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Vaginal Fistula Repair; Aspects of the Real Problem and the Total Approach Workshop 28 Tuesday 24 August 2010

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Vaginal Fistula Repair; Aspects of the Real Problem and the Total Approach Workshop 28 Tuesday 24 August 2010 Vaginal Fistula Repair; Aspects of the Real Problem and the Total Approach Workshop 28 Tuesday 24 August 2010, 09:00 – 12:00 Time Time Topic Speaker 09.00 09.05 Introduction Sherif Mourad 09.05 09.15 Vaginal Fistula Overview Sherif Mourad 09.15 09.30 Anatomical Aspects & Etiology Suzy Elneil 09.30 09.45 Classification of Vaginal Fistulae Edward Stanford 09.45 10.00 Surgery for Low Vaginal Fistulae Dirk De Ridder 10.00 10.15 Surgery for High Vaginal Fistula Suzy Elneil 10.15 10.30 Discussion 10.30 11.00 Coffee Break 11.00 11.15 Difficult & Rare Cases Ahmed Saafan 11.15 11.30 How to Treat Complications of Fistula Repair Sherif Mourad 11.30 11.45 Case Presentation Ahmed Saafan 11.45 12.00 Discussion Aims of course/workshop The aim of this workshop is to introduce the problem of vaginal fistula and to show the epidemiology and prevalence worldwide.. The attendees should understand the different forms of vaginal fistulae and how big and complicated it could be. The surgical approaches together with the surgical skills and tips will be presented in a way that elaborates the technical difficulties and the possible post operative events. Educational Objectives This workshop is very important in showing the audience the real factors after the increased numbers of vaginal fistulae, especially in the developing countries. The anatomical consideration and fistula classification will help in better understanding the workup of the cases. It is also a must to educate them that the best results will be only obtained after the first repair and not with the recurrent cases, so it is crucial to learn how to do it right from the first time. The operative tips are many and help much in improving the results and this includes low and high fistula approach and the interpositioning of different tissues in different approaches. The post operative complications could be a real problem and that is why we shall discuss it in details and show how to repair it successfully. 6/16/2010 Introduction Vesicovaginal Fistula -Vesicovaginal fistula (VVF) is a subtype in the Disadvantaged of female urogenital fistula (UGF). -VVF is an abnormal fistulous tract extending between the bladder and the vagina. Sherif Mourad, MD Professor of Urology, Ain Shams University -It allows continuous involuntary President of Pan Arab Continence Society discharge of urine into the vaginal vault. Chairman of ICS Fistula Committee Countries from which obstetric vesico-vaginal fistulas have been reported (WHO 2003). The prevalence is actually greater than this map indicates. Etiology in Developing countries Types of Urogenital Fistula •Marriage and conception at a young age, often -Vesicovaginal fistula (VVF) before full pelvic growth has been achieved. -Recto-vaginal fistula (RVF) •Chronic malnutrition limits pelvic dimensions, increasing the risk of cephalopelvic -Urethrovaginal fistula (UVF) disproportion and malpresentation. -Ureterovaginal fistula •Few attendances by qualified health care -Vesicouterine fistula professionals or having access to medical facilities during childbirth. 1 6/16/2010 •Prolonged impaction of the fetal presenting •Female circumcision and the practice of part in the pelvis causing widespread tissue harmful traditional medical practices such as edema, hypoxia, necrosis, and sloughing Gishiri incisions (anterior vaginal wall resulting from prolonged pressure on the soft incisions). tissues of the vagina, bladder base, and urethra. •The insertion of caustic substances into the vagina with the intent to treat a gynecologic •Complex neuropathic bladder dysfunction condition or to help the vagina to return to its and urethral sphincteric incompetency often nulliparous state. result, even if the fistula can be repaired successfully. •Patients may complain of urinary incontinence Developed countries or an increase in vaginal discharge . •VVFs is mainly due to inadvertent bladder injury during •The drainage may be continuous; however pelvic surgery (90%). ,with a very small UGF, it may be intermittent. •Bladder wall injury from electro-cautery or mechanical •Increased postoperative abdominal, pelvic, or crushing, and the dissection of the bladder into an flank pain; prolonged ileus; and fever should incorrect plane, causing avascular necrosis. alert the physician to possible urinoma or urine ascites and mandates expeditious evaluation. •The risk of formation of a hematoma or avascular necrosis after a suture is placed through the bladder •Recurrent cystitis or pyelonephritis, abnormal wall can lead to infection, abscess, and subsequent urinary stream, and hematuria also should suture erosion through the bladder wall. initiate a workup for UGF. Pathophysiology •When labor becomes difficult, on account of disproportion •The uterus in such cases usually passes into between the pelvis and presenting part, or when the a state of tonic contractions which prevents presentation is abnormal, the uterine contractions increase any remission in the pressure exerted on the in strength and endeavor to force the presenting part soft parts. through the brim. •The membranes protrude unduly in the vagina, and •As a result of the continued pressure the premature rupture occurs. In consequence of early rupture and disproportion the full force of the uterine contractions tissues undergo necrosis and slough away. is directly exerted upon the fetus and the presenting part is forced against the brim of the pelvis or gets tightly •The slough that develops from this pressure impacted therein. necrosis most commonly results in a vesico- •The vesico-vaginal septum, and the cervix; if the latter is vaginal fistula not dilated, will be tightly compressed against the back of the symphysis pubis. 2 6/16/2010 -The time of clinical presentation depends on Incidence (in millions) of Major Maternal the etiology of the VVF: Health Complications By Region -A VVF secondary to a bladder laceration typically (WHO, 2004) presents immediately. Eastern Western World Africa Americas Europe SE Asia Complication Med. Pacific -Approximately 90% of genitourinary fistulas associated with pelvic surgery are symptomatic within 7-30 days postoperatively. Maternal haemorrhage 12.0 3.0 1.2 1.6 0.7 4.0 1.4 Sepsis 5.2 1.2 0.6 0.7 0.3 1.7 0.6 -An anterior vaginal wall laceration associated with Hyperstensive 8.4 2.1 0.8 1.2 0.5 2.8 1.1 obstetric fistulas typically (75%) presents in the first 24 Disorders hours of delivery. Obstructed labour 4.0 1.1 0.1 0.5 0.0 1.9 0.4 Unsafe Abortion 20.4 4.8 4.0 2.9 0.5 7.4 0.8 -In contrast, radiation-induced UGFs are associated with slowly progressive devascularization necrosis and may Source: WHO Global Burden of Disease Update 2004 present 30 days up to many years later. Percentile chart of causes Causes of V.V.F in India 2007 Maternal complications of of V.V.F in Nigeria in 2006 (UNFPA report) obstructed labor, in Adigrat zonal Hospital in Northen Ethiopia, 1993-2001 5% 4% 13% 12% 24% 66% 18% Maternal sepsis 22% vesicovaginal fistula 83% Rectivaginal fistula post partal hemorrhage 7% Rupture uterus obstructed labour 11% rupture bladder obstetric complications Hysterectomy Maternal death gynacological surgical 6% 1% surgical complications complications mainly 28% posthystrectomy female genitalia other causes mutilation Maternal mortalities and expected numbers of cases of genitourinary fistulae in selected African countries and in Asia: UNFPA’s State of the World Population Report (2007) 2,000 2000 “Nobody wants to stay with me due to the 400 318 300 1500 smell of urine. Even my husband sometimes 300 1,000 1000 880 850 blames me for my condition.” 800 200 140 159 300 690 693 132 500 230370 29-year-old woman, Bangladesh 100 70 132101 0 163 374 440352 303 305 0 “I am distasteful in the eyes of others. It is God’s will” 48- year old woman, Mali Expected number of cases of genitourinary Expected number of fistulae per 100,000 births cases of genitourinary fistulae per 100,000 births Maternal mortality per 100,000 births Maternal mortality per100,000 births 3 6/16/2010 Fistula Repairs Fistula Cure • Treatment complexity and success depend on multiple factors including: – Fistula type • Complete continence by day and night – Size For a 100% • Bladder capacity> 170ml – Degree of scarring cure; the following • No SIU – Involvement urethra, conditions • Normal coitus without ureter and bladder must be fully dyspareunia – Provider capacity satisfied: • No traumatic amenorrhea – Postoperative care and compliance • Ability to bear children Outcome of surgery by repair attempt in Zambia , 2005 (source : Maternity Unit, Monze Mission Hospital, Monze, Southern Province, Women’s potential expectations for reintegration Zambia Department of Public Health and Epidemiology, The Medical School, University of Birmingham) Continence Return to fertility Increased self as desired esteem 76% Return to sexual 65.00% Happiness 80.00% life as desired PHYSICAL MENTAL 60.00% Safe future HEALTH HEALTH delivery 40.00% 6.00% 19.00% 20.00% 18.00% 16% Reduced stigma SOCIAL ECONOMIC Economic status 0.00% Participation in WELL- BEING WELL- BEING regained or religious and improved first repair social life Family support or women has had Social support source of income one or more Marriage/re- Able to support previous repair marriage as others desired stress incontinence failed cured Adapted from DIRG/OFWG, 2006 Reintegration Services National Stakeholders For the woman: In the community: • Counseling . Awareness campaigns • MOH • Peer support to local leaders • Ministry of Women’s Affairs • Reproductive health • Policymakers educ. Community education • Professional Organizations (Ob/Gyn Society, • Life skills education sessions, media, midwifery association) • Doctors, surgeons, midwives, social workers with • Literacy training . Mobilization to support experience in OF. • Skills training, incl. as the women in seeking • Economist/Statistician health workers both prevention and • International agencies and donors • Micro-credit or grants treatment services • CSO (NGOs, FBOs, CBOs, etc) • Accompaniment • Women’s rights groups and advocates, fistula survivors. • Counseling with family/ husband 4 6/16/2010 Challenges in surgery in Africa as seen by surgeons: 12- Generalized poverty/ economic constraints.
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