Vaginal repair of nonradiogenic urogenital fistulas

The utility of Martius fat pad in the repair of urogenital fistulae: review of current evidence

OBJECTIVE

To present the contemporary evidence on transvaginal urogenital fistulae (UGF) repair with Martius fat pad (MFP), compared to direct graftless fistula repair.

METHODS

We reviewed all available studies reporting lower UGF repair via the transvaginal approach in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). The primary outcome of interest was the fistula closure rates. When available, patients' baseline characteristics, indications for surgery, and early and late postoperative complications with focus on MFP-related complications are reported.

RESULTS AND DISCUSSION

In obstetric fistulae, tissue interposition has been almost completely abandoned, with contemporary large series reporting closure rates of >90% with graftless repair, even for complex fistulae. Similarly, most simple, non-irradiated iatrogenic fistulae can be closed safely without or with tissue interposition with success rates ranging between 86% and 100%. However, MFP is valuable in fistulae with difficulty achieving tension-free and layered closure, with significant tissue loss, urethral involvement and with poorly vascularised tissues after radiotherapy, with reported success rates between 80% and 97% in those challenging situations.

CONCLUSION

A UGF repair should be individualised after considering the specific characteristics and complexity of the procedure. MFP interposition is probably unnecessary for the majority of low (obstetric) fistulae within otherwise healthy tissues. However, MFP may still have a place to maximise outcomes in low-income settings, in select cases with higher (iatrogenic) fistulae, and in most cases with radiotherapy.

Urinary Incontinence and Pelvic Organ Prolapse in Women

BACKGROUND

Pelvic floor disorders are common, especially in pregnancy and after delivery, in the postmenopausal period, and old age, and they can significantly impact on the patient's quality of life.

METHODS

This narrative review is based on publications retrieved by a selective search of the literature, with special consideration to original articles and AWMF guidelines.

RESULTS

Pelvic floor physiotherapy (evidence level [EL] 1), the use of pessaries (EL2), and local estrogen therapy can help alleviate stress/urge urinary incontinence and other symptoms of urogenital prolapse. Physiotherapy can reduce urinary incontinence by 62% during pregnancy and by 29% 3-6 months post partum. Anticholinergic and β-sympathomimetic drugs are indicated for the treatment of an overactive bladder with or without urinary urge incontinence (EL1). For patients with stress urinary incontinence, selective serotonin-noradrenaline reuptake inhibitors can be prescribed (EL1). The tension-free tape is the current standard of surgical treatment (EL1); in an observational follow-up study, 87.2% of patients were satisfied with the outcome 17 years after surgery. Fascial reconstruction techniques are indicated for the treatment of primary pelvic organ prolapse, and mesh-based surgical procedures for recurrences and severe prolapse (EL1).

CONCLUSION

Urogynecological symptoms should be specifically asked about by physicians of all relevant specialties; if present, they should be treated conservatively at first. Structured surgical techniques with and without mesh are available for the treatment of urinary incontinence and pelvic organ prolapse. Preventive measures against pelvic floor dysfunction should be offered during pregnancy and post partum.

Minimally invasive complete urinary tract drainage in the treatment of vesicovaginal fistula: A case report

Vesicovaginal fistula is one of the most common types of female genitourinary fistulas encountered in clinical practice, and its treatment is determined by the disease characteristics and at the discretion of the attending physician. The present study describes a unique conservative approach to the management of vesicovaginal fistulas. A 56-year-old woman developed a vesicovaginal fistula after laparoscopic hysterectomy. A bilateral ureteral single-J tube drainage through suprapubic bladder puncture with indwelling catheterization was performed. Thus, urine diversion and bladder emptying were achieved. In addition, the healing of the vesicovaginal fistula was promoted and the trauma of open or laparoscopic surgery was avoided. This minimally invasive method is simple and convenient, has few complications, and may be used as an alternative method for treating vesicovaginal fistulas.

Transvaginal primary layered repair of postsurgical urethrovaginal fistula

INTRODUCTION AND HYPOTHESIS

Urethrovaginal fistula (UVF) is a rare disorder, which implies the presence of an abnormal communication between the urethra and the vagina.

METHODS

Surgical repair options include transurethral, transabdominal and transvaginal procedures, either with or without tissue interposition. The vaginal route is considered a safe and effective option to correct UVF. This video is aimed to present a case of direct transvaginal layered repair of urethrovaginal fistula, without the use of tissue interposition. The featured patient is a 66-year-old woman who developed a symptomatic UVF after a complicated laparoscopic hysterectomy for endometrial cancer 3 years before. Cystoscopy demonstrated the presence of a 7 mm urethral orifice a few millimeters caudal from the bladder neck. After proper informed consent, the patient was admitted to transvaginal primary layered repair, according to the technique demonstrated in the video. The featured procedure was completed in 60 min and blood loss was < 100 ml. No surgical complications were observed.

RESULTS

The procedure was successful in restoring the anatomy and relieving the symptoms.

CONCLUSION

Transvaginal layered repair without tissue interposition represents a safe and effective procedure for the surgical management of postsurgical urethrovaginal fistula.