296,130 women undergoing hysterectomy for benign indications, there were 2,817 (1.0%) ureteral injuries, 2,058 (0.7%) bladder injuries and 834 (0.3%) genitourinary fistulas (80/834 of which developed after an injury repair). Diagnosis was delayed in 18.6% and 5.5% of ureteral and bladder injuries, respectively. Subsequent genitourinary fistula development was lower if the injury was identified immediately (compared with delayed) for both ureteral (0.7% vs 3.4% odds ratio [OR] 0.28; 95% CI 0.14-0.57) and bladder injuries (2.5% vs 6.5% OR 0.37; 95% CI 0.16-0.83). Indwelling ureteral stent placement alone was more successful in decreasing the risk of a second ureteral repair for immediately recognized ureteral injuries (99.0% vs 39.8% for delayed injuries). With multivariate adjustment, prolapse repair (OR 1.44, 95% CI 1.30-1.58), an incontinence procedure (OR 1.40, 95% CI 1.21-1.61), mesh augmented prolapse repair (OR 1.55, 95% CI 1.31-1.83), diagnosis of endometriosis (OR 1.46, 95% CI 1.36-1.56), and surgery at a facility in the bottom quartile of hysterectomy volume (OR 1.37, 95% CI 1.01-1.89) were all associated with an increased likelihood of a genitourinary injury. An exclusively vaginal (OR 0.56, 95% CI 0.53-0.64) or laparoscopic (OR 0.80, 95% CI 0.75-0.86) approach was associated with lower risk of a genitourinary injury as compared with an abdominal approach. Genitourinary injury occurs in 1.8% of hysterectomies for benign indications; immediate identification and repair is associated with a reduced risk of subsequent genitourinary fistula formation.

Knowledge on Genitourinary Fistula among Nurses in a Tertiary Hos-pital of Eastern Nepal

Background: Genitourinary fistula, occurs most commonly due to preventable obstetric causes in developing countries. Women with obstetric fistula are at risk of infection, neglected from family and bear psychological distress due to stigma and social isolation. They require supportive care through multidisciplinary approach. Nurses occupying the larger workforce among the health-personnel are the frontier to care them throughout their life. Their knowledge on obstetric fistula will help to manage patients effectively. The aim of this research was to assess the knowledge on genitourinary fistula among nurses working in maternity wards of B. P. Koirala Institute of Health Sciences, Nepal.&#x0D; Methods: AHospital based cross-sectional study was conducted from May 2018 to January 2019 using self-administered questionnaire among nurses working in antenatal, intranatal, postnatal and gynecology ward of B. P. Koirala Institute of Health Sciences, Nepal. Forty nurses were enrolled after having informed consent. Collected data were entered in Microsoft excel and analysed using SPSS.&#x0D; Results: Only 42.5 % nurses had adequate knowledge on genitourinary fistula. Majority of them (90%) had correct response on definition of genitourinary fistula. Almost 83% correctly responded vesicovaginal fistula is the most common type. About 37.5% stated obstetric causes are main causes of genitourinary fistula in developing countries. Only 20% correctly responded the possible sign and symptoms of genitourinary fistula. Adequate knowledge on prevention of obstetric fistula (35%), surgical repair (20%), pre-operative management (12.5%) and discharge advice (20%) was found.&#x0D; Conclusions: This study concludes that majority of nurses working at antenatal, intranatal, postnatal and gynecology wards of B. P. Koirala Institute of Health Sciences, Nepal had moderate knowledge on genitourinary fistula.

Laparoscopic repair of female genitourinary fistulae: 10-year single-center experience

Laparoscopic repair of different female genitourinary fistulae has been recently reported, including both conventional and laparoendoscopic single-site surgery (LESS). We present our 10-year single-center experience of the laparoscopic repair of different types of female genitourinary fistulae. A retrospective analysis of our records over the last 10years was performed. Type of fistula, etiology, laparoscopic approach, operative data, postoperative outcome, and follow-up were recorded. Overall, 46 patients with laparoscopic repair of genitourinary fistulae were reported: 25 had vesicovaginal fistulae (VVF), 14 had vesicouterine fistulae (VUF), and 7 had ureterovaginal fistulae (UVF). Thirty-three patients had conventional laparoscopic repair, whereas 7 VVF and 6 VUF had LESS repair. In all patients with VVF and VUF, extravesical repair was carried out by excising the fistulous tract and closing both the bladder and the vagina or the uterus with interposing tissue in-between. In patients with UVF, extravesical ureteric re-implantation was performed. Mean operative time was 176 ± 25min. Mean blood loss was 105 ± 25 cc. No intraoperative or postoperative complications occurred. None was converted to open surgery. Mean postoperative hospital stay was 3.2 ± 1.2days. After a mean follow-up of 6.3 ± 3.1years, all patients had undergone successful repair, except for one patient with complex VVF. Laparoscopic repair of VVF, VUF, and UVF is a feasible procedure with a high success rate and low morbidity. LESS repair of VVF and VUF has a comparable success rate to conventional laparoscopy, but with a shorter hospital stay and fewer analgesic requirements.

Spectrum of urologic complications in obstetrics and gynecology: 13 years’ experience from a tertiary referral center

To analyze the patterns of presentation and management for urologic complications of obstetrics and gynecology in the form of genitourinary fistulas at a tertiary referral center and highlight the social issues associated with them. We conducted this retrospective study analyzing 311 patients with genitourinary fistulas after obstetric and gynecologic surgeries between January 2005 and January 2018. We recorded the patients' characteristics and area of residence and then analyzed the etiology, surgical management and success rates by grouping the patients into four types of genitourinary fistulas. The primary end point of success was patient being leak free. Majority of patients (90.4%) were from rural areas. The distribution of genitourinary fistulas in descending order was vesicovaginal (79.7%), ureterovaginal (11.8%), urethrovaginal (10.2%) and vesicouterine fistulas (2.6%). The mean time to presentation was 25.80±48.69 days with a wide range of 10 days to 360 months. The most common etiology was obstructed labour (58.5%) followed by abdominal hysterectomy (32.7%). For vesicovaginal fistulas the route to be used for repair depended on surgeon's preference and both transabdominal and transvaginal routes had almost equal success rates. The success rate of laparoscopic vesicovaginal fistula repair was 89.4% and all (100%) laparoscopic ureteroneocystostomies were successful. Genitourinary fistulas especially due to obstructed labour are still common in developing world showcasing the problem of inequitable distribution of healthcare. The surgical treatment approach depends on the surgeon's familiarity with the said procedure although versatility is required.

Iatrogenic Ureterovaginal Fistulae: Difficulties in Diagnosis and Treatment in Our Case series

Ureteral injury is a known complication of pelvic surgeries, including gynecological, urologic, colorectal, and vascular surgeries. This can occur by transvaginal, laparoscopic, or transabdominal approach [1,2]. Gynecological surgery remains by far the most common means of injury (75%), followed by colorectal surgeries (14%) [3-5], with reports of ureteral injury during gynecologic surgery from 0.35% to 1.5% [4,6]. Total abdominal and laparoscopic hysterectomies are the most common procedures where ureteral injury occurs [1,5]. Injury occurs most often at the level where the ureter courses under the uterine vessels, followed by the ureterovesical junction and the base of the infundibulopelvic ligament [4,7,8]. Many ureteral injuries occur during uncomplicated, routine surgery [8,9]. An abnormal connection between the ureter and vagina, or ureterovaginal fistula, allows for a conduit through which urine can continually leak. This is specific to the combination of ureteral injury and hysterectomy where the urine finds its way to the freshly closed vaginal cuff. Genitourinary fistula formation remains one of the most feared complications of pelvic surgery, with lasting emotional damage, risk for infections, infertility, reoperation, and increased hospital stay [5,10]. Our objective is to present the difficulties encountered in management of our cases and how to rectify them.

945 - Genitourinary fistulas: Changing patterns of causation and evolution in management

945 - Genitourinary fistulas: Changing patterns of causation and evolution in management

Reintegration needs of young women following genitourinary fistula surgery in Uganda

Introduction and hypothesisGenitourinary fistulas (usually arising following prolonged obstructed labor) are particularly devastating for women in low-income counties. Surgical repair is often difficult and delayed. While much attention has been devoted to technical surgical issues, the challenges of returning to normal personal, family, and community life after surgical treatment have received less scrutiny from researchers. We surveyed young Ugandan women recovering from genitourinary fistula surgery to assess their social reintegration needs following surgery.MethodsA cross-sectional survey of 61 young women aged 14–24 years was carried out 6 months postoperatively. Interviews were carried out in local languages using a standardized, interviewer-administered, semistructured questionnaire. Data were entered using EpiData and analyzed using SPSS.ResultsOngoing reintegration needs fell into interrelated medical, economic, and psychosocial domains. Although >90% of fistulas were closed successfully, more than half of women had medical comorbidities requiring ongoing treatment. Physical limitations, such as foot drop and pelvic muscle dysfunction impacted their ability to work and resume their marital relationships. Anxieties about living arrangements, income, physical strength, future fertility, spouse/partner fidelity and support, and possible economic exploitation were common. Sexual dysfunction after surgery—including dyspareunia, loss of libido, fear of intercourse, and anxieties about the outcome of future pregnancies—negatively impacted women’s relationships and self-esteem.ConclusionsYoung women recovering from genitourinary fistula surgery require individualized assessment of their social reintegration needs. Postoperative social reintegration services must be strengthened to do this effectively.

Our Experience with Iatrogenic Ureteric Injuries among Women Presenting to University College Hospital, Ibadan: A Call to Action on Trigger Factors.

Background Ureteric injuries leading to ureterovaginal fistula (UVF) is less common than vesicovaginal fistula, as a cause of urinary incontinence. Recently, there is a surge in the number of UVF cases presenting to University College Hospital (UCH) following a caesarean delivery. The urogynaecology unit at UCH is at the forefront of providing surgical repair for women with all forms of genitourinary fistulas. We describe our experience with managing UVF arising from ureteric injury. Methods A retrospective data collection of UVF cases managed from January 2012–December 2017 at UCH is presented. Information on sociodemographic and obstetric characteristics, presenting complaints, antecedent surgery, treatment received, findings at surgery, and postoperative complications were obtained with a structured proforma. Results Eighteen cases of UVFs due to iatrogenic ureteric injury were managed. Majority (N=11; 61.1%) of the women suffered the injury following the emergency caesarean section (EMCS). Abdominal hysterectomy operation accounted for four (22.2%) cases, and one case each (5.6%) was due to vaginal hysterectomy and destructive operations. Prolonged obstructed labour (POL) (81.8%) was the most common indication for the EMCS, while 18.2% had surgery on account of lower uterine segment fibroid. Most of the ureteric injuries were on the left side. Postoperative complications documented were haemorrhage, urinary tract infection, wound infection, and injury to the neighbouring structure. Conclusion Caesarean section being one of the most performed surgical operations in Nigeria was surprisingly found to be the most common cause of ureteric injury ahead of hysterectomy. It is a pointer that the surgeons might not have properly learnt the art of the caesarean delivery well. We recommend adequate surgical training of medical officers/surgeons that are involved.

The prevalence of psychiatric disorders among genitourinary fistula patients: A study in a tertiary care hospital, Bangladesh

Background: Maternal morbidity and mortality are very potential women’s health issues in many developing countries. Many of these are preventable. The World Health Organization estimated that, the prevalence of obstetric fistula at 0.3% of all deliveries. In Asia, over 200 thousand maternal deaths occur in every year. World-wide it is estimated that, there are over 1000000 new cases of fistula are found each year. Information from UNFPA and Engender health indicates that, well over two million women worldwide are suffering from genital tract fistulas. Aim of the study: The aim of this study was to assess the prevalence of psychiatric disorders among genitourinary fistula patients. Methods and Materials: It was a non-interventional, descriptive, cross sectional study conducted on a special group of population suffering from genitourinary fistula. Prior to commencement of study written permission was taken to work in the “National Fistula Centre” from the Department of Gynaecology &amp; Obstetrics, DMCH. This study was conducted at the National Fistula Centre. This center was established in 2003 in DMCH under the supervision of Gynaecology and Obstetrics Department. One hundred and two (102) patients were included in the study as the study population. Non-probability convenient sampling procedure was used. Samples were collected in two days per week. It was decided that, if any patient refuses, next one will be taken into account, but fortunately none refused the interview. By adopting this method, 102 patients were included and the study was conducted during the period from December 2003 to December 2004. Results: In our study, among total 102 participants the prevalence of the study was 85.29% where include psychiatric illness, depression (63.72%) being the commonest illness. Anxiety disorder was 15.68%, minor emotional disorder was 2.94% and somato form disorder was 2.94%. Fifteen patients (14.70%) were found to be free from psychiatric symptoms. Conclusion: One hundred and two patients diagnosed as genitourinary fistula are studied by Self Reporting Questionnaire (SRQ) to find out psychiatric morbidity among them. Psychiatric diagnosis was confirmed by using DSM – IV criteria under the direct supervision of psychiatrist. The findings of this study may help in the treatment procedure of genitourinary fistula.

Successful Repair of Iatrogenic Cyclical Menouria

Vesicouterine fistula (VUF) is a very rare occurrence and is estimated to occur in only (1-4%) of all genitourinary fistulas. It is an abnormal pathway between the bladder and the uterus. The most common cause is lower segment caesarean section. Patients usually present in the early post operative period with the problem of continuous urinary incontinence. On the rare occasion, recurrent urinary tract infection, recurrent gross painless haematuria, or secondary infertility associated with secondary amenorrhoea would be the presenting complaint. Among all vesicouterine fistula 90% are Youseef’s Syndrome the least common of the urogynaecological fistulas. Youseef’s syndrome is characterized by cyclic haematuria (menouria), absence of vaginal bleeding (amenorrhea) and urinary incontinence due to vesicouterine fistula (VUF).TAJ 2017; 30(1): 70-72

Management and Outcome of Postoperative Complications among the Patients Undergoing Common Obstetric and Gynaecological Surgery outside the RMCH

Objective: To review the management and outcome of postoperative complications after common obstetric and gynecologic surgeries performed in outside nonacademic private hospitals (clinics) and peripheral public hospitals (districts hospitals) and later admitted in Department of Obstetrics and Gynecology of Rajshahi Medical College Hospital (RMCH). RMCH is a tertiary referral hospital where all complicated patients were referred for better management from surrounding hospital.Methodology: This Quasi-experimental study was carried out in the Department of Obstetrics and Gynecology at Rajshahi Medical College Hospital, Rajshahi, Bangladesh between July 1, 2015 and June 30, 2017. All patients admitted with post operative complications following common obstetric and gynecologic surgeries during this period were included. Patients admitted with post operative complications, where primary surgery was done in this hospital were excluded. The common obstetric and gynaecological surgeries were caesarean sections (LUCS), total abdominal hysterectomy (TAH) and vaginal hysterectomy (VH) performed outside Rajshahi Medical College Hospital.Result: During this period a total of 39,929 patients were admitted through emergency way in obstetrics and gynecology department of Rajshahi Medical College Hospital. Among them 675 patients were admitted with the complaints of post operative complications following common obstetric and gynecologic surgeries with rate being 1.7%. In 560(83%) cases surgery was done in clinics and 115(17%) cases surgery was done in district hospitals. Among the patients 580(85.9%) cases primary operation was done by non-gynaecologic surgeon and 95(14.1%) cases by gynaecologic surgeon. Caesarean section was the primary obstetric surgery in 405(60%) cases .Gynecologic surgeries included TAH in 185(27.4%) cases and VH in 85(12.6%) cases. We found 25(3.7%) patients died from these complications. Repeat surgery was done in 90(13.33%) cases. Genitourinary fistula repair was done in 41 cases (45.55%). Rests were improved by conservative management.Conclusion: Any surgical procedure carries risk of complications. Careful selection of patients with suitable indications for operations, expertise of the surgeon, good surgical technique, proper knowledge of pelvic anatomy and careful postoperative follow up can minimize recognized complications.TAJ 2017; 30(2): 7-12

Iatrogenic Genitourinary Fistula: Changing Trends

Aims: To study the frequency of iatrogenic cause amongst the surgery done for genitourinary fistula and to study the type and cause of iatrogenic genitourinary fistula.&#x0D; Methods: This is a 5 year retrospective study analyses 73 iatrogenic fistulas from 217 women undergoing surgery for genitourinary fistula repair from year 2013 to 2018 on going. The analysis considers frequency and characteristics of type of fistula.&#x0D; Results: Out of 217 genitourinary fistula 73(33.6%) were iatrogenic. Vaginal vault fistulas were 54.7% followed by ureteric fistula 32.8%, vesicovaginal fistula 10.9% and there were 2 iatrogenic RVF. The frequency of surgeries for iatrogenic fistula were found to be in increasing trend towards current years and 83.5% of the iatrogenic fistula were found with history of hysterectomy followed by emergency caesarean section 16.4%. &#x0D; Conclusions: Women undergoing hysterectomy were under risk for iatrogenic fistula. Optimum work environment is important to reduce surgical error during procedures. Operating training should be emphasized on optimal surgical skills, decision making.