Successful Fistula Repair Research Articles

Proportions and determinants of successful surgical repair of obstetric fistula in low- and middle-income countries: A systematic review and meta-analysis.

Obstetric fistula is a serious and debilitating problem resulting from tissue necrosis on the reproductive and urinary and/or lower gastrointestinal tract organs due to prolonged labor. Primary studies of the treatment of obstetric fistulae report significantly variable treatment outcomes following surgical repair. However, no systematic review and meta-analysis has yet estimated the pooled proportion and identified the determinants of successful obstetric fistula surgical repair. To estimate the proportion and identify the determinants of successful surgical repair of obstetric fistulae in low- and middle-income countries. The protocol was developed and registered at the International Prospective Register of Systematic Reviews (ID CRD42022323630). Searches of PubMed, Embase, CINAHL, Scopus databases, and gray literature sources were performed. All the accessed studies were selected with Covidence, and the quality of the studies was examined. Finally, the data were extracted using Excel and analyzed with R software. This review included 79 studies out of 9337 following the screening process. The analysis reveals that 77.85% (95%CI: 75.14%; 80.56%) of surgical repairs in low and middle-income countries are successful. Women who attain primary education and above, are married, and have alive neonatal outcomes are more likely to have successful repair outcomes. In contrast, women with female genital mutilation, primiparity, a large fistula size, a fistula classification of II and above, urethral damage, vaginal scarring, a circumferential defect, multiple fistulae, prior repair and postoperative complications are less likely to have successful repair outcomes. The proportion of successful surgical repairs of obstetric fistula in low and middle-income countries remains suboptimal. Hence, stakeholders and policymakers must design and implement policies promoting women's education. In addition, fistula care providers need to reach and manage obstetric fistula cases early before complications, like vaginal fibrosis, occur.

Tethered vagina syndrome: massive urine loss caused by bladder neck scarring cured by skin graft.

The bladder neck area of the vagina is known as the "zone of critical elasticity" (ZCE). Adequate vaginal elasticity at ZCE is required for the oppositely-acting muscles to independently close the distal urethra and bladder neck. Scarring at ZCE "tethers" the more powerful posterior muscles to the anterior muscles and the bladder neck is forcibly pulled open, resulting in massive urine loss. This condition is known as "tethered vagina syndrome" (TVS). In developed countries, the main cause of TVS is iatrogenic. Vaginal repairs, vaginal mesh, may cause scarring at ZCE and this directly links the oppositely-acting muscle forces. Over-elevated Burch colposuspensions may stretch the ZCE to the point where its elasticity is lost so the muscles can no longer function independently. The treatment is to dissect the vagina clear of the scarring and to insert a skin graft to the bladder neck to restore ZCE elasticity. In developing countries, extensive trauma to the vagina and bladder from obstructed childbirth can cause obstetric fistulas. In up to 40-50% of these women, there is ongoing massive urine loss after the fistula has been successfully closed. Performing a prophylactical skin graft during fistula closure if there is vaginal tissue deficit is proving to be revolutionary. In women with Goh type 4 fistula (n=45), 46% were cured (full dryness) against an expected 19%. The same operation can produce equally dramatic cures in women who continue to leak urine after successful fistula repair.

A successful endovascular aortic repair of aortoesophageal fistula following esophagectomy: a case report and literature review

BackgroundAortoesophageal fistula (AEF) is an extremely rare and highly fatal complication leading to a high risk of morbidity and mortality. Successful management of AEF after esophagectomy for esophageal carcinoma has rarely been reported in the literature.Case presentationHere we present a rare case of a 44-year-old female with complications of AEF after esophagectomy for esophageal carcinoma, mainly presented as vomiting of blood. Both computed tomographic and computed tomography angiography of the chest showed bilateral pleural effusion and atelectasis, while gastroscopy showed large gastrointestinal bleeding. Emergency surgery was performed that included the removal of the mediastinal abscess, left lower pulmonary wedge resection, and thoracic endovascular aortic repair (TEVAR), followed by supportive treatment. The surgery went successful, and the patient was followed up for 1 year after discharge and showed good recovery. We also reviewed previous literature on the history, causes, pathophysiology, clinical presentation, diagnosis, and treatment of AEF after esophagectomy for esophageal adenocarcinoma.ConclusionsIn our case, thoracotomy combined with TEVAR was effective in treating AEF after esophagectomy for esophageal adenocarcinoma. This case provides successful experiences for clinical diagnosis and treatment of AEF after esophagectomy for esophageal carcinoma.

Early and Mid-Term Results of Native and Abdominal Aortic Graft Infection Treatment via Surgeon-Constructed Porcine Pericardial Aortic Tubes.

The search for optimal material for aortic infection reconstruction is ongoing. Our study presents the early and mid-term results of surgeon-constructed porcine pericardial tubes in the in-situ reconstruction of abdominal aortic infections, focusing on the safety as well as the durability of surgeon-created tubes. We performed a retrospective analysis of 8 patients treated for native aortic (n = 3) and aortic graft infections (n = 5) with surgeon-created tubes made of porcine pericardium patch (8 × 14cm NO-REACT Ⓡ, BioIntegral Surgical Inc., Mississauga, ON, Canada). There were 7 males and 1 female, aged 68.5 (±4.8years). Three patients had an aorto-enteric fistula. Technical success was obtained in all patients. Thirty-day mortality was 12.5% (n = 1). Mid-term follow-up was 12months (2-63months). One-year mortality was 37.5% (n = 3). Reintervention rate was 28.5% (n = 2). False aneurysm rate in the follow-up was 14.2% (n = 1). Surgeon-constructed porcine pericardial tubes seem to be a promising alternative as a replacement for native as well as graft-related abdominal aortic infections. The mid-term durability is encouraging, once the infection is controlled in cases with successful fistula repair and in native aortic infections patients. Further observations on larger groups, in longer follow-ups are necessary to confirm these preliminary observations.

A case of successful repair of urethrocutaneous fistula post proximal hypospadias repair managed by Johanson’s 2 stage urethroplasty

A case of successful repair of urethrocutaneous fistula post proximal hypospadias repair managed by Johanson’s 2 stage urethroplasty

Living with obstetric fistula for ten years: a delayed diagnosis and review of pertinent surgical technique

Obstructed labour is a common cause of vesicovaginal fistula in the developing world. Those fistulae occurring after labour and its complications is called obstetric fistula. We report a case of complex obstetric fistula in a 32 y woman who was having continuous leakage of urine since last 10 y following caesarean section for obstructed labour. A successful fistula repair was done with transvaginal approach with Latzko technique and interposition with Martius flap.

12 Urethrovaginal fistulas: How to plug a leaky pipe

This video demonstrates the surgical approach to repair of a urethrovaginal fistula, emphasizing key principles for successful fistula repair. Urethrovaginal fistulas occur infrequently in the developed world and are typically caused by trauma or iatrogenic injury to the urethra during surgery. Surgeries such as mid-urethral sling placement or revision and urethral diverticulum repair can cause inadvertent damage to the urethra, predisposing to fistula formation. We present a unique case of a urethrovaginal fistula presenting as stress incontinence in a patient without prior urogenital surgery. Our patient is a 58-year-old para 3 with stress incontinence that began following a difficult high forceps delivery in her first pregnancy. On examination, she had extra-urethral leakage from a pinpoint defect in the anterior vaginal wall. Office cystoscopy confirmed a 2 mm urethrovaginal fistula. In the operating room, the fistula was isolated using a Fogarty embolectomy catheter. An inverted U-incision was made in the anterior vaginal wall, and the epithelium was generously mobilized. The urethra was closed in two layers, with confirmed watertight closure after the first layer. A Martius flap was then performed to enhance the layered closure, add neovascularization, and promote healing. The patient did well postoperatively with resolution of her stress incontinence by her 6-week postoperative visit. Urethrovaginal fistulas are rare but should be considered as a cause of stress incontinence in women with prior pelvic surgery or trauma, to include difficult instrumented deliveries. Keys to a successful repair include proper visualization, tension-free closure, and repair in multiple layers with avoidance of overlapping suture lines.

Efficacy of Staged Oronasal Fistula Reconstruction and Improved Bone Graft Survival in Cleft Patients Undergoing Secondary Reconstruction.

To evaluate the efficacy of the senior author's technique of staged reconstruction in patients with recalcitrant oronasal fistulas. A retrospective review of the Pediatric Plastic Surgery Cleft & Craniofacial Surgery Database of cases from September 2013 to December 2018 was conducted. A total of 31 patients who had previously undergone >1 surgical attempt to repair a fistula or patients who have failed >1 attempt at bone graft were included in this study. All patients were referrals from outside facilities. Primary outcomes examined included fistula recurrence, infection rates, ability to proceed with second stage bone grafting after first stage fistula takedown and reconstruction, and bone graft loss. Charts of 1053 patients were reviewed and 31 (2.94%) cases met inclusion criteria for this study. Nineteen (61.3%) of these patients proceeded with the second stage of reconstruction and 100% did not experience any graft loss. Seven patients who completed the first stage are undergoing orthodontic optimization prior to bone grafting. The remaining 5 are adult patients not interested in pursuing bone grafting. All 31 patients with recurrent and recalcitrant fistulas had successful fistula reconstruction with our approach, despite multiple previous failed reconstructions. The 2-staged reconstructive approach described herein effectively resulted in resolution of prior recurrent recalcitrant fistulas and resulted in eventual bone grafting. By employing this technique, we report successful fistula repair and bone grafting in patients who had previously undergone multiple surgical reconstructions.

Microbiome diversity predicts surgical success in patients with rectovaginal fistula.

Growing literature details the critical importance of the microbiome in the modulation of human health and disease including both the gastrointestinal and genitourinary systems. Rectovaginal fistulae (RVF) are notoriously difficult to manage, many requiring multiple attempts at repair before correction is achieved. RVF involves two distinct microbiome communities whose characteristics and potential interplay have not been previously characterized and may influence surgical success. In this pilot study, rectal and vaginal samples were collected from 14 patients with RVF. Samples were collected preoperatively, immediately following surgery, 6-8weeks postoperatively and at the time of any fistula recurrence. Amplification of the 16S rDNA V3-V5 gene region was done to identify microbiota. Data were summarized using both α-diversity to describe species richness and evenness and β-diversity to characterize the shared variation between communities. Differential abundance analysis was performed to identify microbial taxa associated with recurrence. The rectal and vaginal microbiome in patients undergoing successful fistula repair was different than in those with recurrence (β-diversity, p= 0.005 and 0.018, respectively) and was characterized by higher species diversity (α-diversity, p= 0.07 and p= 0.006, respectively). Thirty-one taxa were enriched in patients undergoing successful repair to include Bacteroidetes, Alistipes and Rikenellaceae as well as Firmicutes, Subdoligranulum, Ruminococcaceae UCG-010 and NK4A214 group. Microbiome characteristics associated with fistula recurrence have been identified. The association of higher vaginal diversity with a favorable outcome has not been previously described. Expansion of this pilot project is needed to confirm findings. Taxa associated with successful repair could be targeted for subsequent therapeutic intervention.

Characteristics of persistent urinary incontinence after successful fistula closure in Ethiopian women.

Obstetric fistulas have devastating consequences for women. Although surgical repair is largely successful in closing the defect, many women with successful fistula closure report persistent urinary incontinence. Our study is aimed at characterizing incontinence after successful fistula repair and its impact on quality of life. This cross-sectional study enrolled women with a history of successful obstetric fistula closure with (n= 51; cases) or without (n= 50; controls) persistent urinary incontinence. Data were collected in Mekelle, Ethiopia, between 2016 and 2018. All cases underwent clinical evaluation and completed questionnaires characterizing the type, severity, and impact of incontinence. Cases were significantly more likely to have acquired their fistula at an earlier age and with their first vaginal delivery compared with controls. Almost all cases reported both stress (98%) and urgency (94%) incontinence, and half reported constant urinary leakage (49%) despite successful fistula closure. Of cases who completed urodynamic evaluation (n= 22), all had genuine stress incontinence and none had detrusor overactivity. All cases reported moderate to severe (80.4%) or very severe (19.6%) incontinence (measured by ICIQ-SF) and this had a moderate to severe negative impact on their quality of life (as measured by ICIQ-QoL). Although history of suicidal ideation was not significantly different between the groups, among those with suicidal ideation, cases were more likely to report having made a plan and/or attempted to commit suicide. When urinary incontinence persists after successful fistula closure, it tends to be severe and of mixed etiology and has a significant negative impact on quality of life and mental health.

182: Restoration of the vaginal microbiome & Its ecology following obstetrical fistula repair in Lilongwe, Malawi

The vaginal microbiome is a key mediator of reproductive health and disease, and fluctuations in its ecology and dysbiosis as a result of pregnancy and infection/antibiotics are well known. However, community restoration following major disruptive events have not been studied. We hypothesized that characterizing the vaginal microbiome community restoration following surgical repair of chronic obstetrical fistula would be unique and highly informative. Following Malawi IRB approval, n=15 women undergoing delayed repair of their obstetrical VVF or RVF consented for participation in this observational, prospective cohort arising from the Fistula Care Centre (Bwaila Hospital, Lilongwe, Malawi). Detailed surgical, medical, dietary & other metadata were collected alongside daily vaginal, urine & rectal microbiome specimens (CatchAll swabs) from pre-op (d0) through discharge (d9-28) & at 6 weeks post-operative and stored in sterile SCF-1 media. For metagenomics, DNA was extracted in a BSL2 hood with parallel “contaminant” controls & subjected to 16S V4 & shotgun metagenomic sequencing (Illumina). Customized bioinformatics pipelines were developed for longitudinal microbiome community assessment. There are several key and novel findings. 1) Following obstetric fistula repair, the vaginal community was restored and differentiated from the body site communities (Fig.1A); 2) Each woman demonstrated near daily changes in her vaginal ecology, being more similar to herself than to others (Figs.1B-2); 3) Community microbial dynamics were shaped by several keystone genera, including lactobacilli and bifidobacteria (Fig.2C); 4) All women with a successful fistula repair demonstrated microbial restoration within 6 weeks, despite months to years of symptomatic VF. We report for the first time restorative vaginal community ecology in n=15 subjects undergoing delayed obstetrical fistula repair. While larger cohorts are needed to understand potential microbial predictors of successful obstetrical VF repair, these findings illustrate the remarkable resilience of the vaginal microbiome.

Non-Fistulous Complications of Prolonged Obstructed Labour among Obstetric Fistula Patients in Southern Nigeria

Background: Long-term complications of prolonged obstructed labour are multisystemic, obstetric fistula about the most devastating. Efforts at controlling obstetric fistula pay little attention to the non-fistulous injuries which reduce the quality of life of the affected women even after a successful fistula repair. The objectives of this study were to determine the burden of the non-fistulous complications among fistula patients, identify these injuries and the factors associated with them. Methods: This cross-sectional study was conducted at the National Obstetric Fistula Centre, Abakaliki, South-East Nigeria from July to December 2016. The hospital has performed over 2600 free fistula repairs. This study was approved by the Research and Ethics Committee of the hospital. The study population comprised of women who developed obstetric fistula following prolonged obstructed labour. Direct questioning, examination findings, operation findings and laboratory results, using a pre-tested, semi-structured and interviewer-administered proforma were used to collect data. Informed consent was obtained from the subjects. Data were analyzed using the Statistical Package for Social Sciences [SPSS] version 21. Frequency and proportions were used to describe categorical variables while means and standard deviation were used to describe continuous variables. Association between categorical variables and direct obstructed labour injuries was tested using chi-square test and predictors of obstructed labour injuries were determined using logistic regression. A P-value 0.05 was considered statistically significant. Results: One hundred and sixty one (161) women participated in the study. The mean age of the women was 33.4 years while the mean parity was 3.2. Non-fistulous complications of prolonged obstructed labour were found in 96.9% (156) of the women. These included cervical retraction (42.2%), obstetric nerve palsy (30.4%), vaginal scarring (29.8%), partial urethral loss (16.1%), anal sphincter injury (3.1%), cervical stenosis (5.0%) and urethral stenosis (3.7%). Others were ammoniacal dermatitis (29.2%), secondary amenorrhoea (21.7%), secondary infertility (9.3%), dyspareunia (6.8%), hypomenorrhea (1.2%) and bladder stone (3.7%). Majority (79.4%) of the women with cervical retraction had caesarean section (CS) as against 20.6% who had vaginal delivery. This was statistically significant (P 0.001). A higher proportion of participants with amenorrhea were delivered via CS (44.3%) compared to those who had vaginal delivery (21.2%). This was also statistically significant (P = 0.012). Neurologic injury was associated with primiparity although this was not statistically significant (P = 0.171). Conclusion: Almost all fistula patients also have non-fistulous complications of prolonged obstructed labour. Efforts to manage the fistula should equally address these complications. We advocate comprehensive care for identification and management of these injuries to improve the quality of life and overall well-being of these women. To reduce complications like cervical retraction, there should be an emphasis on safer caesarean section for women with prolonged obstructed labour.

Predictors of Successful Urogenital Fistula Repair and Incidence of Urinary Problems Post Successful Fistula Repair

Objective: Despite the successful fistula repair many patients may continue to complaint of persistence of symptoms in terms of frequency, urgency, urge incontinence and stress incontinence. To evaluate the association of various predictive factors with the outcome of surgical repair of urogenital fistula and todetermine the incidence and association of urinary problems post successful fistula repair.
 Methods: The retrospective analysis was conducted at Maternal Child Health, PIMS, Islamabad. It comprised data related to vesicovaginal fistula repair of patients from January 2008-June 2018. Various modalities were used to determine the underlying cause of these symptoms including patient’s history, examination, ultrasound, urine examination and urodynamic studies.
 Results: A total of 364 patients of urogenital fistula repair were reviewed, with an overall success in 318 (87.4%) cases.Primary surgical repair of vesicovaginal (90.0%), vesicouterine (86%), ureteric (100%) & ureterovaginal (98%) were more successful. Success rate was further decreased with the history of >1repair attempt of vesicovaginal (71.4%) & vesicouterine (66.5%) fistula.
 Among 318 successful fistulas repair patients, 78 (24.5%) had urinary problems post operatively. Out of these 78, 56.4% had stress incontinence, 41% infection and 2.6% urge incontinence.
 Conclusions: Urinary incontinence after fistula repair requires careful evaluation as the successful repair of a urogenital fistula can correct the fistula defect, but it might not make the patient dry.

Incidence of Urinary Problems Post Successful Fistula Repair

Aims: The aim was to determine the incidence and association of urinary problems post successful fistula repair.
 Methods: The retrospective analysis was conducted at Maternal Child Health Pakistan Institute of Medical Sciences, Islamabad, and comprised data related to patients having undergone vesicovaginal fistula repair from January 2008 to June 2018. Various modalities were used to determine the underlying cause of these symptoms including patient’s history, examination, ultrasound, urine examination and urodynamic studies. Statistical analysis of the record was done using SPSS 21 software.
 Results: Among total 318 successful fistulas repair patients, 78 (24.5%) had urinary problems post operatively. Out of these 78, 56.4% had stress incontinence, 41% infection and 2.6% urge incontinence.13.6% of the stress incontinence was due to sphincter weakness. Urge incontinence was found to be due to detrusor instability. These post-operative urinary complaints were significantly associated with the repair of vesicovaginal (31.3%), urethral (23.1%) and vesicouterine (15.7%) fistula compared to those involving ureter(p 0.04). No significant association was found between the incidence of post-operative urinary complaints and previous history of surgical repair, parity, fistula size and duration of fistula.
 Conclusions: Urinary incontinence after fistula repair requires careful evaluation as the successful repair of a urogenital fistula can correct the fistula defect, but it might not make the patient dry. Moreover, performing further continence surgery may exacerbate the condition in some cases.

Success Rate of Urogenital Fistula Repair and Predictors of Success-An Audit of Ten Years Data

Aims: To evaluate the association of various predictive factors with the outcome of surgical repair of vesicovaginal fistula.
 Methods: The retrospective analysis was conducted at Maternal and Child Health, Pakistan Institute of Medical Sciences, Islamabad, and it comprised data related to patients having undergone vesicovaginal fistula repair from January 2008 to June 2018. Statistical analysis of the record was done using SPSS 21 software.
 Results: A total of 364 patients of urogenital fistula repair were reviewed, with an overall success in 318 (87.4%) cases. There were no significant differences in fistula duration (p0.4), size of fistula (p 0.34) and accessibility (p0.5) between successful and unsuccessful group. However, we found the association between the type of fistula and history of previous repair attempts with the success of fistula repair. Primary surgical repair of vesicovaginal (90.0%), vesicouterine (86%), ureteric (100%) and ureterovaginal (98%) were more successful as compared to repair with the history of 1 previous attempt (90.3%, 83.3%, 66.6% and 75% respectively). Success rate was found to further decrease with the history of more than one repair attempt of vesicovaginal (71.4%) and vesicouterine (66.5%) fistula. Further, successful fistula repair in women was also found to be significantly associated with parity less than 4 (p 0.038).
 Conclusion: Despite the higher success rate of urogenital fistula repair, it’s important to refer the urogenital fistula patients timely to specialized fistula centres in order to achieve best results.

Primary Posterior Sagittal Anorectoplasty and Repair of Esophageal Atresia with Tracheoesophageal Fistula in the Same Sitting

Esophageal atresia and tracheoesophageal fistula is often associated with anorectal malformation. Traditionally, staged surgeries are performed in this condition. We did a successful repair of esophageal atresia and tracheoesophageal fistula and primary posterior sagittal anorectoplasty for anorectal malformation in the same sitting.

30: Minimally invasive repair of a vesicovaginal fistula after loop electrosurgical excision procedure with concurrent hysterectomy

The objective of this video is to demonstrate a minimally invasive vesicovaginal fistula repair with concurrent hysterectomy in a patient with a fistula caused by a loop electrosurgical excision procedure (LEEP). Through surgical footage, we review the preoperative, intraoperative, and postoperative foundations of a successful fistula repair in addition to describing the unique aspects of the repair when performed at the time of hysterectomy. While this case represents an unusual circumstance given that fistulas are most often caused by hysterectomy, the same surgical principles may be applied for an excellent outcome.

The use of platelet gel for repair of a cerebrospinal fluid fistula of the skull base (a case report and literature review)

Nasal liquorrhea is a serious problem in surgery of skull base tumors, which is associated with a high risk of purulent-septic complications. This paper presents a case of successful repair of a cerebrospinal fluid fistula with an autologous platelet gel in the postoperative period after removal of meningioma of the anterior cranial fossa base, which was accompanied by a purulent-inflammatory complication in the surgical wound area.

Neobladder-Vaginal fistula: The University of Southern California experience.

The use of orthotropic neobladder (ONB) construction in women has increased in popularity. With increasing numbers so have complications distinct to this procedure. Neobladder vaginal fistula (NVF) is a rare but challenging complication. We present our experience correcting this problem. An IRB approved database of female patients with an ONB was retrospectively reviewed. Patients with a history of NVF were identified and charts reviewed. Our standard technique of radical cystectomy and orthotopic diversion in female patients includes interposition of omentum between the neobladder and anterior vaginal wall and sacrocolpopexy. Two hundred and forty-nine female patients underwent cystectomy and ONB construction between 1995 and 2015. Fourteen patients were diagnosed with a NVF (5.6% incidence). The average age and follow-up was 67 years and 33.7 months, respectively. Surgery for fistula closure was attempted in 13 patients. One repair was combined abdominal and transvaginal; the remaining 12 were performed transvaginally. Location of NVF was categorized as at the urethra-neobladder anastomosis (UNA, nine patients) and anterior vaginal wall (AVW, four patients). Eight patients had a successful fistula repair (61.5%) but only five patients ultimately retained their ONB (39%). Patients with a NVF pose a surgical challenge. Successful fistula repair does not necessarily result in adequate continence due to an incompetent outlet. NVF location at the UNA is the more common location and is more challenging in regard to successful resolution of the NVF as well as possible urinary incontinence post-NVF repair.

Outcomes of Surgical Management in Patients with Stress Urinary Incontinence and/or Neovesicovaginal Fistula after Orthotopic Neobladder Diversion

To our knowledge there are no guidelines for the evaluation and management of incontinence in women with an orthotopic neobladder. We propose a treatment algorithm based on our experience with treating this patient population. We identified women in whom orthotopic neobladder diversion and surgery for incontinence were performed from January 1, 1995 to January 1, 2014. Charts were reviewed for management, outcomes and complications within 30 days of surgery. At this institution 12 women with orthotopic neobladder diversion were treated with surgery for incontinence between 1995 and 2014. Six women (50%) had an undiagnosed neovesicovaginal fistula, of whom 3 (50%) underwent successful fistula repair. A total of 12 bulking agent injections were performed in 6women (50%). The outcomes were continued dryness after 1 injection (8%), transient improvement after 9 (75%), immediate failure after 1 (8%) and secondary fistula development after 1 (8%). Four transobturator slings and 4 pubovaginal slings were placed in a total of 6 patients (50%), of whom 1 (17%) was dry and 1 (17%) was improved. At a median followup of 22.9 months (IQR 11.1-46.4) 6 women (50%) were dry or improved and 6 (50%) had no improvement in leakage. Of the 6 (50%) women who were dry or improved 2 (17%) achieved planned intermittent catheterization after surgery and 2 (17%) underwent ileal conduit conversion. Bulking agents have low long-term efficacy and carry the risk of fistula formation. The efficacy of tension-free sling placement is low and continence requires an obstructing sling. Counseling should include acceptance of multiple procedures, which may be necessary to achieve continence, and consideration of conduit diversion.