Int Urogynecol J (1997) 8:30-35 1997 Springer-Verlag London Ltd International Urogynecology Journal

Special Contribution

Fistula : Past, Present and Future Directions*

T. E. Elkins Department of and Gynecology, School of Medicine in New Orleans, Louisiana State University Medical Center, New Orleans, LA, USA.

This text is about , but it cannot help but become 4070 maternal deaths per 1000 deliveries in a study of much more. It is also a discussion of the foundational maternal mortality in remote rural Ghana in 1989 [2]. development of gynecologic pelvic floor surgery and the Maternal morbidity is even more common, with the innovations and motivations in our field, throughout incidence of urogenital obstetric fistulas reaching near history. epidemic proportions in parts of West . Waaldjik Reflections on genital tract fistulas in women take us [3] estimates that almost 20000 women with fistulas back to the beginnings of written history itself. Such await repair in Northern at present, and that 1-2 reflections also unite the problem of (urinary) inconti- laboring women in every 1000 develop vesicovaginal nence with that of pelvic prolapse, since these fistulas. These numbers resemble those found in Europe were the two common gynecologic problems of women in the Middle Ages, and make us aware of the history of noted in the Kahun papyri of ancient Egypt (--2000 BC), gynecologic pelvic floor defect surgery. It is a history perhaps the earliest written 'medical' text [1]. tied to the zeal on the part of surgeons to care for the To understand the history of genitourinary fistulas neglected and undeserved women of our world ... and subsequent pelvic surgery, it has been helpful to those who, even today, are often left in labor for as long return to rural West Africa, where such findings are still as 2-5 days. Over 95% of patients in Nigeria are common. Over 35 trips, spanning nearly 4 of the past 21 illiterate, having never been exposed to any formal years, have resulted in many of the insights presented in education, and 82% are abandoned by their husbands this discussion. In rural Africa true obstructed labor is after the fistula occurs [4]. Just as these women of West common because of early childbearing, an inherited Africa demand the concern of surgeons today, the anthropoid/android with marked lumbar lordosis, history of our specialty has its origins in the motivation and a lack of medical care. The absence of modern and innovation required to meet these same needs of healthcare systems results in a reliance upon traditional underserved women long ago. healthcare customs and treatments that often delay or For simplicity, the history of fistula surgery may be prevent access to contemporary obstetric care when it is broken into five sections: available. The general lack of effective also contributes to the problem. When appropriate care 1. The 'Pre-Leak' Period (1000 BC--1300 AD) -- a time of for a laboring patient is finally sought, the lack of questioning the origin of the constant leakage that often occurred after delivery. transportation, roads and communication systems often make such efforts futile. The result has been a mortality 2. The 'Mend-the-Leak' Period (1300 AD--1940 AD) -- a ratio of 6-10 maternal deaths per 1000 deliveries in prolonged period in which surgeons sought, often major medical centers in West Africa, and an average of vainly, to repair fistulas successfully ... a time of constant innovation, persistence and debate over tech- Correspondence and offprint requests to: Thomas E. Elkin, MD, niques and surgical principles. Department of Obstetrics and Gynecology, School of Medicine in 3. The 'Mega-Leak' Period (1940-1990 AD) - a time in New Orleans, Louisiana State University Medical Center, 1542 Tulane Avenue, New Orleans, LA, 70112-2827, USA. which gynecologic surgery expanded to include radical * J. Marion Sims Annual Lecture presented at the American Urogy- pelvic procedures, and became part of necology Society Meeting in New Orleans, LA, 4 October 1996. cancer therapy, both increasing the Fistula Surgery: Past, Present and Future Directions 31 problem. It was a time of expanded techniques to ever, his innovations changed the lives of women include a multitude of grafts and flaps, and a time of worldwide, and should be analyzed. fistula repair masters. 4. The Tara-Leak' Period (1990-2000 AD) - a time of concerns beyond fistula closure to the management of The 'Bent Spoon" fistula-related complications; and a new focus on pelvic floor defect surgery in the management of pelvic relax- As others had often noted, Sims had struggled for years ation syndromes, including urinary stress incontinence. to see the edges of many of the large obstetric fistulas. 5. The 'Never-Leak' Period (2000 AD -+) - a time of Some today are still noted to be even greater than 6 cm prevention of urogenital fistulas (both gynecologic and in diameter. When the edges were not visible, fistulas obstetric), and a time of successful management of the were not (and are not) generally reparable. In his fistulas that have already occurred. autobiography Sims described his great excitement when he inserted a bent spoon with the patient in a knee-chest position, and was able to see the fistula clearly in its entirety [8]. This fundamental concept of The 'Pre-Leak' Period seeing the defect clearly led to a career of successful repairs with 230 of 312 patients' fistulas being closed over the next 20 years [6]. It was not until Avicenna of Persia described a postpar- tum in 1300 AD that the cause of maternal leakage after delivery began to be The Sims Surgical Method understood [1]. The exact causes of prolapse were even more unclear, and of less concern. It was the beginning This included denuding of fistula edges, minimal mobili- of a time of inquiry into pelvic floor problems that would zation of tissues, wire sutures placed for 10-14 days in frustrate gynecologic surgeons for centuries. an interrupted fashion, and catheter drainage. His technique became the standard for many, and successes soon became much more common worldwide. How- ever, many, many surgeons added their own modifi- The 'Mend-the-Leak' Period (1300-1940 AD) cations and interventions to the basic concerns of J. Marion Sims. The list of these innovators reads like a This period was a time of persistent effort to close the history of pelvic surgery, and shows the zeal of surgeons fistula defects found. A Dutch surgeon, von Rynhoos - to find the best possible techniques for fistula repair. called the father of fistula surgery - wrote one of the Every surgical aspect was clarified and debated over the very first textbooks on gynecologic surgery in 1663 AD, next 100 years. which was based on efforts at fistula repair [1]. How- Sir Henry Collis of Ireland (1861) significantly ever, his success rate was admittedly very low. Fatio, increased vaginal wall mobilization from the bladder from Switzerland, wrote about two successful repairs in and developed the split-flap technique [9]. Mackenrodt which he performed extensive vaginal wall-bladder wrote the definitive discussion of this mobilization dissection, but none of his followers could duplicate his technique in 1894 [10]. In 1902 Howard Kelly developed results [5]. This was not uncommon. In the mid-1800s special sharply curved scissors to aid in the wide dissec- Friedrich Diffenbach, then the master plastic surgeon of tion required to repair suburethral obstetric fistulas Europe, stated that 'the lucky repair of a vesicovaginal [11]. In 1916 Mayo argued for crossing (vertical then fistula is the rarest of occurrence'. He described wards transverse, etc.) tissue layers in fistula closure [11]. full of chronically leaking women kept in hospital in vain Halban, in 1937, cautioned against too much tissue for months all over Europe [1]. mobilization [12]. In 1942 Norman Miller of Michigan It is in this setting that the work of J. Marion Sims, a spoke against pursestring suturing of fistula edges [13]. surgeon in Montgomery, Alabama, must be evaluated. Moir refined fistula diagnosis in the office and invented Called the Father of Gynecologic (Vaginal) Surgery, more new instruments [14]. Sims was clearly the first surgeon who succeeded in Even positioning of the patient at surgery was consistently repairing obstetric urogenital fistulas [6]. debated. The older knee-chest position had been modi- John Mettauer of Virginia actually had the first success- fied to a reverse lithotomy or Lawson position [15]. ful repair in America in 1838 [7]. However, Sims' work Others, like Miller from Michigan, chose to use an has also been reviewed very critically over the years. He exaggerated Trendelenburg tilt with lithotomy [13]. collected slaves in need of repair in a travelling surgery Even the fathers of urologic surgery (such as Trende- unit, and worked on a single individual with little or no lenburg) gained their fame in fistula surgery - done anesthesia as often as 30 times, vainly attempting to abdominally [16]. close these major defects in the pelvic floor. Though The arguments seemed endless. However, the closure admired for his persistence, dedication and tireless rates of fistulas began to improve steadily, and the once effort, he was criticized for his use of very vulnerable, 'rare' surgical repair success became commonplace. desperate patients in an almost inhuman fashion. How- Perhaps most importantly, contemporary obstetric care 32 T.E. Elkins grew in America and Europe until the phenomenon of significant risk. Postoperative vaginal leakage of urine neglected, obstructed labor became non-existent. The soon required a retrograde IVP as well as cystoscopy for dreaded occurrence of an had become proper evaluation in America before any repair of a an uncommon event by 1940, thanks to a relatively new fistula was attempted. specialty called obstetrics and gynecology, and its Radiation therapy became a standard approach to influence. Mayo Clinic reviews showed the trends urogenital cancer during this time, and urogenital fistu- cleary. In 1920, Judd reported that 39% of fistulas las became a standard risk of such therapy. The patho- repaired at the Mayo Clinic were caused by obstructed physiology of endarteritis obliterans explained the labor [17]. Lee, in 1988, reported that only 3% of greatly delayed injuries that often made permanent fistulas repaired were still from obstetrics [18], and none surgical repair difficult [25]. of these were caused by obstructed labor. 'New' causes It soon became clear that operations for radiation- of fistulas were well recognized by 1940, introducing the induced fistulas were most often successful when tissue next period of fistula surgery. grants and flaps were used [26]. However, failures even years later could be expected because of the ongoing nature of radiation injury [27]. By the 1980s these injuries were being seen much less often, owing to The 'Mega-Leak' Period (1940-1985) marked refinements in radiation therapy. Adjunctive plastic surgery procedures to enhance The expansion of the fistula problem occurred with the fistula closure techniques became popular in this era as increase in radical pelvic surgery and the advent of well. The Martius graft was refined as early as 1932 by radiation therapy for pelvic cancer. Surgeons, having Heinrich Martius of Germany [281. Long described as a struggled for centuries to prevent and to repair obstetric bulbocavernous muscle graft, it was actually a very vesicovaginal fistulas, now faced an increasing problem vascular flap of fibrofatty tissue (which forms the base of with gynecologicallyinduced ureteral and bladder injur- the round ligament) beneath the labia majora that is ies. transposed to the fistula repair site [29]. The gracilis By the 1980s the Latzko repair, or partial colpocleisis, muscle graft, the omental interposition for abdominal had become the gynecologic procedure of choice for the repairs, rectus muscle grafts and sartorius muscles grafts posthysterectomy fistula [19]. This usually appeared as a all became useful to surgeons struggling to improve pinpoint leak at or near the vaginal cuff. Both Lee and closure rates [30]. Tancer published extensive studies of successful repairs Masters of fistula repair surgery also became promi- to these surgically induced fistulas [18,20]. Blaivas [21] nent in this era. The mark of the gynecologic surgeon in has recently published a similar series which confirms America was their referral base for both obstetric and that surgically induced fistulas may be approached gynecologic fistulas, which were usually repaired tran- successfully transabdominally or transvaginally. vaginally. Norman Miller of Michigan gave his famous The time from 1940 to 1980 was an era of ureteral principles for successful repair of these gaping pelvic injury enlightenment. Multiple studies documented that defects after over 50 such cases had been managed by this was far too common in early radical cancer surgery 1944 [13]. But, as the obstetric fistula became a rarity in and in benign surgery, especially when pelvic , America with improved perinatal care, the techniques or leiomyomata were present [22-24]. It of fistula surgery were transferred to developing soon became clear that to perform major pelvic surgery countries, where massive repair numbers became without identifying the was to flirt with disaster common. Table 1 shows the reported series of some of for the patient. Unlike the effects of obstructed labor, these efforts [32-40], while others (such as Reginald and which lead almost entirely to bladder, urethral or rectal ) rarely published their work but were injury, difficult gynecologic surgery placed the ureter at documented by others. By the end of this era fistula

Table 1. Fistula repair masters

Author Year Country No. of patients Primary closure rate (%)

Aziz [32] 1965 100 82 Bird [33] 1967 Kenya 70 71 Lawson [34] 1989 (1960s) Nigeria 369 75 Bhasker Rao [35] 1972 India 269 85 Ashworth [36] 1973 Ghana 152 74 Abbo and Mukhtar [37] 1975 Sudan 70 95 Ward [38] 1989 Nigeria 1789 85 Waaldijk [39] 1989 Nigeria 500 88 Kelly [40] 1983 248 83 Fistula Surgery: Past, Present and Future Directions 33 repair successes had risen to 65%-95% in almost all survived years of arguing about types of cases. individual techniques, until correction of simple stress incontinence became commonplace. However, it soon became clear that correction of the incontinence could The 'Para-Leak' Period (1980-2000) lead to other complications (, detrusor instability, urinary retention etc.). It was also clear that New concerns in fistula surgery began to replace the other related problems, caused by failed pelvic support simple need for successful closure, which had finally and neuromuscular dysfunction, and often by birth- become more common. Other complications often seen related trauma, had also to be addressed. Finally, with in patients with obstetric fistulas became more of a the rapidly growing number of aging women in Amer- focus: foot drop from peroneal nerve injury, secondary ica, the needs of this underserved group became a , and the severe social isolation that concern with new significance. Appropriate training of patients suffered. Attempts to avoid or manage compli- specialists and subspecialists had to be considered in cations related to the surgery itself also became concerns, such as stress incontinence after suburethral order to address the volume and seriousness of pelvic fistula repairs and neourethra procedures, vaginal floor defects being encountered. When pelvic floor atresia after large midvaginal fistula repairs, and hemor- surgery in America, with its needs, innovations and rhage with juxtacervical procedures [41]. New obstetric issues, is compared to fistula surgery, still ongoing in fistula classifications emphasized those fistulas most West Africa, the gynecologic-pelvic floor surgeon real- likely to lead to such problems, even if successful izes a unique blend of past and present. History closure was accomplished. Perhaps most importantly, becomes reality. prevention of obstetric fistulas in developing countries As dissection for large obstetric fistulas led to entry through improved maternal healthcare became a major into the retroperitoneal, paravaginal spaces, identifi- emphasis. Finally, training of specialists both to prevent cation of the arcus tendineus and paravaginal repair and to repair these problems became prominent inter- became a rediscovered method to address some pelvic national efforts [42,43]. relaxation syndromes in America [47]. As full-thickness A number of other surgical projects have been under- Martius grafts were needed to restore the pelvic surface taken to address the multiple complications associated after large fistulas were repaired, fascial slings and with obstetric fistulas in West Africa. artificial grafts were used to restore anatomic depth and 1. Urodynamics equipment was utilized for the first time support to the pelvic floor. As multinational, and in West Africa to categorize the stress urinary inconti- multispecialty input (from obstetrics/gynecology, nence that followed the repair of suburethral fistulas general surgery, pediatrics, community medicine, and total urethral sloughs [43]. The use of elevating public health and others) was required to train periurethral sutures, grafts and slings, even at initial physicians to address maternal mortality and morbidity repair, soon followed. appropriately in West Africa, multispecialty input (from 2. Full-thickness skin flaps, attached to Martius graft obstetrics/gynecology, , colorectal surgery, plas- pedicles, were tunneled into the to restore tic surgery and others) will be required to train vaginal depth, which was usually lost with large mid- physicians appropriately to address pelvic floor vaginal fistula repairs [44]. problems in American women. 3. Initial success was noted with a Tanagho-like anterior bladder flap to reform a when total urethral slough had resulted from vaginal outlet obstruction in labor [45]. The 'Never Leak' Period (2000 AD--~) Training programs for senior-level gynecology resi- dents were devised, and pilot programs have taken The dream of improved radiation therapy and gynecolo- place in both Ghana and Nigeria, resulting in a new generation of surgeons to address the fistula problem in gic surgery and adequate, worldwide obstetric care that these areas [46]. Simple closure of the fistula had will result in a near total absence of urogenital fistulas is become truly something to antcipate most of the time, still far from reality. The ideal repair method for the and other associated problems had become a new focus. complex obstetric fistula or the complex pelvic floor The evolution of pelvic floor reconstructive surgery defect is still yet to be discovered. Thoughts must focus can be seen today in America as a direct correlate to the on innovation guided by appropriate motivation to history of fistula surgery. The following is clear: achieve these successes in the future. Incontinence of urine, the initial focus of many It will require breakthroughs equivalent to the bent gynecologic surgeons, has become a broader issue spoon of J. Marion Sims. It was this simple innovation incompassing pelvic floor relaxation syndromes, pelvic that allowed him to see the edges of the surgical floor defects, and even anal incontinence. This has been problem he faced clearly enough to achieve success for the result of a process similar to that already seen in his patients. For us in pelvic floor surgery, such a fistula surgery. Dozens of ways to correct simple stress breakthrough may come on another trip to the anatomy 34 T.E. Elkins laboratory, or in another look at pelvic floor biomecha- Conclusion nics, or in the cellular anatomy of pelvic structures, or in any number of ways. Persistence and dedication to We in America are under great pressures today to make progress will lead to innovations that will make a money at all costs, to preserve turf boundaries among difference for patients with pelvic floor defects. specialties, even at the expense of patients' best inter- The desire to serve the underserved women of our ests.., and to perform the quickest procedures in the world becomes a driving force in a place like West most cost-effective ways. It is an era of 'managed care' Africa. It is this same sense of urgency that we should in every sense. The 'business' of medicine seems clearly, feel towards the underserved women of our inner cities, at times, to have displaced the priority of the art and the women with mental and/or physical disabilities, the science of our profession. It is in such times as these that women suffering from domestic violence . . . and the we must be encouraged to recall the motivations that women suffering from pelvic floor defects, whether men and women have followed for centuries to become these be fistulas, other forms of incontinence or pelvic physicians and surgeons. These sensitivities are univer- relaxation syndromes. sal and timeless. They transcend geographic, political To solve the problems that face us as pelvic surgeons and economic issues and are highlighted by the history we need to understand our past as well as our present. It of fistula surgery reviewed today. is the approach to the problem and the ethics of the It is a history of skilful surgeons influencing each effort that should be sought, as much as the procedural other over time.., in which change came, though often skill. slowly. So many have come before us in this effort called In rural Africa I have often met with village chiefs and pelvic surgery. Each of us has our mentors, our leaders who love to share their peaceful wisdom regard- teachers, our examples. For me it was a group that ing the slow, steady progress and change they see, included Curt Abell, Don Gallup, Ralph Chesson, Bert despite the horrors that life can bring. They have a way Buxton, Ed McGuire and George Morley in surgery, of watching the worst'of life's hardships, and still being and Preston Dilts and Jack Sciarra in medical education. able to applaud even the most feeble efforts to prevent, Each of you has a similar list, or should. Some are to relieve or to alter the suffering of their people. They famous. But there will be those whom only a few will have learned to see hope in activities that we would ever know. consider futile or outright failures. Their world view is I think, for example of T. S. Ghosh, the recently forever tied to the struggles and agonies of the ancients, retired patron saint of pelvic surgery at the University of by whose measure they seem blessed. Where we from Ghana. He represented, to me, an apex of dedication the industrialized western world see disaster, they see and enlightenment, even as he entered his 70s. It was T. evolutionary stages of growth and change for their S. Ghosh who received a Drogemueller's Comprehen- people over time. Our restless demands for immediate sive Gynecology text from our Carnegie program and cures, societal success and positive outcomes are tem- joyfully read and underlined the entire work in only 2 weeks [48]. It was T. S. Ghosh who came to me one day pered by their emphasis on patience, persistence and and said that he would like to try a new procedure using inner peace. anterior bladder wall, 'as Tanagho had done abdomi- There is also a rhythm to the seemingly slow, yet nally', to rebuild lost . When the residents in vibrant life in Africa, symbolized by the rural drums that Ghana faced procedures that would be a disaster, one seem to add a constant beat to all activity. I never feel would come to stand with them, to share their burden, like I've really been to Africa until I hear that rhythmic to show them a way.., it was T. S. Ghosh. His meager beat of the drums, at a rural church or in a village salary went, in part, to buy catheters and food for his ceremony. I am reminded of an Ashanti proverb that fistula patients. He never kept numbers. Some say he hangs on the wall in my office. It states: 'only' repaired 500 fistulas, some say 1500. Who knows? I am old, and need to remember. You are young, and Such accounting did not interest T. S. Ghosh. need to learn. When I think further of fistula surgeons, pelvic If I forget the words, Will you remember the music. surgeons and motivational ethics, I cannot help but recall Dr Catherine Hamlin of Ethiopia. After over 30 Many things have been mentioned today that most years of service, with over 15 000 fistulas repaired in her will not remember. The names of long-ago surgeons, hospital, the boldness of her surgical knife became age-old techniques, postfistula repair remarkable [49]. But there can be no more humble, rates, rural outpost hospitals in West Africa, flaps, more gracious person than Catherine Hamlin. Age is grafts and prolapses . . . all represent words that few not the only criterion for such wisdom, as Dr Steven will recall in another day. It has been a discussion of Arrowsmith showed when he joined her, to work at her fistulas, perhaps, but hopefully much more. It is the side. Who works at your side? What do they learn?... 'music', as much as the words that we need to take away about surgery and life? from this year's J. Marion Sims lecture. My own surgical roots and thoughts will forever have The story of fistula surgery leads us into pelvic floor a historical influence and African overtones. Such surgery and is indeed a song of progress, of hope, of brings meaning to our efforts. remarkable surgical innovation, of an unending moti- Fistula Surgery: Past, Present and Future Directions 35 vation to help undeserved women who suffer chronic, 26. Gowing NFC. Pathological changes in the bladder following debilitating pelvic floor problems.., and of the people, irradiation. Br J RadioI 1960;33:484-488 27. Boronow RC. Management of radiation-induced vaginal fistulas. like us, who struggle to remember at least to hum, and Am J Obstet Gynecol 1971 ;100:1-5 to sing the spirit of the music. 28. AartsenEJ, SindramIS. 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