changing scenario of female fistula
DESCRIPTION
This presentation is aimed to reflect the present scenario of female genital fistulas at a tertiary care centre of India.TRANSCRIPT
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Dr. Amita Jain Consultant UrogynaecologistMedanta Institute of Kidney & Urology Medanta -The MedicityGurgaon, Haryana -122001, INDIA
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Female Genital Fistula(FGF) is a socially debilitating problem with important medicolegal implications.
In the developing nations, nearly 5 million women annually suffer severe morbidity with obstetric fistulae being the foremost on the list. (WHO 1991)
Around > 2 million women living with fistula, with approximately 50,000 to 100,000 cases occurring annually, mostly in Africa, Asia, and the Arab world. Stanton C et al, Int J Gynaecol Obstet 2007, 99:S4-S9.
The unmet need for fistula repair is estimated to be as high as 99%. Ahmed S et al, Int J Gynaecol Obstet 2007, 99:S1-S3.
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• 74 years• C/O Involuntary leakage of urine with coughing, sneezing & change in posture • Co - morbidities
Old age (Postmenopausal)Past multiple surgeries - Wertheim’s hysterectomy followed by Radiotherapy – carcinoma cervix 1986 - Laparotomy - intestinal obstruction 1990 - Repeated urethral dilatation - retention of urine 2008 - Abdominal Sacrocolpopexy - vaginal vault prolapse March 2010HypertensionHypothyroidismOsteoarthritis DR AMITA JAIN
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Aa+2.0
Ba+1.0
C-5
Gh7
Pb 3.5
TVL7
Ap-3
Bp-3
D0
POPQ
STAGE III CYSTOCELE
Urethral Hypermobility +Stress leak +
General & Neurological Examination: normal
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SENSATION Bladder filling
Pdet
First Sensation 110 cc 10 cmH2O
Strong Desire 280 cc 11 cmH2O
Max Cyst Capacity
280 cc 15 cmH2O
Bladder filling Pabd Pdet
1 156 cc 13 cmH2O 10 cmH2O
2 248 cc 10 cmH2O 7 cmH2O
3 276 cc 10 cmH2O 11 cmH2O
SENSATION RESULTS LEAK POINT PRESSURES
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Total bladder capacity 281cc
Peak flow rate 7ml/s
Pdet at peak flow 15 cmH2O
Average flow rate 3 ml/s
Residual Urine 0 ml
Opening Pdet 9 cmH2O
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Braided Suture Piercingbladder wall
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Blind pit at Ant. Vaginal wall ( ? healed fistula opening)
Negative Three Swab Test
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Suture Removal
3 weeks
Cystocele Repair&
Midurethral Sling Placement
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Peak Flow Rate
15 ml/s
Average Flow Rate
7 ml/s
Voided Volume
267 ml
Voided Time
24 s
Flow Time
24 s
Post Void Residual
150 cc
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• Able to hold & void herself
• Fully continent ( Pads not required)
• Clean Intermittent Self Catheterisation (3 times a day)
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• 54 years• Recurrent UTI • On & off pinkish foul smelling vaginal discharge
• Past Surgical History - Lap Hysterectomy 2 yrs back (Menorrhagia cause ? fibroid uterus) - Cholecystectomy 20 yrs back - Incisional hernia repair 16 yrs back
• Co-morbidities - Hypertension 3-4 months - Diabetes Mellitus 3-4 months
1.5 yrs
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Per speculum:
- Black colored material at the apex of vaginal vault
- Foul smelling black to brown dirty discharge soiling the walls of vaginal vault
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Impression:
Low Rectovaginal fistula
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A black colored ? Suture at the apex of vaginal vault
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On removal – black brown colored infected material drained.
Communicating path traced through a probe.
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Abdominal Repair
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Vaginal opening traced
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No communicating path into sigmoid colon or rectum
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Edges of Vaginal opening freshened up & closed
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No foul smell discharge
Not a single episode of UTI
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• 54 years• Pain in left loin – 1 month• Continuous urinary leakage – 1 month• H/O present illness - D & C for menorrhagia 4 months back. - f/b Vaginal hysterectomy with left oophorectomy after one month - C/O continuous significant vaginal bleeding in postop - re-evaluated after 2 weeks & some stiches were put through vaginal route - developed high grade fever after 2 days f/b urinary incontinence • Past H/O - Tubal ligation 30 yrs back• No Co - morbidities
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Findings: Moderate Left sided Hydroureteronephrosis with dilatation of left ureter in its entire extent with abrupt cut off at distal end, which appears to merge with vaginal stump
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Abrupt cut off at 2 cm distance from left ureteric
orifice
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Post Hysterectomy Iatrogenic Left Ureteric
Trauma with Vesico-vaginal fistula
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Left Percutaneous Nephrostomy 4 weeks
Cystoscopy + O’Conner’s VVF Repair* + Left Ureteric Reimplantation (stented)
[ discharged on POD 5 with SPC in situ]
“The best approach for complex fistulas is transabdominal using the O'Connors bivalve technique.” O'Connor VJ et al. Suprapubic closure of vesicovaginal fistula. J Urol. 1973;109:51–4.
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At 2 Weeks
Findings:
•Well maintained bladder outline
•No leak
DJ Stent removal done
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Normal KFT
Normal findings of DTPA Scan and USG Whole Abdomen
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• 31 years• Continuous urinary leakage per vaginum for 2 year
• Past Surgical History - MTP with tubal ligation (continous leakage in postop) - Hysterectomy with reimplantation of right ureter - Cystoscopy (0.5 cm sized fistula inferomedial to left ureteric orifice, right ureteric orifice not seen) + LRGP + LDJS - 2 failed attempts of vaginal repair of VVF - LRGP + Left Laser endoureterotomy + Laser fulgration of VVF
• No Co-morbidities
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USG KUB: B/L Chronic Renal Parenchymal Disease
KFT: Bld Urea 93 mg/dl S. Creatinine 4.76 mg/dl
Hb 8 g/dl
Urine C/S: E Coli >10 cfu/ml
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Impression: B/L contracted Kidneys, Re-implantation of right ureter ? into bowel (dilated 8 mm), DJ Stent on left side, 4 mm sized focal defect in posterior wall of UB communcating to vaginal stump (fluid in endovaginal canal)
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Renal Transplantation after Fistula Repair
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• 52 years• Continuous urinary leakage per vaginum for 2 year• Large bed sore over sacrum• Past History - Received multiple courses of chemoradiation for Ca Cervix (grade III) diagnosed in 1999 - Multiple cystoscopies for gross hematuria in 2009 - Cystoscopic fulgration & angioembolisation in Aug 2009 - Admitted in ICU for septicemia - on catheter removal at discharge noticed continuous leakage of urine • No Co-morbidities
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Left small sized kidney
Right normal sized kidney
No Ureterovaginal fistula/ no ureteric stricture
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Frozen Pelvis
Large Vesico-vaginal fistula
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Small capacity bladder
Fluffy tissue inside
Patchy inflammation
Supratrigonal large irregular hole at
left side of posterior wall
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Urinary Diversion ( Transverse Colonic Urinary Conduit)
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POD3 Myelosuppresion with pancytopenic sepsis B/L Parotitis with right parotid abscess Respiratory failure with Metabolic Acidosis Acute Renal Failure with Dyselectrolytemia Liver Dysfunction with Hypoalbuminemia Paralytic ileusPOD 11 Anastomotic leakageConservative Management in ICU by Multidisciplinary Team
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Went home on full recovery after 6 weeks
Doing well at 2years 6 months
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Obstretical fistulas are associated with high incidence of recurrence and failure rates due to their large size and presence of ischaemic tissues. Arrow SS et al, Obstet Gynecol Surv. 1996;51:568–74.
Postsurgical fistulas are result of more direct and localised trauma to otherwise healthy tissue, so having better results after repair. Hadley HR. Vesicovaginal fistula. Curr Urol Rep. 2002;3:401–7.
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To date improvements in health care facilities may have led to change in etiological aspect of FGF.
Surgical correction is still a great challenge and requires a team approach for better results.
“Prevention is better than cure".
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Dr. Amita JainUrogynaecology Clinic
12th Floor, OPD Wing,Medanta -The Medicity
Gurgaon, Haryana -122001, INDIATel: +91 124 4141 414 [email protected] www.medanta.org
MOB. +91-9871136110 http://www.urogynecologistindia.in/
http://amitajainurogynaecolgist.blogspot.in/http://www.linkedin.com/mbox?displayMBoxItem=&itemID=I225857003_75
Medanta Institute of Kidney & Urology