Vesicovaginal Fistula Repair Research Articles

Identifying opportunities for prevention of adverse outcomes following female genital fistula repair: protocol for a mixed-methods study in Uganda

BackgroundFemale genital fistula is a traumatic debilitating injury, frequently caused by prolonged obstructed labor, affecting between 500,000-2 million women in lower-resource settings. Vesicovaginal fistula causes urinary incontinence, and other morbidity may occur during fistula development. Women with fistula are stigmatized, limit social and economic engagement, and experience psychiatric morbidity. Improved surgical access has reduced fistula consequences yet post-repair risks impacting quality of life and well-being include fistula repair breakdown or recurrence and ongoing or changing urine leakage or incontinence. Limited evidence on risk factors contributing to adverse outcomes hinders interventions to mitigate adverse events. This study aims to quantify these adverse risks and inform clinical and counseling interventions to optimize women’s health and quality of life following fistula repair through: identifying predictors and characteristics of post-repair fistula breakdown and recurrence (Objective 1) and post-repair incontinence (Objective 2), and to identify feasible and acceptable intervention strategies (Objective 3).MethodsThis mixed-methods study incorporates a prospective cohort of women with successful vesicovaginal fistula repair at approximately 12 fistula repair centers in Uganda (Objectives 1-2) followed by qualitative inquiry among key stakeholders (Objective 3). Cohort participants will have a baseline visit at the time of surgery followed by data collection at 2 weeks, 6 weeks, 3 months and quarterly thereafter for 3 years. Primary predictors to be evaluated include patient-related factors, fistula-related factors, fistula repair-related factors, and post-repair behaviors and exposures, collected via structured questionnaire at all data collection points. Clinical exams will be conducted at baseline, 2 weeks post-surgery, and for outcome confirmation at symptom development. Primary outcomes are fistula repair breakdown or fistula recurrence and post-repair incontinence. In-depth interviews will be conducted with cohort participants (n ~ 40) and other key stakeholders (~ 40 including family, peers, community members and clinical/social service providers) to inform feasibility and acceptability of recommendations.DiscussionParticipant recruitment is underway. This study is expected to identify key predictors that can directly improve fistula repair and post-repair programs and women’s outcomes, optimizing health and quality of life. Furthermore, our study will create a comprehensive longitudinal dataset capable of supporting broad inquiry into post-fistula repair health.Trial Registration ClinicalTrials.gov Identifier: NCT05437939.

Prevalent practices and changing trends in the management of vesicovaginal fistula: a cross-sectional study from a nationwide questionnaire-based survey of urologists from a developing country

Vesicovaginal fistula (VVF) management is primarily backed by evidence from retrospective studies and expert opinions and therefore lacks standardization. Newer generations of surgeons are more proactive toward changing clinical practices in domains lacking good-quality evidence. This survey-based cross-sectional study aims to elicit consensus on management practices regarding various domains of VVF management and look for any changes in clinical practice trends. A nationwide survey of urologists was conducted, and responses were grouped into 3 categories (overall response, response from young urologists, and response from experienced urologists) and compared. Based on the level of overall consensus, the responses were categorized as highly preferred, preferred, and somewhat preferred. Consensus was noted in conservative and endoscopic management of VVF, timing of VVF repair, definition of simple/complex VVF, approach for surgical repair for trigonal and supratrigonal VVF, use of interposition tissue for repair, and patient positioning in the postoperative period. A lack of consensus was noted in other domains. Changing trends in clinical practices were noted in attempts at conservative and endoscopic management, investigations considered mandatory for evaluation, surgical approach for complex VVF with bladder neck involvement and radiation-induced fistulas, the use of interposition grafts during surgical repair, the use of cystograms during follow-up, and the definition of a successful repair. There is uniformity in practices regarding many domains of VVF management. Those areas, where discordance in opinions is noted, require further research to bring standardization into practice. Regarding certain aspects of VVF management, there appears to be a change in trends among the younger generation of urologists.

Hospital-related factors associated with incontinence following vesicovaginal fistula repair at Bwaila fistula care centre

Background/Aims Surgery remains the only reliable treatment option for vesicovaginal fistula; however, not all women who undergo surgical treatment regain continence. Information on predictors of vesicovaginal fistula closure outcomes is scarce and mostly limited to patient-related factors. This study examined hospital-related factors associated with incontinence in women following vesicovaginal fistula repair at the Bwaila fistula care centre in Malawi. Methods This quantitative retrospective cross-sectional study used simple random sampling to identify 174 case files of women who underwent vesicovaginal fistula repair. Data were analysed using binary and multivariable logistic regression to explore the effects of hospital-related variables on the likelihood of women remaining incontinent after obstetric fistula repair. Results The overall closure rate was 73.6%. Only number of days with a Foley catheter was found to predict incontinence after fistula repair at discharge from the hospital (P=0.013), in multivariate analysis. Conclusions Number of days with a catheter was the only significant predictor of incontinence after repair. Surgeons should consider reducing the number of days assigned with a catheter following surgery. Future studies should follow a prospective approach in settings where all variables can be effectively explored.

Outcome of Transvaginal Local Repair of Vesicovaginal Fistula

Background: Vesicovaginal fistula (VVF) is a significant cause of physical & psychological disability with social stigmatization especially in low- and middle-income countries. Over 80% of such cases result from neglected prolonged and obstructed labour. Objective: The purpose of the study was to observe the outcome of transvaginal local repair of vesicovaginal fistula (VVF). Methods: This descriptive study was carried out at the Department of Obstetrics & Gynaecology, Sylhet M.A.G. Osmani Medical College Hospital, Bangladesh, from July 2007 to June 2008, on 50 patients of vesicovaginal fistula. We included women who were suffering from VVF and who were operated before and diagnosed as a failed repair of VVF. We excluded those patients who had VVF with associated problem like rectovaginal fistula (RVF), any repair through transabdominal route and unwilling to take part in this study. Before surgery, each woman was assessed by medical and surgical history, examination and necessary investigations. Typically, regional anesthesia was utilized for the fistula surgery. However, general anesthesia was given when required. During surgery, transvaginal approach was taken for repair. The vagina was packed for haemostasis. Vaginal pack was removed after 1-2 days depending on instruction of the surgeon. Repacking of vagina was also done sometimes when there was some leaking during post-operative period. Few patients developed severe constipation post operatively. Results: The participants aged between 16 and 70 years. Among them, majority of the patient belongs to the age 31-35 years (26%) followed by 2nd common group 26-30 years of age (20%) and 3rd one in between 21-25 years of age (16%). Among them 44% patients were primipara and 22% patients were grand multipara. The mobilization during operation was excellent in 30%, satisfactory 64% cases and not enough in 6% cases. After mobilization fistula closed in double layer in 10% and in single layer 90% cases, labial fat graft was given 38% and peritoneal graft was given in 2% cases. During operation bleeding was minimum in 92% cases and in 34% cases catheter was block, urine leakage occurred in 30% cases. Among all patients 14% suffered from fever postoperatively. There was vaginal discharge in 10% cases and UTI in 12%cases which was evidenced by urine culture. Operation was fully successful in 60 percent cases, urethral incontinence in 22% cases & failed in 18% women. Conclusion: In this study, majority of the transvaginal local repair of VVF operations were successful; however, few difficult cases were observed. Mugda Med Coll J. 2023; 6(1): 25-29

The Microcirculation of Vaginal Tissue in Women with Obstetric Vesicovaginal Fistula and Short-Term Effects of Surgical Repair on Microvascular Parameters

Objectives: The objective of the study was to better understand the extent of the ischemic trauma and the effects of surgical repair on the vaginal microcirculation in patients with obstetric vesicovaginal fistula (VVF). Design: In this observational study, we evaluated the vaginal microvasculature surrounding VVF using handheld vital microscopy (HVM) before, during, and 2 weeks after surgical VVF repair. Participants: Seventeen women undergoing VVF repair were included in this study. Setting: The study was conducted in the Fistula Care Centre in Lilongwe, Malawi. Methods: We used HVM with incident dark-field imaging to non-invasively visualize the microvasculature of the vaginal tissue surrounding fistulas. The primary outcome was the presence of microvascular flow. Secondary outcomes included angioarchitecture, fistula closure (postoperative dye test), and urinary continence (pad weight test). Results: Microvascular flow was present before, during, and after surgical repair in, respectively, 83.8%, 83.9%, and 93.4% of obtained image sequences. The angioarchitecture was normal in 75.8% of the image sequences before surgery, 69.4% at fistula closure, and 89.1% two weeks after VVF repair. Fourteen (82.4%) patients had a closed fistula after surgical repair. Limitations: The study was limited by the lack of a control group and the relatively small sample size. Conclusion: Although the vaginal microcirculation in women with VVF is compromised, extensive ischemic damage is not observed in the tissue surrounding fistulas. This suggests significant regenerative capacity of the vaginal vasculature in young women, or less extensive ischemic damage than presumed. Following surgical repair, we observed improvement of microcirculatory flow and angioarchitecture, suggesting that surgery is a good option for patients with obstetric VVF.

Experiences with an Extraperitoneal Transvesicoscopic Repair of a Vesicovaginal Fistula.

Purpose A vesicovaginal fistula (VVF) is a debilitating condition for women in terms of both its personal and social impacts. A reported transperitoneal laparoscopic approach to treatment has some limitations such as risk of intra-peritoneal organ injury and unnecessary bladder dissection. We here report on our experiences with an extraperitoneal transvesicoscopic approach to a VVF repair, which overcomes these drawbacks. Materials and Methods Seven VVF patients were treated using the transvesicoscopic approach. Under general anesthesia, patients were placed in the dorsal lithotomy position. The VVF orifice was obstructed via the vaginal canal using a Foley catheter. The bladder was then filled with normal saline under cystoscopic inspection, and a 5 mm trocar was inserted into it at the suprapubic area. The bladder wall was next fixed to the anterior abdominal wall. Thereafter, two 3 mm ports were punctured at the interspinous skin crease allowing the fistula margin to be cut and sutured in layers. Results Six of the study subjects in whom we attempted a transvesicoscopic repair of VVF had undergone a hysterectomy due to myoma and one had an intraabdominal abscess removal with Behcet's disease. One myoma patient who had a preexisting vesicoperitoneal fistula was converted to an open transabdominal VVF repair. The mean age of the 6 remaining patients was 46.0 ± 7.2 years (range, 35-57). The mean operation time was 273 ± 40.6 minutes (range, 223-323). There was no instances of significant pain or other immediate complications. Five patients showed no recurrence of the fistula during the follow-up period (8.7±5.1 months). Conclusion A transvesicoscopic approach is an effective modality for the repair of a VVF that is more minimally invasive and has a lower morbidity than a transabdominal procedure.

Perioperative Outcomes of Vesicovaginal Fistula Repair by Surgical Approach.

Data comparing perioperative outcomes between transvaginal, transabdominal, and laparoscopic/robotic vesicovaginal fistula (VVF) repair are limited but are important for surgical planning and patient counseling. This study aimed to assess perioperative morbidity of VVF repair performed via various approaches. The American College of Surgeons National Surgical Quality Improvement Program database was used to identify women who underwent transvaginal, transabdominal, or laparoscopic/robotic VVF repair from 2009 to 2020. Associations of surgical approach with baseline characteristics, blood transfusion, prolonged hospitalization (>4 days), and 30-day outcomes (any major or minor complication or return to the operating room) were evaluated with χ 2 , Fisher exact, and Kruskal-Wallis tests. Multivariable logistic regression models assessed the adjusted association of approach with 30-day complications and prolonged hospitalization. Overall, 449 women underwent VVF repair, including 252 transvaginal (56.1%), 148 transabdominal (33.0%), and 49 laparoscopic/robotic procedures (10.9%). Abdominal repair was associated with a longer length of hospitalization (median, 3 days vs 1 day transvaginal and laparoscopic/robotic; P < 0.001), higher risk of prolonged length of stay (abdominal, 21.1%; transvaginal, 4.0%; laparoscopic/robotic, 2.0%; P < 0.001), major complications (abdominal, 4.7%; transvaginal, 0.8%; laparoscopic/robotic, 0.0%; P = 0.03), and perioperative transfusion (abdominal, 5.0%; transvaginal, 0.0%; laparoscopic/robotic, 2.1%; P = 0.01). On multivariable analysis, the abdominal approach was independently associated with an increased risk of prolonged hospitalization compared with laparoscopic/robotic (odds ratio, 12.3; 95% confidence interval, 1.63-93.21; P = 0.02) and transvaginal (odds ratio, 6.09; 95% confidence interval, 2.87-12.92; P < 0.001) but not with major/minor complications ( P = 0.76). Transvaginal and laparoscopic/robotic approaches to VVF repair are associated with lower rates of prolonged hospitalization, major complications, and readmission compared with a transabdominal approach.

Robot-assisted vesicovaginal fistula repair: comparison of the extravesical and transvesical techniques.

Almost two decades after the description of robotic vesicovaginal fistula repair (R-VVF), the literature remains limited. The aims of this study are to report the outcomes of R-VVF and to compare the transvesical versus extravesical techniques. We performed an observational, retrospective, multicenter study, including all patients who underwent R-VVF from March 2017 to September 2021 at four academic institutions. All abdominal VVF repair over the study period were performed using a robotic approach. The success of R-VVF was defined as the absence of clinical recurrence. The outcomes of the extravesical versus transvesical techniques were compared. Twenty-two patients were included. The median age was 43 years old (IQR 38-50). Fistulas were supratrigonal and trigonal in 18 and 4 cases respectively. Five patients had undergone previous attempts of fistula repair (22.7%). The fistulous tract was systematically excised, and an interposition flap was used in all but two cases (90.9%). The transvesical and extravesical techniques were used in 13 and 9 cases respectively. There were four postoperative complications, three minor and one major. None of the patients had vesicovaginal fistula recurrence after a median follow-up of 15 months. The present series, one of the largest R-VVF reported to date, is consistent with the few series already published with a 100% cure rate. Systematic excision of the fistulous tract and the high rate of flap interposition may explain the high success rate. The transvesical and extravesical approaches yielded similar outcomes.

LATE UROLOGICAL COMPLICATIONS OF PELVIC RADIOTHERAPY PRESENTING TO A TERTIARY CARE INSTITUTE

Background: The present study aims to assess various presentations of radiotherapy-induced late urological complications and management done in a tertiary care institute. Methods: A prospective study was carried outin two-year which included 30 patients.Patients who received pelvic radiotherapy anytime in the past and presented with complications related to it were included. Their demographic data, primary malignancy, radiotherapy details, presentations, complications and management done were studied. Results: The mean age and interquartile range of patients was 59.76 yr. (57 – 65 yr.). 23 patients (76.66%) were females. Ca cervix was the most common indication for primary radiotherapy (20 patients) followed by ca prostate (six patients). The mean duration of presentation after radiotherapy was 11.96 year with EBRT being the most common modality.The median dose per fraction (IQR) was 2 (2) Gy per fraction. The median number of fractions (IQR) of radiation therapy was 25 (20 – 31.25) and the median total dose (IQR) was 50 Gy (40 – 70.50 Gy). Radiation-induced hemorrhagic cystitis was the most common complication in 15 patients (50%). Other complications include urethral stricture, ureteral stricture and vesicovaginal fistula. The surgical intervention rate was 63.33%. Cystourethroscopy, clot evacuation and electrocoagulation was the most common procedure done in 23.33%. Other operative intervention includes ileal conduit with or without cystectomy, vesicovaginal fistula repair and transureteroureterostomy. Conclusion: Complications of pelvic radiotherapy can manifest very late, are usually irreversible in nature and frequently needs surgical management. Surgery remains the mainstay of treatment modality for many of the complications.

Quality of life, voiding & sexual dysfunction following robot-assisted vesicovaginal fistula repair: a tertiary care centre experience.

Robot-assisted VVF (RA-VVF) repair has the advantage of small cystotomy, precise dissection and minimal surrounding tissue trauma. Translation of this to better functional outcomes is not studied so far. This study aims to evaluate the quality of life, voiding, and sexual dysfunction following robot-assisted VVF repair. Women with successful RA-VVF repair were screened using UDI-6, IIQ-7, FSFI, and WHOQOL-BREF questionnaires. The preoperative assessment was done in the prospective cohort only. Of the 75 women who underwent RA-VVF repair, 47 were enrolled, 33 in retrospective, and 14 in a prospective cohort. Overall, 28 (60%) women had urinary complaints with a median UDI-6 total score of 4 (0-100) and IIQ-7 score(0-23) in 5 (10%) women. However, UDS (15 women) showed no DO with cystometric capacity (352 ± 98.12) ml and normal compliance in 14 (93%) women. Mean BOOI and DCI were 11.90 ± 7.01 and 44.25 ± 8.60 respectively, with PdetQmax ranging from 17 to 44. None had difficulty in voiding (Qmax 13.85 ± 4.90). Twenty (43%) women were sexually active, and 2 had sexual dysfunction (FSFI score < 26.55). Quality of life was "good" to "very good" in all domains (score > 90) except for the social domain. The prospective cohort showed significant improvement in UDI-6 score (p < 0.05), IIQ-7 score (p < 0.05), and quality of life (p < 0.05) postoperatively. RA-VVF repair results in minimal voiding dysfunction and significant improvement in overall quality of life. For sexual dysfunction assessment, a longer follow-up is required.

V12-08 TRANSVESICAL SINGLE PORT ROBOTIC VESICOVAGINAL FISTULA REPAIR

You have accessJournal of UrologyCME1 Apr 2023V12-08 TRANSVESICAL SINGLE PORT ROBOTIC VESICOVAGINAL FISTULA REPAIR Lauren Gleich, Sandip Vasavada, Mohamed Eltemamy, and Jacqueline Zillioux Lauren GleichLauren Gleich More articles by this author , Sandip VasavadaSandip Vasavada More articles by this author , Mohamed EltemamyMohamed Eltemamy More articles by this author , and Jacqueline ZilliouxJacqueline Zillioux More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003347.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This video reviews a unique patient case and the surgical management of a vesicovaginal fistula repair using the single port robot through a transvesical approach. A 37-year-old nulliparous female was referred to our department for management of a vesicovaginal fistula after failing conservative management with indwelling Foley catheter for four weeks. The fistula was diagnosed following treatment for locally advanced ovarian adenocarcinoma. Eight weeks prior to presentation, she underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, partial omentectomy, sigmoid resection, and coloanal anastomosis. Her post-operative course was complicated by an anastomotic bowel leak managed conservatively with pelvic drain. The vesicovaginal fistula was diagnosed by x-ray cystogram completed after she reported new urinary incontinence. METHODS: Surgical management required creativity due to factors unique to our patient's situation. We recognized transvaginal exposure would be limited due to the patient’s nulliparous status and due to religious and personal beliefs, our patient did not consent to a transvaginal repair. A transabdominal approach would be challenging with her history of multiple complex abdominal surgeries and pelvic abscess. Additionally, ability for tissue interposition would be limited due to a prior partial omentectomy. RESULTS: Using the techniques described in our video, the vesicovaginal fistula was repaired successfully. Our patient was discharged home the same day as surgery. At 15 days post-op, a cystogram was obtained and a successful trial of void was completed. At subsequent follow-up, our patient is doing well with absence of incontinence. CONCLUSIONS: Our technique and approach to vesicovaginal fistula repair should be considered in unique situations such as this case. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1067 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lauren Gleich More articles by this author Sandip Vasavada More articles by this author Mohamed Eltemamy More articles by this author Jacqueline Zillioux More articles by this author Expand All Advertisement PDF downloadLoading ...

MP68-12 OUR EARLY CLINICAL EXPERIENCE WITH MANTRA TM MULTI ARM SURGICAL ROBOTIC SYSTEM (SS INNOVATIONS GROUP COMPANY) IN MAJOR URO-ONCOLOGICAL SURGERIES

You have accessJournal of UrologyCME1 Apr 2023MP68-12 OUR EARLY CLINICAL EXPERIENCE WITH MANTRATM MULTI ARM SURGICAL ROBOTIC SYSTEM (SS INNOVATIONS GROUP COMPANY) IN MAJOR URO-ONCOLOGICAL SURGERIES Amitabh Singh, Ashish Khanna, Sarbartha Kumar Pratihar, Vivek Vasudev, Nikhil Saurabh, and Sudhir Rawal Amitabh SinghAmitabh Singh More articles by this author , Ashish KhannaAshish Khanna More articles by this author , Sarbartha Kumar PratiharSarbartha Kumar Pratihar More articles by this author , Vivek VasudevVivek Vasudev More articles by this author , Nikhil SaurabhNikhil Saurabh More articles by this author , and Sudhir RawalSudhir Rawal More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003331.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: SSI MantraTM is a new addition to the arsenal of robotics systems in India for clinical usage. Here, we provide the initial outcomes of patients undergoing different types of major uro-oncological procedures. METHODS: A total of 32 patients affected by various urological conditions like prostate cancer, renal cancer, bladder cancer, and vesicovaginal fistula underwent treatment with SSI MantraTM system. Study was approved by institutional board (IRB No- 765/SO/SKR-35). Clinical use of MantraTM was registered with national clinical trial registry (CTRI/2020/11/029053). This system has four independent Arms which are docked. Demography of patient and clinical outcome like docking time, console time, total operative time, complications like bleeding, bowel injury, urinary incontinence, conversion to open, total hospital stay and perioperative outcomes were reported. RESULTS: A total of thirty–two patients were included in this study. This includes radical prostatectomy (n=15), radical cystectomy with ileal conduit (n=6), radical cystectomy with neo-bladder(n=4), radical nephrectomy (n=3), partial nephrectomy (n=2), partial cystectomy (n=1) and vesico-vaginal fistula repair (n=1). Mean age, BMI, ASA, draping time, patients positioning time, arm cart positioning, docking time, surgeon console time, total surgery time, undock time of radical prostatectomy and radical cystectomy patient was 66.1 vs 57.3 yrs , 26.1 vs 22.3, 3.3 vs 2.66, 19.3 vs 13.4 mins, 3.2 vs 5.66 mins, 13.8 vs 12.7 mins 7.2 vs 5.8 mins, 3hrs 12 min vs 5 hrs 20 mins, 5 hrs 6 mins vs 6 hrs 10 min, 10.9 vs 10.2 min respectively. There were total three conversions to open (radical prostatectomy (n=1), radical nephrectomy (n=1) and radical cystectomy with ileal conduit (n=1). CONCLUSIONS: Our experience with SSI MANTRA platform confirms that it is a robust, safe and efficient platform for all major urooncological procedures and it would expand the reach of robotic platform. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e957 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amitabh Singh More articles by this author Ashish Khanna More articles by this author Sarbartha Kumar Pratihar More articles by this author Vivek Vasudev More articles by this author Nikhil Saurabh More articles by this author Sudhir Rawal More articles by this author Expand All Advertisement PDF downloadLoading ...

V09-07 HOW TO USE A MESH SLING SAFELY AFTER THE POST-VESICOVAGINAL FISTULA REPAIR REPAIR PATIENT WITH STRESS URINARY INCONTINENCE

You have accessJournal of UrologyCME1 Apr 2023V09-07 HOW TO USE A MESH SLING SAFELY AFTER THE POST-VESICOVAGINAL FISTULA REPAIR REPAIR PATIENT WITH STRESS URINARY INCONTINENCE Micheal Breen Tamatave, Madagascar, Ly Hoang Roberts, and Larry Sirls Micheal Breen Tamatave, MadagascarMicheal Breen Tamatave, Madagascar More articles by this author , Ly Hoang RobertsLy Hoang Roberts More articles by this author , and Larry SirlsLarry Sirls More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with complicated obstetric fistulas may have stress urinary incontinence (SUI) after vesicovaginal fistula repair (VVF), especially if the urethra in involved. Various techniques to treat post-VVF SUI have low success rates or is technically challenging due to thin and scarred peri-urethral tissue. We describe a technique to place a midurethral mesh sling outside of the pre-existing vaginal mucosa. METHODS: With the patient in dorsal lithotomy under spinal anesthesia, a foley catheter is placed into the bladder and the labial majora is retracted for adequate exposure. A rectangular area of the same size as the mesh sling (3x1cm) at the midurethra is marked. A number 15 scalpel is used to incise the vaginal mucosa at the marked lines, and Metzenbaum scissors are used to dissect and mobilize the edges. The dissection is then carried out laterally to be behind the inferior pubic bone. This is done on both sides. The island of vaginal mucosa is then superficially scored using low power bovie cauterization to allow for mesh adhesion and tissue ingrowth. The mesh is sutured to the island of skin using a 3-0 Chromic or vicryl suture at the mesh edges in 4 areas. 0- prolen sutures are then placed on each lateral edge of the mesh in a running stitch. The Metzenbaum scissors are then used to enter into the endopelvic fascia behind the pubic bone to develop the retropubic space. Next, a suprapubic incision is made 1cm cranial to the pubic bone down to the rectus fascia. The Stamey needle is passed in a top-down approach approximately 2cm from midline and end delivered into the vaginal incision. To check for bladder perforation, a metal catheter is placed into the bladder and swept laterally to evaluate for any metallic noise indicative of contact. The prolene suture is passed up to the suprapubic incision and the same is done contralaterally. Bladder is backfilled with sterile saline with methylene blue by gravity and foley removed. Sutures are tied together midline with the sling tension adjusted while patient performs a Valsalva. Suprapubic incision is then closed in multiple layers. The vaginal incision is closed with mobilization of the proximal vaginal mucosa and reapproximation to the distal edge. For larger incisions, a Singapore flap can be done for adequate coverage. RESULTS: Successful managment of SUI. CONCLUSIONS: For challenging cases of SUI after a post-VVF repair, this technique can be an option. Further investigation is needed for clinical outcomes. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e839 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Micheal Breen Tamatave, Madagascar More articles by this author Ly Hoang Roberts More articles by this author Larry Sirls More articles by this author Expand All Advertisement PDF downloadLoading ...

HF01-05 UKRAINIAN CONTRIBUTIONS TO UROLOGY: AN IMPORTANT REMINDER

You have accessJournal of UrologyCME1 Apr 2023HF01-05 UKRAINIAN CONTRIBUTIONS TO UROLOGY: AN IMPORTANT REMINDER Daniel Nemirovsky, Maksym Pikul, Zoe Blake, Alexander Kenigsberg, Neil Mendrihatta, Peter Pinto, and Gennady Bratslavsky Daniel NemirovskyDaniel Nemirovsky More articles by this author , Maksym PikulMaksym Pikul More articles by this author , Zoe BlakeZoe Blake More articles by this author , Alexander KenigsbergAlexander Kenigsberg More articles by this author , Neil MendrihattaNeil Mendrihatta More articles by this author , Peter PintoPeter Pinto More articles by this author , and Gennady BratslavskyGennady Bratslavsky More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003243.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Over the past year, the world has witnessed acts of unprovoked violence and aggression in Ukraine. The AUA issued a strong statement standing against the atrocities and inhumanity of war. Many urologists, both with and without ties to Ukraine, have shown support to the country in various ways. In this light, it is imperative to not only support its citizens, but also to remember the contributions Ukraine has had on our understanding of urology. METHODS: Data was obtained with review of both PubMed and non-PubMed indexed literature, as well as through personal interviews with leading urologists in Ukraine. RESULTS: In the field of genitourinary reconstruction, the first ever use of oral mucosa in urethroplasty was pioneered by Kirill Sapezhko in the late 19th century, while working in Kyiv. Interestingly, Dr. Sapezhko was also the first recorded surgeon to describe a two-stage urethroplasty, using a method now known as the Thiersch-Duplay technique. Ludwik Rydygier, as head of the University of Lviv (then Lemberg), developed an early method for transperineal simple prostatectomy, as well as innovating several techniques for repair of vesicovaginal fistulae in the late 1800s. Yurii Voronoy, while working in Kherson during the early 20th century, revolutionized transplantation by conducting the first recorded renal allotransplant, as well as studying the various stages of immunologic rejection. In the mid-to-late 1900s, urologic oncologists in Kharkiv, including Boris Polonsky, Alexey Pereverzev, and Viktor Karpenko, conducted valuable research describing innovative techniques for IVC thrombectomy. More recently, Ukrainian scientists have made enormous strides in our understanding of urologic carcinogenesis, in large part due to the devastating Chernobyl disaster and related chronic ionizing radiation exposure. These studies have led to better insight into the development of kidney and bladder cancers, including the description of ionizing-radiation induced carcinoma in situ, termed “Chernobyl Cystitis”. CONCLUSIONS: Ukrainian urologists have made significant impacts to the field, with important and novel studies spanning across many urologic subspecialties. As urologists, one of the ways that we can support Ukraine is to highlight their many contributions to the field. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e257 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Nemirovsky More articles by this author Maksym Pikul More articles by this author Zoe Blake More articles by this author Alexander Kenigsberg More articles by this author Neil Mendrihatta More articles by this author Peter Pinto More articles by this author Gennady Bratslavsky More articles by this author Expand All Advertisement PDF downloadLoading ...

Removal of retained pessary and repair of vesicovaginal fistula with colpocleisis

Removal of retained pessary and repair of vesicovaginal fistula with colpocleisis

Vaginal-Laparoscopic Repair (VLR) of Primary and Persistent Vesico-Vaginal Fistula: Description of a New Technique and Surgical Outcomes

The main aim of our study was to describe the surgical technique and evaluate the feasibility, efficacy and safety of a vaginal-laparoscopic repair (VLR) of iatrogenic vesico-vaginal fistulae (VVF). Between April-2009 and November-2017, we retrospectively reviewed all clinical, radiological and surgical details of surgery for benign or malignant disease and ended up with VVF. All patients were diagnosed by CT urogram, cystogram and clinical test. The surgical technique was standardised and is described here. Eighteen patients developed VVF after hysterectomy, three after caesarean section and three after hysterectomy and pelvic lymphadenectomy. Twenty-two patients had an average 3 (range 1-5) attempts at fistula repair in other hospitals. In one patient, five attempts were made. The mean size of the fistula was 2.4 cm (range 0.7-3.1 cm). A median 8 weeks (6-16) conservative management with Foley catheter failed in all patients. No conversion to laparotomy and no complication occurred at VLR. Median hospitalisation was 1.4 days (range 1-3). The latter confirmed all patients were dry and tested negative at a repeated filling test. At 36 months follow-up, all patients remained dry. In conclusion, VLR successfully repaired VVF in all patients with primary and persistent VVF. The technique was safe and effective.

Predictors and outcomes of surgical repair of obstetric fistula at Mekelle Hamlin Fistula Center, Northern Ethiopia.

Obstetric fistula is a medical condition that involves an opening between vagina and bladder or vagina and rectum. From 2010 to 2013, on average, around 2000 women each year had surgery for obstetric fistula in Ethiopia. The success and failure rate of obstetric fistula repair varies from center to center and is determined by many factors. Thus, this study aimed to assess the predictors and outcomes of surgical repair of obstetric fistula at Mekelle Hamlin Fistula Center (MHFC). A retrospective reviewed medical records of 328 patients with obstetric fistula were carried out at MHFC. Multivariable logistics regression analysis was conducted, a significant association was declared when the p-value was less than 0.05, and the strength of the association was determined by computing the odds ratio at 95% CI. The analysis was done using SPSS version 24. Obstetrics fistula patients who had formal education were 13% more likely to be successfully repaired than obstetrics fistula patients who had no formal education. Additionally, obstetrics fistula patients who had a live birth were 32.325 (exp (β) = 32.325) times more likely to have had a successful repair than those who had a stillbirth. Fistula closure was achieved in 89.3% of cases. The success rate for VVF (vesico-vaginal fistula) and RVF (recto-vaginal fistula) surgical repair was 86.9% and 100% respectively, which is higher than the WHO target. Body mass index between 18.5-24.9kg/m2, formal education, antibiotic use, live birth, large fistula size, and home and cesarean delivery were predictors of successful closure of obstetric fistula.

Mechanical reinforcement of amniotic membranes for vesicovaginal fistula repair

IntroductionAmniotic membranes (AM) have shown its great potential in reconstructive surgery due to their regenerative capacity. However, AM is regarded to be relatively weak when applied for load-bearing purposes. This study aims to produce an AM-based scaffold that can withstand the mechanical loads applied in vesicovaginal fistula repair. Different strategies are investigated to improve the mechanical characteristics of AM. MethodsSingle and multilayered AM, and composite constructs of AM with electrospun poly-4-hydroxybutyrate (P4HB) or bovine pericardial tissue combined with the use of fibrin glue, were mechanically tested in this study. Suture retention strength and mechanical characteristics (tensile stress, elongation, tangent modulus and maximum load) were assessed by uniaxial testing. The effect of degradation of the composite constructs on the mechanical characteristics was determined by uniaxial testing after 4 and 8 weeks. ResultsSingle and multilayered AM could not provide the mechanical requirements needed for surgical implantation (>2N load). AM was combined successfully with electrospun P4HB and bovine pericardium with the use of fibrin glue and were able to exceed the 2N load. ConclusionThe composite constructs with AM showed sufficient mechanical characteristics for surgical implantation. Electrospun P4HB combined with AM seemed the most promising candidate since the mechanical characteristics of P4HB can be further modified to meet the requirements of the application site and the degradation of the P4HB allows a gradual transfer of load. Eventhough the scaffold is intended for fistula repair, it can potentially be applied in surgical reconstruction of other hollow organs by modifying the mechanical characteristics.

OUTCOME OF VESICOVAGINAL FISTULA REPAIR AT TERTIERY HOSPITAL: COHORT STUDY

Objective: This study aims to provide an evaluation of the outcome of patients with history of vesicovaginal fistula repair by assessing the success rate and complications that occur. Material &amp; Methods: This study was a retrospective cohort study to describe the etiology, approach, and outcome in patients undergoing vesicovagina fistula repair. We analyzed the complication with vesicovaginal fistula type, etiology and technique used. Results: There were 10 vesicovaginal fistula patients, with mean age 33.4 ± 14.5 years. Both transabdominal and transvaginal approach were equally used. Sixty percent patient was successfully treated without complication. Forty percent patient with incontinence came with mild urinary incontinence and need further repair. Conclusion: Both transvaginal and transabdominal approach were equally effective to repair fistula with relatively low complication rate and high successful rate.&#x0D; Keywords: Vesicovaginal fistula, retrospective, transabdominal and transvaginal.&#x0D;

Robotic-Assisted Surgery—a Highly Effective Modality for Vesicovaginal Fistula Repairs

To summarize recent experience with robotic vesicovaginal fistula repair and describe the contemporary technique. Robotic vesicovaginal repair has been tested at multiple centers, with similar outcomes to open surgery. It has benefits including decreased hospital stay, less blood loss, and similar long-term outcomes. As long as the surgeon is experienced in robotic surgery, this technique appears to be promising. Robotic vesicovaginal repair results in similar outcomes to open surgery with decreased morbidity.