Vesicovaginal fistulas: a gynecological experience in 41 cases at a German pelvic floor center

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.

Spontaneous utero-cutaneous fistula between a benign uterine leiomyoma and abdominal skin: A case report

The case of a 56-year-old woman with a fibroid uterus who developed utero-cutaneous fistula is presented. The woman was para 0, had an unremarkable medical history, and had no prior diagnosis of a gynecologic pathology, no operative interventions involving the uterine wall or any other risk factor for fistula. Abdominal examination revealed an abdominal mass with overlying deep, purulent ulceration. ¹⁸F-FDG PET/CT scan was consistent with uterine leiomyoma, but a differential diagnosis of sarcoma was considered due to the presence of the fistula, patchy increased FDG uptake of the tumor and several mildly enlarged lymph nodes bilaterally in the inguinal and iliac region. Hysterectomy with bilateral salpingo-oophorectomy was performed. Histological diagnosis was of leiomyoma with focal bizarre atypia, degenerative and metaplastic changes and utero-cutaneous fistula. To the best of our knowledge, this is the first case report describing a benign leiomyoma forming a fistula between the uterus and abdominal surface.

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Utero-cutaneous fistula is a rare condition.

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We report a case of a 56-year-old woman with benign leiomyoma with a utero-cutaneous fistula.

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Degenerative leiomyoma can mimic malignancy in medical imaging.

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A multidisciplinary team approach is recommended in such unusual cases.

Endometriosis and the Urinary Tract: From Diagnosis to Surgical Treatment

We aim to describe the diagnosis and surgical management of urinary tract endometriosis (UTE). We detail current diagnostic tools, including advanced transvaginal ultrasound, magnetic resonance imaging, and surgical diagnostic tools such as cystourethroscopy. While discussing surgical treatment options, we emphasize the importance of an interdisciplinary team for complex cases that involve the urinary tract. While bladder deep endometriosis (DE) is more straightforward in its surgical treatment, ureteral DE requires a high level of surgical skill. Specialists should be aware of the important entity of UTE, due to the serious health implications for women. When UTE exists, it is important to work within an interdisciplinary radiological and surgical team.

Vaginal repair of nonradiogenic urogenital fistulas

INTRODUCTION AND HYPOTHESIS

In developed countries urogenital fistulas are rare and usually a complication of surgery or radiation therapy. Surgical repair can be accomplished transvaginally or by laparotomy, laparoscopy, robotic-assisted laparoscopy, or transurethral endoscopy. Closure can be achieved with or without tissue interposition. The vaginal approach is the least invasive and a variety of techniques with or without tissue interpositions and flaps have been described. This study reviews surgical approaches and techniques for the repair of nonradiogenic urogenital fistulas.

METHODS

We identified and reviewed records from all patients treated for urogenital fistulas at our unit between 2008 and 2018. We analyzed fistula location, etiology, type and duration of corrective surgery, length of hospitalization, as well as complication and success rates.

RESULTS

Fifty patients (mean age 52 years) were identified. 49 fistulas were related to previous gynecological surgery, 3 were related to obstetric trauma. Thirty-four patients had vesicovaginal, 11 urethrovaginal, 3 ureterovaginal, and 2 neobladder-vaginal fistulas. Forty-eight patients (96%) were operated on using a vaginal approach; a modified Sims-Simon repair was used in 47 cases (94%). No flaps or tissue interpositions were used. In 48 patients (96%) successful closure was achieved with one operation; the modified Sims-Simon technique was successful in all 47 cases. The median operation time was 40 min (range, 20-100 min); the complication rate was 14%.

CONCLUSIONS

This series demonstrates the feasibility and advantages of vaginal repair of benign gynecological fistulas. The success rate was high and extensive procedures were avoided.

Pelvic MRI in the diagnosis and staging of pelvic endometriosis: added value of structured reporting and expertise

PURPOSE

To compare the diagnostic characteristics of routine-read (RR), structured-reported read (SR), and structured expert-read pelvic (SER) MRI for staging of pelvic endometriosis in a tertiary care academic center.

METHODS

Of 530 patients with endometriosis (2013-2018), 59/530 (11.1%) were staged surgically and underwent pelvic MRI. Radiology reports were considered RR; MRI studies were independently reassessed by SR and SER. Involvement was recorded by compartment [anterior (AC), middle (MC), posterior (PC), adnexal (AX), and other (OC)]. Diagnostic discrepancy between review methods was assessed with McNemar's test. Interobserver agreement was assessed using Cohen's unweighted kappa.

RESULTS

Of 295 compartments in 59 women (mean age = 38.8 years; range 20-69), 147/295 (49.8%) had confirmed endometriosis. Overall sensitivity: RR = 42.9%; SR = 86.4%; SER = 74.2%. SR's increased sensitivity was significant for PC (p < 0.001), MC (p < 0.001), AC (p = 0.001), AX (p = 0.038). Higher sensitivity by SER was significant for PC (p < 0.001), MC (p = 0.004) and AC (p < 0.001), but not AX (p > 0.05). Overall specificity: RR = 95.3%; SR = 45.9%; SER = 81.8%. SER specificity was no different than RR for PC or AX (p > 0.5). RR sensitivity relied heavily on detection of AX involvement, whereas SR and SER showed additional sites of disease while maintaining comparable specificity for SER. Overall agreement between SR and SER was fair [k = 0.342 (95% CI 0.25, 0.44)].

CONCLUSIONS

Even at a tertiary care academic center, SER outperforms both SR and RR in the assessment of pelvic endometriosis. Although lack of expertise may negatively impact specificity, use of structured reporting is significantly more sensitive than RR. Therefore, its use can be of assistance in surgical planning and patient counseling.

Diverticular Colovaginal Fistulas: What Factors Contribute to Successful Surgical Management?

BACKGROUND

Diverticular disease is the leading cause of colovaginal fistulas. Surgery is challenging given the inflammatory process that makes dissection difficult. To date, studies are small and include fistula secondary to multiple etiologies.

OBJECTIVE

The objectives of this study were to examine surgical outcomes of diverticular colovaginal fistulas and to identify variables associated with successful closure.

DESIGN

This was a retrospective study of a prospectively maintained clinical database.

SETTINGS

The study was conducted at a single tertiary referral center.

PATIENTS

Women with diverticular colovaginal fistulas, who underwent surgical repair with intent to close the fistula, were included.

INTERVENTIONS

Repair of colovaginal fistula through minimally invasive or open techniques was involved.

MAIN OUTCOME MEASURES

Successful closure of fistula, defined as resolution of symptoms and no stoma, was measured.

RESULTS

Fifty-two patients underwent surgical treatment of diverticular colovaginal fistula, 23 (44%) of whom underwent a minimally invasive approach (conversion rate of 22%). Ostomy construction and omental pedicle flaps were used in 28 (54%) and 38 patients (73%). Surgery was successful in 47 patients (90%). Accounting for secondary operations, ultimate success and failure rates were 49 (94.0%) and 3 (5.7%). There was no difference in postoperative morbidity between the 2 groups (5 patients with Clavien-Dindo III/IV complications in the success group versus 2 patients in the failure group; 10.6% vs 40.0%; p = 0.44). Failure to achieve fistula closure was not associated with perioperative variables, age, BMI, diabetes mellitus, ASA grade, steroid use, previous abdominal surgery or hysterectomy, use of omentoplasty, or ostomy. Patients who failed were more likely to be smokers (60.0% vs 12.8%; p = 0.03).

LIMITATIONS

Limitations include the retrospective design and lack of power.

CONCLUSIONS

Surgery is effective in achieving successful closure of diverticular colovaginal fistula. Smokers should be encouraged to stop before embarking on an elective repair. Although the use of fecal diversion and omental pedicle flaps did not correlate with success, they should be used when clinically appropriate. See Video Abstract at http://links.lww.com/DCR/A983. FÍSTULAS COLOVAGINALES DIVERTICULARES ¿QUÉ FACTORES CONTRIBUYEN AL ÉXITO DEL TRATAMIENTO QUIRÚRGICO?: La enfermedad diverticular es la causa principal de fístulas colovaginales. La cirugía es un reto dado el proceso inflamatorio que dificulta la disección. Hasta la fecha, los estudios son pequeños e incluyen fístulas secundarias a múltiples etiologías.

OBJETIVO

1) Examinar los resultados quirúrgicos de las fístulas colovaginales diverticulares; 2) Identificar variables asociadas a un cierre exitoso. DISEÑO:: Estudio retrospectivo de una base de datos clínicos prospectivamente mantenida. CONFIGURACIÓN:: Centro de referencia superior.

PACIENTES

Mujeres con fístulas colovaginales diverticulares, que se sometieron a una reparación quirúrgica con la intención de cerrar la fístula.

INTERVENCIONES

Reparación de la fístula colovaginal mediante técnicas mínimamente invasivas o abiertas.

MEDIDAS DE RESULTADOS PRINCIPALES

Cierre exitoso de la fístula definida como resolución de los síntomas y sin estoma.

RESULTADOS

Cincuenta y dos pacientes se sometieron a tratamiento quirúrgico de la fístula colovaginal diverticular, 23 (44%) de los cuales se sometieron a un acceso mínimamente invasivo (tasa de conversión del 22%). La construcción de la ostomía y los pedículos omentales se utilizaron en 28 (54%) y 38 pacientes (73%), respectivamente. La cirugía fue exitosa en 47 pacientes (90%). Tomando en cuenta las operaciones secundarias, las tasas finales de éxito y fracaso fueron 49 (94.0%) y 3 (5.7%). No hubo diferencias en la morbilidad postoperatoria entre los dos grupos (5 pacientes con complicaciones de Clavien-Dindo III / IV en el grupo de éxito versus a 2 pacientes en el grupo de fracaso, 10.6% versus a 40.0%; p = 0.44). El fracaso para lograr el cierre de la fístula no se asoció con variables perioperatorios, edad, IMC, diabetes, grado ASA, uso de esteroides, cirugía abdominal previa o histerectomía, uso de omentoplastia u ostomía. Los pacientes que fracasaron eran más propensos a ser fumadores (60.0% versus a 12.8%; p = 0.03).

LIMITACIONES

Las limitaciones incluyen el diseño retrospectivo y la falta de poder.

CONCLUSIONES

La cirugía es efectiva para lograr el cierre exitoso de la fístula colovaginal diverticular. Se debe aconsejar a los fumadores a parar de fumar antes de embarcarse en una reparación electiva. Mientras el uso de desviación fecal y pedículos omentales no se correlacionó con el éxito, deberían utilizarse cuando sea clínicamente apropiado. Consulte el Video del Resumen en http://links.lww.com/DCR/A983.

Management of Urethral Lesions and Urethrovaginal Fistula Formation Following Placement of a Tension-Free Suburethral Sling: Evaluation From a University Continence and Pelvic Floor Centre

Introduction The complication of tape erosion in the urethra following placement of a retropubic (TVT) or transobturator (TOT) tension-free suburethral vaginal sling or an accidental iatrogenic transurethral tape position can result in the formation of a urethrovaginal or vesicovaginal fistula. The objective of the investigation is the evaluation of the management of such rare complications.

Patients and Methods Retrospective analysis of 14 patients who were treated for a urethral lesion or urethrovaginal fistula formation status post TVT/TOT placement between June 2011 and February 2018 in the Tübingen University Department of Gynaecology.

Results As surgical therapy, 57.1% (n = 8) cases underwent vaginal fistula closure using a Martius flap of the labium majus and in 21.4% (n = 3) using a vaginal rotation skin flap. In 21.4% (n = 3), exclusively vaginal suture reconstruction of the urethra following excision of the tape running transurethrally or tape erosion was performed. 50% (n = 7) of the patients had lasting continence postoperatively without any further need for therapy. In 28.6% (n = 4), there was ongoing stress urinary incontinence, in 21.4% (n = 3) mixed urinary incontinence. Six of the 7 patients with persistent incontinence underwent new placement of a tension-free suburethral retropubic sling (TVT) an average of 8.8 months (5 – 13 months) postoperatively which was uncomplicated in all patients and achieved satisfactory continence. The 3 patients with mixed urinary incontinence and persistent urgency components additionally received anticholinergic medication. During the time period investigated, there were no long-term complications, in particular no recurrent fistulas.

Conclusion The rare but relevant complications of a urethral erosion, transurethral tape position or urethrovaginal fistula formation status post TVT/TOT placement can be successfully managed via vaginal surgery. Persistent postoperative urinary incontinence with the need for a two-phase repeat TVT placement following sufficient wound healing must be preoperatively clarified.

Genital tract fistula: a case series from a tertiary centre in South Africa

INTRODUCTION AND HYPOTHESIS

We describe the demographic profile, aetiology, management and surgical outcomes in women with genital tract fistula presenting to a tertiary urogynaecology unit.

METHODS

This retrospective audit included 87 patients managed in our unit between 2008 and 2015. Frequencies and means with standard deviations are presented for categorical and continuous data. Continuous dependent variables are categorized as above or below the median for bivariate analyses performed using the chi-squared test (α = 0.05).

RESULTS

The mean age of the women was 34.7 years, 64.4% were Black African, 70.2% were multiparous, 49.4% were married, 82.8% were employed, and 21.8% were HIV-infected, with 47.4% on antiretroviral treatment. Vesicovaginal (47.1%) and rectovaginal (41.4%) fistula were the most frequent injuries. The majority of the injuries (67.8%) were obstetric, with 26.4% occurring during caesarean delivery. Repair had been attempted previously in 43.7% of patients. In 63.2% of the repairs the approach was vaginal and in 35.6% abdominal. Interposition grafts were used in 23% of repairs. In 85.1% of patients the initial repair at our centre was successful. Patients with multiple repairs were more likely to have complications (p = 0.03). HIV infection was not significantly associated with complications.

CONCLUSIONS

A high rate of successful repair was found, with previous unsuccessful repairs associated with poorer outcomes, highlighting the need for centralized management.