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Vaginal Fistulas; Lessons Learned W21, 15 October 2012 14:00 - 18:00

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Vaginal Fistulas; Lessons Learned W21, 15 October 2012 14:00 - 18:00 Vaginal Fistulas; Lessons Learned W21, 15 October 2012 14:00 - 18:00 Start End Topic Speakers 14:00 14:20 Introduction and Overview Sherif Mourad 14:20 14:40 Epidemiology of Vaginal Fistulas Sohier Elneil 14:40 15:00 Anatomic Aspects & Aetiology Hassan Shaker 15:00 15:20 Classification of Vaginal Fistulas Edward Stanford 15:20 15:30 Discussion All 15:30 16:00 Break None 16:00 16:20 Surgery for Low Vaginal Fistulae Dirk de Ridder 16:20 16:40 Surgery for High Vaginal Fistula Sohier Elneil 16:40 17:00 Laparoscopic/Robotic Surgery for Vaginal Fistula Hassan Shaker Repair 17:00 17:20 Ureterovaginal, uterovaginal and other rare cases Dirk de Ridder 17:20 17:40 How to Treat Complications of Fistula Repair Sherif Mourad 17:40 18:00 Discussion All Aims of course/workshop This workshop is very important in showing the audience the real factors after the increased numbers of vaginal fistulae, not only in the developing countries, but among the well developed countries as well. Educational Objectives Attendees will be able to learn more about the anatomical relations and why different types of fistula may occur and the strategy of repair. This is important to understand the different approaches and avoid complications. Classification of the vaginal fistulae, how to differentiate between one fistulae and the other, and how to diagnose it will be presented with details. Attendees will be able to see the different techniques of repair including the tips and tricks of both low and high vaginal fistulae repair and the interposing tissues. This will allow attendees to find out different techniques used for different forms of fistulae including robotic surgeries and other reconstructive procedures for the urethra or ureters. Attendees will get oriented with the possible complications that may appear after fistula repair. The different problems and persistent leakage or de novo overactive bladder or ureteric injuries and others will be discussed in details. This will enable the audience to know how to deal with every possible complication. At the end of the course the attendees will have the time to discuss all the aspects of the fistula problems with the speakers and to exchange knowledge with others. 13/06/2012 Vaginal Fistula; Lessons Learned Workshop # 00 / Monday, 15 October 2012 14:00 – 18:00 Time Time Topic Speaker 14.00 14.15 Introduction & Overview Sherif Mourad 14.15 14.30 Epidemiology Of Vesicovaginal Fistula Suzy Elneil 14.30 14.45 Anatomical Aspects & Etiology Hassan Shaker 14.45 15.00 Classification of Vaginal Fistulae Edward Stanford 15.00 15.15 Discussion All 15.30 16.00 Coffee Break 16.40 17.00 Surgery for Low Vaginal Fistulae Dirk De Ridder 17.00 17.20 Surgery for High Vaginal Fistula Suzy Elneil 17.20 17.40 How to Treat Complications of Fistula Repair Sherif Mourad Discussion All Workshop # Vesicovaginal Fistula in the Introduction Disadvantaged, An Overview •Vesicovaginal fistula (VVF) is a subtype 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, Cairo •It allows continuous involuntary discharge of President of African Fistula & Continence Society urine into the vaginal vault. Chairman of ICS Fistula Committee Types of Urogenital Fistula • Vesicovaginal fistula • Recto-vaginal fistula • Urethrovaginal fistula • Ureterovaginal fistula • Vesicouterine fistula Countries from which obstetric vesico-vaginal fistulas have been reported (WHO 2003). The prevalence is actually greater than this map indicates. 1 13/06/2012 30% Etiology in Developing Countries 26% 25% •Marriage and conception at a young age, often before full pelvic growth has been achieved. 20% 14% 15% 12% 12% 10% 10% 8% •Chronic malnutrition limits pelvic dimensions, 10% 5% 3% increasing the risk of cephalopelvic 2% 2% 1% disproportion and malpresentation. 0% •Few attendances by qualified health care professionals or having access to medical percent Bar chart showing the age at which the women developed facilities during childbirth. obstetric fistula around whole Africa 2007( WHO report) Percentile chart of V.V.F cases in Percentile chart of V.V.F cases in relation to age in Ethiopia in 2005 relation to age in Nigeria (UNFPA report) 10% less than 20 20-25 more than 25 25% 42% 23% 22% 23% 55% less than 20 yrs 20-25 yrs 26-35 yrs more than 35 yrs Age of genitourinary fistulae cases in Ghana 2007 •Female circumcision and the practice of (UNFPA report) harmful traditional medical practices such as Gishiri incisions (anterior vaginal wall below 25 years old above 25 years old incisions). •The insertion of caustic substances into the 53% 47% vagina with the intent to treat a gynecologic condition or to help the vagina to return to its nulliparous state. 2 13/06/2012 •Prolonged impaction of the fetal presenting part in Developed Countries the pelvis causing widespread tissue edema, hypoxia, necrosis, and sloughing resulting from prolonged •VVFs is mainly due to inadvertent bladder injury during pressure on the soft tissues of the vagina, bladder pelvic surgery (90%). base, and urethra. •Bladder wall injury from electro-cautery or mechanical crushing, and the dissection of the bladder into an incorrect plane, causing avascular necrosis. •The risk of formation of a hematoma or avascular •Complex neuropathic bladder dysfunction and necrosis after a suture is placed through the bladder urethral sphincteric incompetency often result, even if wall can lead to infection, abscess, and subsequent the fistula can be repaired successfully. suture erosion through the bladder wall. The time of clinical presentation depends on Maternal complications of the etiology of the VVF: obstructed labor, in Adigrat zonal Hospital in Northen Ethiopia, 1993-2001 •A VVF secondary to a bladder laceration typically presents immediately. 5% •Approximately 90% of genitourinary fistulas associated 24% with pelvic surgery are symptomatic within 7-30 days 18% Maternal sepsis postoperatively. vesicovaginal fistula •An anterior vaginal wall laceration associated with Rectovaginal fistula post partal hemorrhage obstetric fistulas typically (75%) presents in the first 24 7% Rupture uterus hours of delivery. 11% rupture bladder •In contrast, radiation-induced UGFs are associated with Hysterectomy Maternal death slowly progressive devascularization necrosis and may 6% 1% present 30 days up to many years later. 28% Percentile chart of Causes of V.V.F in South Causes of V.V.F in Ghana Causes of V.V.F in India causes of V.V.F in Nigeria 2007 Africa 2001-2006 in 2007 in 2006 (UNFPA report) (UNFPA report) obstructe d labour 9% 3% 17% 4% 13% 12% 22% 66% 80% 83% 91% gynacolo obstetric complications gical obstructed labour obstructed labour surgical complicat surgical complications ions complications of gynacological mainly surgeries complications of gynacological surgeries posthystr advanced carcinoma of cervix female genitalia ectomy mutilation 3 13/06/2012 Possible Social Consequences Marital status after Social effect of V.V.F genitourinary fistulae in Ethiopia between around Africa,2007 2001-2005 -Stigma and discrimination. (UNFPA report) -Social isolation. 33% -Community/familial rejection. 45% -Divorce or abandonment. 22% 29% -Verbal and Physical Abuse. -Loss of income, extreme 71% deserted by husband poverty. divorced deserted by husband and begging food get support from get support from husband husband and family & family Marital status of cases after Social effect of the V.V.F cases Fistula Repairs affection with genitourinary in Zambia , 2005 (Birmingham fistula in Nigeria University and Maternity unit • Treatment complexity and (prepared by grassroots health , Monze , Southern province , Zambia) success depend on multiple organization of Nigeria) (2005) factors including: – Fistula type – Size – Degree of scarring 15% – Involvement urethra, 40% 60% ureter and bladder – Provider capacity 85% – Postoperative care and compliance divorced get family support divorced still married Outcome of surgery by repair attempt in Zambia , 2005 (source : Maternity Unit, Monze Mission Hospital, Monze, Southern Province, Fistula Cure Zambia Department of Public Health and Epidemiology, The Medical School, University of Birmingham) 76% 80.00% 65.00% • Complete continence by day and night 60.00% For a 100% • Bladder capacity> 200ml 40.00% cure; the 6.00% 19.00% following • No SIU 20.00% 18.00% 16% conditions • Normal coitus without 0.00% must be fully satisfied: dyspareunia first repair • No traumatic amenorrhea women has had one or more • Ability to bear children previous repair stress incontinence failed cured 4 13/06/2012 Fate of V.V.F repair Women’s potential expectations for reintegration in Nigeria Continence Return to fertility Increased self as desired esteem 100 Return to sexual Happiness 80 life as desired PHYSICAL MENTAL Safe future HEALTH HEALTH 60 delivery 40 20 Reduced stigma SOCIAL ECONOMIC Economic status Participation in WELL- BEING WELL- BEING regained or 0 religious and improved first attempt cured social life Family support or second attempt Social support source of income third attempt Marriage/re- Able to support marriage as others first attempt second attempt third attempt desired cured 90 50 33 Adapted from DIRG/OFWG, 2006 failed 10 50 67 Challenges in surgery in Africa Challenges in surgery in Africa as seen by surgeons as seen by surgeons: •Severe shortage of surgeons. •Lack of opportunities for surgeons to improve and keep up with the times. •Poor conditions
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