Vesicovaginal Fistula Formation Research Articles

Incidental urinary tract injury and the formation of vesicovaginal fistula at the time of hysterectomy for benign indications.

The association between hysterectomy type, laparoscopy use and vesicovaginal fistula (VVF) is currently unclear and would be useful to determine route of surgery and provide adequate patient counseling. The objective of this study was to evaluate the magnitude of association between the use of laparoscopic assistance, recognized intraoperative urinary tract injury and subsequent VVF repair and to quantify any differences in fistula repair and injury detection by hysterectomy type. Lastly, we sought to determine whether the type of hysterectomy is a risk factor for VVF repair independent of injury identification. We performed a retrospective cohort study utilizing the Healthcare Cost and Utilization Project database examining benign hysterectomies performed in California, New York and Florida from 2005-2011. Multivariable logistic regression models were used to evaluate associations among hysterectomy type, reported injury and VVF. Of 581,395 eligible hysterectomies, urinary tract injuries occurred in 6702 patients (1.15%) and 640 patients developed VVF (0.11%). Patients with reported injury were 20-fold more likely to develop VVF than those without (OR = 20.6; 1.96% vs. 0.089% respectively). The association between reported injury and VVF development was stronger if laparoscopy was involved (OR = 30) than if it was not (OR = 17). Patients undergoing laparoscopic procedures were less likely to have injury reported (OR = 0.6) but more likely to undergo VVF repair (OR = 1.5). This association with VVF repair was independent of injury identification. Patients developing VVF were more likely to have undergone total abdominal hysterectomy compared to other hysterectomy types. Laparoscopy is an independent risk factor for the need for subsequent VVF repair, independent of hysterectomy type and presence of intraoperatively recognized urinary tract injury.

Cytological Evaluation of Urinary Samples among Vesicovaginal Fistula Patients in National Obstetrics Fistula Centre, Southeastern Nigeria

Vesicovaginal fistula (VVF) is a non-physiological epithelial fistulous tract between the bladder and the vagina, resulting in continuous urinary incontinence. VVF occurs most commonly after obstetrical and gynecological injury. This study is a descriptive cross-sectional study designed to carry out cytological evaluation of urine samples of vesicovaginal fistula patients in National Obstetrics Fistula Centre, Southeastern Nigeria. The voided and catheterized urine samples collected were stained using Papanicolaou and Diff-Quick staining techniques. A total number of 123 patients were involved in this study. The mean age of the patients was 36.66 (± 6.21) years. The patients were grouped according to age into 4 groups: 1 (0.8%) was ≤ 24 years, 59 (48.0%) were 25 to 34 years, 43 (35.0%) were 35 to 44 years and 20 (16.2%) were ≥ 45 years of age. The parity status of these cases was grand multipara 29 (23.6%), multipara 32 (37.4%), primipara 46 (37.4%) and nullipara 16 (13.0%). Majority of the patients 111 (90.2%) were from rural areas, 8 (6.5%) from urban areas and 4 (3.3%) were from semi-urban areas. According to marital status, 91 (74.0%) were married, 16 (13.0%) were widowed, 5 (4.1%) were single and 11 (8.9%) were divorced. According to the period the patients had lived with fistula, majority of the patients 94 (76.4%) had lived less than one year with this problem, while 29 (23.6%) had suffered from VVF for 1-5 years. Cytological evaluation of the urine smears showed that a total of 92 (74.8%) urine samples had normal findings. The rest of the 31 (25.2%) urine samples showed a variety of findings. Out of these 31 samples, 16 (51.6%) showed inflammatory aggregates suggestive of urinary tract inflammation, 3 (9.7%) showed decoy cells suggestive of Polyoma virus infection, 7 (22.6%) cases showed perinuclei halo suggestive of Trichomonas vaginalis infection, 3 (9.7%) showed oval fat bodies suggestive of possible nephrotic syndrome, 8(25.8%) cases showed koilocytes, indicative of Human papilloma virus infections. Cases that showed presence of haematuria were 7 (22.6%). There was no case of tumor cells detected in all the urine samples examined. From the outcome of this study, it is important to take special note of the presence of the viral carcinogens: Polyoma virus and Human papilloma virus, since in theory and as reported in few case reports, malignancy of the urinary tract can lead to formation of vesicovaginal fistula.

Пузырно-влагалищные свищи: современные концепции диагностики и лечения.

Introduction. Vesicovaginal fistula (VVF) is a pathological communication between the urinary bladder and the vagina. The lack of common approaches to the treatment choice, its timing and postoperative management of patients makes this disorder one of the challenges of modern urogynecology. Materials and methods. Relevant publications were searched using the PubMed database, the Google Scholar search system, and the scientific electronic library eLibrary.ru. Results. VVF is the most common form of urogenital fistulas. In developed countries, the formation of VVF mainly are the result of surgical trauma or radiation therapy, but in developing ones the majority of VVF have an obstetric etiology. There are different classifications of VVF; however, there is no overall accepted one that is suitable for predicting treatment efficacy and long-term outcomes regardless of etiology of VVF. Treatment of VVF with long-term bladder drainage should be performed only for small, benign and unformed VVF. Surgical closure of VVF is the primary method of treatment. Surgery can be performed using abdominal and vaginal access. Regardless of the access, a positive result (closure of the fistula) on average is achieved in 90,8% of cases. The treatment of post-radiation fistulas is more challenged and associated with a high failure rate. Conclusion. Despite of the variety of VVF treatment options, unfortunately, there is no the perfect one yet due to the variability of VVF ethiology, the lack of unified curative approaches and the shortage of studies comparing different therapies.

Dosimetric predictors of local control and complications in gynecologic transperineal implant patients: The medical college of wisconsin experience

Investigate the relationship between dosimetric parameters with local control (LC) and complications following transperineal high-dose rate (HDR) interstitial brachytherapy (ISBT) for gynecologic (GYN) malignancies. Between 2001 and 2016, 59 patients were treated for primary or recurrent GYN malignancies. Most patients received external beam irradiation, followed by transperineal ISBT via the Syed-Neblett applicator set with CT-based planning. Treatment plans were retrospectively reviewed to evaluate for an association among LC or toxicity with the equivalent dose at 2 Gy per fraction (EQD2) for the clinical target volume (CTV), 0.1 cc (D0.1cc), and 2 cc (D2cc) volumes of the organs at risk (OAR), low/high dose volumes for the OAR and CTV, and ratio of dose at the core vs. the implant periphery. The median follow-up among survivors was 24 months. 34% of patients had a component of local failure and in 12%, this was isolated. Late grade 3 (G3) toxicity occurred in 15% of patients. There were no G4-5 toxicities. Rectal D0.1cc > 75 Gy trended toward significance in predicting the development of non-fistula late G2-3 rectal complications. Bladder D0.1cc > 94 Gy significantly predicted for the development of late G2-3 vesicovaginal fistula formation. The ratio of the total dose at the vaginal surface to the needle periphery above 121% trended in predicting for any complication or fistula formation. HDR ISBT combined with EBRT achieved LC in 66% of patients with advanced or recurrent GYN cancers. Rectal and bladder D0.1cc doses may be predictive of complications as may the ratio of the implant dose at the core vs. periphery.

New vesicovaginal fistula formation in a rabbit model

Objective: To create an animal model of vesicovaginal fistula as a modality to develop therapy.Material and Methods: This study was an preliminary experimental study to create new fistula vesicovaginal formation in a rabbit model. Six female New Zealand white rabbits of Stem Cell Research and Development Center of Universitas Airlangga were used in this study and were divided into 3 groups in which there were 2 rabbits in each group. Vesicovaginal fistula formation was performed through laparotomy surgery. After the abdomen is opened, the Nasogastric tube is inserted vaginally into the anterior vaginal wall. The incision is made on the anterior vaginal wall and the posterior wall of the bladder. The Nasogastric tube that comes out of the vagina is inserted into the bladder incision to maintain the formation of vesicovaginal fistula. Both mucosal walls are sutured and tested to determine if there is any leak. Evaluation the model of vesicovaginal fistula was carried out 3 weeks postoperatively according the group.Result: Four out of six rabbits have formed vesicovaginal fistulas, which are from groups two and three. There are no complications during the treatment period until terminationConclusion: Rabbits have the potential to become experimental animals for the vesicovaginal fistula model. The best time to release a nasogastric tube to maintain a fistula is 2 weeks.

Schistosomiasis among obstetric fistula patients in Lilongwe, Malawi.

Schistosoma haematobium infection has been documented as an uncommon cause of vesicovaginal fistula (VVF) and can result in impaired wound healing of urogenital tissues. For these reasons, it could potentially be linked to an increased rate of obstetric fistula among women who experience obstructed labor and/or in a higher failure rate of fistula repair. Therefore, the primary objective of our study was to determine the prevalence of S. haematobium infection among women undergoing obstetric VVF repair in Lilongwe, Malawi. Our secondary objectives were to assess if S. haematobium infection could be a risk factor for obstetric fistula development or unsuccessful VVF repair in our patient population. From July to October 2013, we conducted S. haematobium testing via urine microscopy on 96 patients undergoing obstetric VVF repair surgery at the Fistula Care Centre in Lilongwe, Malawi. The prevalence of S. haematobium infection among women undergoing obstetric VVF repair was 2% (n=2). Both women with S. haematobium had successful VVF repairs. Although S. haematobium has the potential to be a risk factor for obstetric VVF formation or unsuccessful VVF repair, it was uncommon among the women in our clinic with obstetric VVF.

Locally advanced cervical cancer with bladder invasion: clinical outcomes and predictive factors for vesicovaginal fistulae.

ObjectiveWe report outcomes of cervical cancer patients with bladder invasion (CCBI) at diagnosis, with focus on the incidence and predictive factors of vesicovaginal fistula (VVF).ResultsSeventy-one patients were identified. Twenty-one (30%) had para-aortic nodal involvement. Eight had VVF at diagnosis. With a mean follow-up time of 34.2 months (range: 1.9 months–14.8 years), among 63 patients without VVF at diagnosis, 15 (24%) developed VVF. A VVF occurred in 19% of patients without local relapses (9/48) and 40% of patients with local relapse (6/15). Two-year overall survival (OS), disease-free survival (DFS) and local control rates were 56.4% (95% CI: 44.1–67.9%), 39.1% (95% CI: 28.1–51.4%) and 63.8% (95% CI: 50.4–75.4%), respectively. Para-aortic nodes were associated with poorer OS (adjusted HR = 3.78, P-value = 0.001). In multivariate analysis, anterior tumor necrosis on baseline MRI was associated with VVF formation (63% vs 0% at 1 year, adjusted-HR = 34.13, 95% CI: 4.07–286, P-value = 0.001), as well as the height of the bladder wall involvement of >26 mm (adjusted-HR = 5.08, 95% CI: 1.38–18.64, P-value = 0.014).ConclusionsA curative intent strategy including brachytherapy is feasible in patients with CCBI, with VVF occurrence in 24% of the patients. MRI patterns help predicting VVF occurrence.MethodsPatients with locally advanced CCBI treated with (chemo)radiation ± brachytherapy in our institute from 1989 to 2015 were analyzed. Reviews of baseline magnetic resonance imaging (MRI) scans were carried out blind to clinical data, retrieving potential parameters correlated to VVF formation (including necrosis and tumor volume).

Radiation therapy for stage IVA uterine cervical cancer: treatment outcomes including prognostic factors and risk of vesicovaginal and rectovaginal fistulas.

PurposeTo evaluate the safety and efficacy of radiation therapy for stage IVA uterine cervical cancer and to identify an optimal radiation regimen.ResultsSeventeen of the 28 patients developed recurrence after radiation therapy (local recurrence in 10 and distant metastasis in 12). The local control and distant metastasis-free rates at 3 years in all patients were 61% and 49%, respectively. Fourteen patients died after radiation therapy, and all but 2 died of tumor progression. The disease-free, cause-specific, and overall survival rates at 3 years in all patients were 32%, 49%, and 45%, respectively, and the estimated median survival time was 32 months. Tumor size (P = 0.007) and involvement in the lower third of vagina (P = 0.006) were significant prognostic factors for local control. Older age (P = 0.018) and performance status (P = 0.020) were significant prognostic factors for distant metastasis. The presence of hydronephrosis was the sole significant prognostic factor for survival (P = 0.026). Only 2 patients developed grade 3 late toxicities (vesicovaginal fistula and radiation proctitis, respectively).Materials and MethodsTwenty-eight patients with stage IVA uterine cervical cancer received radiation therapy. All patients initially received external pelvic irradiation at a median dose of 50.4 Gy in 28 fractions. Twenty patients also received high-dose-rate intracavitary brachytherapy at a median dose of 22 Gy in 4 fractions. These fraction sizes were lower than conventional sizes. The total median dose for all 28 patients was 68.7 Gy.ConclusionsRadiation therapy is safe and effective for treatment of stage IVA uterine cervical cancer. The reduced radiation dose per fraction may contribute to the prevention of vesicovaginal fistula formation.

Uterine artery embolisation as management of postoperative gynaecological haemorrhage.

Uterine artery embolisation is already known as a simple, effective procedure for management of a wide variety of obstetric [1] and gynaecological [2] haemorrhages. Embolisation aims to achieve immediate and effective control of haemorrhaging. In what follows we shall report a clinical case dealt with at the Albacete General University Hospital, where embolisation was performed in order to manage bleeding in the early gynaecological postoperative period. The patient has given informed consent for publication of this research. The case concerns a 44-year-old woman with menorrhagia and intramural myoma of 82 × 69 mm. In December 2012 simple vaginal hysterectomy was carried out on the patient. No complications arose during surgery, but in the immediate postoperative period the patient suffered heavy vaginal bleeding and needed a blood transfusion due to symptomatic anaemia (Hb: 7.1 g/dl, Hto: 19%). The patient being young and haemodynamically stable, it was decided to perform uterine artery embolisation 24 h after surgery; we chose such a conservative measure in order to avoid laparotomy. The patient was informed of all advantages and disadvantages of this technique and agreed to its use. In our hospital there is a round-the-clock, long-experienced Interventional Radiology Service with enough human and material resources. Uterine artery embolisation was carried out using Seldinger's technique. First of all, access was obtained to the left hypogastric artery, where an area of hypervascularisation associated with the cranial uterine artery going to the urinary bladder was found. Therefore, embolisation with 3 mm coils was performed. Accessing the right hypogastric region afterwards, an image similar to the one in the left region was seen, leading to an additional embolisation (Figure 1). In Figure 2 embolisation of the right uterine artery with coils can be observed. A control arteriography subsequently confirmed cessation of vascular leakage (Figure 3). The technique was performed without complications, causing an immediate end of the patient's vaginal bleeding. Her evolution was favourable, and she remained totally asymptomatic. Figure 1 Arteriography of the right hypogastric artery, visualising the vanishing point Figure 2 Catheterisation of the right uterine artery and subsequent embolisation with coils Figure 3 Control arteriography confirming cessation of vascular leakage The aim of this paper is to suggest that selective embolisation of uterine arteries is a technique to be taken into account in the management of haemorrhages arising in the immediate postoperative period of gynaecological surgery. In the literature there are many research papers describing embolisations done in order to manage obstetrical haemorrhages [3]. But published data on the embolisation of haemorrhages that arise in the immediate postoperative period following gynaecological surgery are limited [4, 5]. It is generally believed that the same techniques and general principles of embolisation are also applicable in such cases. However, this technique is not free of complications. Complications such as transient fever, transient buttock ischemia, lower limb paraesthesia, groin haematoma and pelvic abscess or vesicovaginal fistula formation have been reported. But these situations are exceptional; the benefits of embolisation are greater than the disadvantages [4]. Embolisation is more complex to perform in gynaecological than in obstetrical haemorrhages. This is due to the fact that patients who have undergone surgery, radiotherapy or even both are distorted, as well as their normal anatomic relationships, which renders the existence of atypical sources of vascular replacement for the bleeding point perfectly possible. That is why gynaecological embolisation, in order to be effective, sometimes needs to be more extensive than what is usually the case for obstetrical embolisation [2]. To conclude, selective uterine artery embolisation can be described as a simple, minimally invasive technique that should be taken into account in the management of gynaecological postoperative bleeding. It could play an important role in complex patients, since it achieves good haemorrhage control without need of further surgical intervention.

Vesicovaginal fistula formation after oocyte retrieval

Development of a vesicovaginal fistula (VVF) is a devastating condition that has profound effects on both the physical and psychological health of a patient [1]. VVF is uncommon in the developed world. In modern urological practice, around 90% of cases are caused by inadvertent injury to the bladder during surgery [2]. The reported incidence after pelvic surgery is 0e52% [3]. Other less common causes include pelvic malignancy, pelvic irradiation, obstetric trauma, and infection including tuberculosis [4]. Transvaginal ultrasound-guided oocyte retrieval has been performed since 1985 [5]. It is a safe and well-tolerated procedure. In this technique, oocytes are collected by passing a 16e18 gauge needle attached to a transducer through the vaginal wall in the lateral superior fornices under ultrasound (US) guidance into the stimulated ovarian follicles. The main reported complications are minor vaginal bleeding and pelvic infection. Injuries to the surrounding organs, such as the bowel and bladder or large vessels, are rare. In the literature, a few case reports of ureterovaginal fistula have been found, but to our knowledge, VVF formation after oocyte pickup has not been reported [6]. Recent advances have improved the success ofVVF repairda challenge that can test even the most experienced gynecologic surgeon. For example, it is now apparent that small, uncomplicated fistulae respond well to conservative treatment [7]. Here, we present a rare case of VVF after US-guided oocyte retrieval and its conservative management in the form of continuous urinary catheter drainage for 3 weeks’ duration. The patient was a 28-year-old woman P0 þ 1 referred from the Assisted Conception Unit to the urogynecology clinic at a university hospital after embryo transfer with a history of passing watery vaginal discharge requiring a pad. The couple had infertility due to a male factor and was on the second cycle of in vitro fertilization (IVF). Oocyte retrieval was performed by a junior consultant at a private center using a single-lumen 16gauge needle. Day 3 after oocyte retrieval, three embryos

Bladder Injury during Cesarean Section

Bladder injury during cesarean section is associated with significant morbidity. It can lead to prolonged operative time, urinary tract infection and formation of vesico-uterine or vesico-vaginal fistula. Post cesarean pregnancy, presence of abdominal and or bladder adhesions, emergency cesarean section, placenta previa and/or accrete/ increta/percreta, all are significant risk factors for bladder injury during cesarean section. Immediate repair of the bladder injury always yield better result. But the availability of an urologist is not always certain. The obstetrician should better be well conversant with the bladder repair, which is relatively simple technique and can manage the situation effectively.

An uncommon case of inflammatory infiltration of the urinary bladder in the long–term process of the purulent inflammation of the cervix and vaginal fornix, complicated with vesicovaginal fistula of unknown etiology

We shall discuss the case of a female patient, aged 64 years, who was suffering from long–term purulent inflammation of the vaginal fornix that later involved the vaginal stump. This inflammatory process spread to the bladder trigone and resulted in vesicovaginal fistula (VVF) formation together with a bilateral hydronephrosis that required the placement of a temporary percutaneous nephrostomy. A non–cicatrized inflammatory reaction occurred at the right–sided insertion of the nephrostomy, which has yet to be successfully treated despite intensive dermatological and surgical approaches that included skin grafting. In the course of five–year treatment we observed a gradual regression of the inflammatory infiltration of both the trigone of the bladder and the vagina as well as a gradual closing of the VVF. The extremely long–lasting and uncommon local inflammatory reactions in the vagina, bladder, and dermal layers mandated the application of conservative treatment. The possibility of difficulties and defective healing of tissues that could result from surgical correction of the VVF are discouraging for both the patient and medical staff.

A multicenter study of vesicovaginal fistula following incidental cystotomy during benign hysterectomies

To evaluate factors for vesicovaginal fistula (VVF) formation following incidental cystotomies during benign hysterectomies. Hysterectomies performed at two university centers between January 1, 2000 and December 31, 2008 were reviewed. Demographic and operative data were abstracted. Patients who developed VVF were compared to those with no VVF. During the study period, 5,698 hysterectomies performed for benign indications were identified. One hundred two (1.8%) cystotomies occurred with 6 (5.9%) developing a VVF. Patients with VVF were more likely to have uteri weighing > 250 g (83% vs. 36%, P = 0.03), had longer surgeries (317 ± 82 vs. 208 ± 10 min, P = 0.02) and more ureteral injuries (33% vs. 1%, P = 0.009). American Association for the Surgery of Trauma (AAST) grade V bladder injuries (OR, 93.00; 95% CI, 10.30-838.92) were associated with VVF formation. Patients with AAST grade V bladder injuries are at increased risk for developing vesicovaginal fistulas following incidental cystotomies during benign hysterectomies.

Can We Predict Vesicovaginal or Rectovaginal Fistula Formation in Patients With Stage IVA Cervical Cancer?

Patients with cervical carcinoma that invade the bladder or rectum (International Federation of Obstetrics and Gynecology stage IVA) have a high risk to develop vesicovaginal and/or rectovaginal fistulae. If we could identify pretreatment factors that predict fistula formation, these patients could be offered less debilitating treatment. Data were retrieved from the database of consecutive patients diagnosed with stage IVA cervical cancer from 1992 to 2008. Overall survival and fistula-free survival were calculated using the Kaplan-Meier method. Univariate and multivariate Cox regression analyses were used to study the association between pretreatment prognostic variables and fistula formation. Thirty patients with stage IVA cervical cancer were diagnosed. Extension to the bladder was present in 27 patients; three patients had only rectal involvement. Twenty-three patients (77%) had curative radiotherapy with or without chemotherapy and/or hyperthermia. Seven patients (23%) received only palliative therapy or no treatment at all. The 5-year overall survival in the curatively treated group was 42%. Five (22%) of these 23 patients developed one or more fistulae: 3 vesicovaginal, 1 rectovaginal, and 1 vesicovaginal and rectovaginal fistulae. The 5-year fistula-free survival of this group was 64%. No significant association was found between the prognostic variables and fistula formation. The risk to develop vesicovaginal and/or rectovaginal fistulae is high after curative radiotherapy with or without chemotherapy and/or hyperthermia in patients with stage IVA cervical cancer. We could not identify further pretreatment factors that might have predicted fistula formation.

Transurethral and suprapubic mesh resection after Prolift® bladder perforation: a case report

Bladder perforation is a complication which can occur after a Prolift® procedure and may enhance vesicovaginal fistula formation. Different methods of management of bladder perforation caused by mesh procedures are described in the literature, and most authors advise complete excision of the mesh. In the case described in this article, we propose a combined transurethral and suprapubical approach as the optimal method for maximal tape removal, being both minimally invasive and less damaging to the vesical wall. A suprapubical catheter can be removed shortly after surgery to enable optimal tissue healing of the vesical mucosa.

The Relationship Between Female Genital Cutting and Obstetric Fistulae

To evaluate any association between female genital cutting and vesicovaginal fistula formation during obstructed labor. A comparison was made between 255 fistula patients who had undergone type I or type II female genital cutting and 237 patients who had not undergone such cutting. Women were operated on at the Barhirdar Hamlin Fistula Centre in Ethiopia. Data points used in the analysis included age; parity; length of labor; labor outcome (stillbirth or not); type of fistula; site, size, and scarring of fistula; outcomes of surgery (fistula closed; persistent incontinence with closed fistula; urinary retention with overflow; site, size, and scarring of any rectovaginal fistula; and operation outcomes), and specific methods used during the operation (use of a graft or not, application of a pubococcygeal or similar autologous sling, vaginoplasty, catheterization of ureters, and flap reconstruction of vagina). Primary outcomes were site of genitourinary fistula and persistent incontinence despite successful fistula closure. The only statistically significant differences between the two groups (P=.05) were a slightly greater need to place ureteral catheters at the time of surgery in women who had not undergone a genital cutting operation, a slightly higher use of a pubococcygeal sling at the time of fistula repair, and a slightly longer length of labor (by 0.3 day) in women who had undergone genital cutting. Type I and type II female genital cutting are not independent causative factors in the development of obstetric fistulae from obstructed labor.

Vesicovaginal fistulae.

Vesicovaginal fistula (VVF) formation represents a condition with devastating consequences for the patient and continues to pose a significant challenge to the surgeon. Quick and accurate diagnosis, followed by timely repair is essential to the successful management of these cases. A thorough understanding of the pathophysiology and anatomy of the fistula, potential factors that may compromise healing and experience in the fundamental principles of fistula repair are the vital tools of the fistula surgeon. This review was undertaken to provide an overview of the key areas in VVF investigation and management.

Vesicovaginal Fistula Repair Using a Transurethral Pointed Electrode

The most common cause of vesicovaginal fistulasis injury to the bladder at the time of surgery. The operation most frequently responsible for vesicovaginal fistula formation is hysterectomy. The first successful transvaginal approach to vesicovaginal fistula repair was reported by Sims in 1838. Although many surgical procedures exist, there is no best approach for all patients with vesicovaginal fistula. However, it is an essential surgical principle that the fistulous tract and scar should be excised completely. Here we report our technique using a transurethral pointed electrode for the treatment of multiple, small vesicovaginal fistulas and its outcome.

Risk factors for the development of vesicovaginal fistula after incidental cystotomy at the time of a benign hysterectomy

We sought to evaluate risk factors for vesicovaginal fistula (VVF) after incidental cystotomy during benign hysterectomies. All benign hysterectomies between January 2000 and May 2004 were reviewed. Demographic and operative data were abstracted. Cystotomies were graded using the American Association for the Surgery of Trauma (AAST) system. Patients developing VVF after cystotomy were compared to those who did not. Categorical variables were analyzed with Fisher exact test while Student t test was used for continuous data. A total of 1317 benign hysterectomies were reviewed (46% abdominal, 48% vaginal, and 6% laparoscopically assisted vaginal). In all, 34 cystotomies occurred with 4 (11.7%) developing a VVF. Patients developing VVF were more likely to have an AAST grade V cystotomy (75% vs 7%; P = .004). Patients developing VVF trended toward greater tobacco use, larger uterine size, and more operative blood loss. Patients with an AAST grade V cystotomy are at increased risk for VVF formation.

Aspects of psychosocial problems of patients with vesico-vaginal fistula

SummaryOur objective was to evaluate psychosocial problems among patients presenting with vesico-vaginal fistula (VVF), and their close relatives. All patients presenting with VVF and their spouses or attendant close relatives were administered a structured questionnaire followed by an in-depth interview. A total of 20 patients and 10 attendant relatives were interviewed. The average age of patients was 24.7 years, range 16–38 years. A total of 11 patients (55%) had their first marriage between the ages of 15–20 years, with one nulliparous, unmarried patient, who acquired VVF following infertility treatment with herbs. Of the interviewed respondents, 19 affirmed that prolonged labour was the cause of VVF, while four patients developed VVF sequel to unsupervised vaginal birth after a previous caesarean section. Reported medical problems were dermatitis (20%), foul smell of urine (15%), recurrent UTI (10%), infertility (5%), amenorrhoea (5%), in that order. Socially, 45% felt ostracised and 50% were economically impoverished by job loss. The divorce rate was 25%, with one case of remarriage and childbirth with an unrepaired VVF. Some 56.6% respondents suggested hospital delivery was a preventive measure, while 33.3% felt avoidance of premarital sex and early marriage would prevent VVF. VVF is still a major social and reproductive health problem and most patients and relatives understand the place of difficult childbirth in VVF formation. The need to empower patients to timely access standard maternity and emergency obstetric care is recommended.