Characteristics of Genitourinary Fistula in Kigali, Rwanda; 5-Year Trends

Surgical repair of post-cesarean vesicouterine fistula: A systematic review and a plea for prevention

BACKGROUND

Vesicouterine fistula (VUF) is a iatrogenic injury in the vast majority of cases. The worldwide increase of cesarean delivery rates is expected to lead to increased complications.

OBJECTIVES

To assess current evidence on VUF pathogenesis and surgical management.

SEARCH STRATEGY

Pubmed and Embase databases were searched from January 2000 to January 2023 using relevant key words.

SELECTION CRITERIA

Only original articles including either transabdominal or transvaginal surgical routes for post-cesarean VUF repair, in English language, were included.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the references for eligibility, data extraction, and assessment of methodologic quality. All available surgical outcomes were recorded.

MAIN RESULTS

Of the 1160 studies retrieved, 67 were selected for analysis. Most of these were case reports, case series, or observational cohort studies including a total of 284 patients. The majority (78.6%) of patients had more than one cesarean section, and approximately 10% of them experienced an overt bladder injury and/or uterine rupture at the time of cesarean delivery. The supratrigonal part of the bladder was most commonly involved (92.5%). The majority of patients (88.8%) underwent delayed VUF repair through laparotomy. Length of stay and blood loss were significantly less in patients treated via a minimally invasive approach (P < 0.001 and P = 0.02, respectively). Most patients had double-layer bladder repair and single-layer uterine repair. The overall success rate was 100% on first attempt for each independent combination of different surgical approaches and techniques. Live birth following VUF repair was reported in 23 patients.

CONCLUSIONS

Paying close attention to surgical details is crucial to reduce the incidence of this complication and recurrence rates. Double-layer bladder closure and delayed timing of repair of VUF are recommended.

Vesicouterine Fistula After Cesarean Delivery at Full Cervical Dilation

IMPORTANCE

Vesicouterine fistula (VUF) is an iatrogenic consequence of cesarean section in the vast majority of cases. The worldwide increase of cesarean delivery rates is likely to be accompanied by a rise of this complication, and surgery is the mainstay treatment.

OBJECTIVE

The aim of the study is to assess current evidence on VUF pathogenesis and management.

STUDY DESIGN

The study is a case report and literature review on PubMed and Embase spanning over the past 2 decades.

RESULTS

An early VUF developed after a cesarean section at full cervical dilation and concurrent incidental bladder injury. A transabdominal extravesical repair was performed 3 months after cesarean delivery. Both the cystotomy and hysterotomy were repaired in a double-layer fashion with no interposition flap. A contemporary literature review including 25 patients showed that VUF was repaired transabdominally in 21 patients (84%), and an open approach was adopted in 18 patients (85.7%). In most patients, the uterine side was closed with a single-layer suture and an interposition flap was used to reinforce the repair. Concomitant hysterectomy was performed in 6 patients (24%). Overall, successful term pregnancies were reported in 2 patients after VUF repair.

CONCLUSIONS

Vesicouterine fistula is a rare event and is commonly associated with cesarean sections, especially those with a concurrent bladder injury. Careful and meticulous surgical technique may prevent the occurrence of this condition. Delayed repair and double-layer closure of both bladder and uterus, with or without an interposition flap, are recommended.

Vesico-Vaginal Fistula in Females in 2010-2020: a Systemic Review and Meta-analysis

INTRODUCTION

In the Western world today, urogenital fistula, including vesicovaginal fistula (VVF), is rare. However, while it remains significant in developing parts of the world due to prolonged and obstructed labor, in this study, we systematically reviewed the existing literature, discussing VVF occurrence, its etiology, and outcomes.

MATERIAL AND METHODS

We used electronic databases to search relevant articles from 2010-2020. The screening was performed with the help of Covidence. Relevant data from included studies were extracted in excel sheets, and final analysis was done using CMA-3 using proportion with 95% confidence interval (CI).

RESULTS

Fifteen studies reported the VVF among the fistula series. The pooled result showed 76.57% cases of VVF (CI, 65.42-84.96), out of which 27.54% were trigonal, 55.70% supra-trigonal, and the rest with a varied description like circumferential, juxta-cervical, juxta-urethral. Obstetric etiology was commonly reported with 19.29% (CI, 13.26-27.21) with cesarean section and 31.14% (CI, 18.23-47.86) with obstructed labor. Hysterectomy was the commonly reported etiology among gynecological etiology (46.52%, CI; 36.17-57.19). Among different surgical treatments employed for fistula closure, 49.50% were by abdominal approach (CI, 37.23-61.82), and 42.31% by vaginal approach (CI, 31.82-53.54). Successful closure of fistula was reported in 87.09% of the surgeries (CI, 84.39-89.38).

CONCLUSION

The vesicovaginal fistula is the most common type of genitourinary fistula. Major causes of fistula are gynecological surgery, obstructed labor, and cesarean section. The vaginal approach and abdominal are common modalities of repair of fistula with favorable outcomes in the majority of the patients.

Abdominal sacrohysteropexy for large iatrogenic early postpartum vesicouterine fistula

Sacrohysteropexy is a surgical technique employed for the surgical treatment of uterine prolapse when uterine preservation is desired. Vesicouterine fistulae are rare iatrogenic complications of difficult operative childbirth, typically via caesarean section. If further childbearing is planned, uterus-sparing fistula closure in layers, with interposition grafts, has been described. To further decrease recurrence rates, temporary suspension of the uterus away from the fistula site can be achieved via sacrohysteropexy with absorbable biologic graft. The graft eventually resorbs with return of the uterus to its normal pelvic anatomic location.

Management strategies and outcome of ureterovaginal fistulae: A systematic review and meta-analysis

BACKGROUND

Genitourinary fistula is a distressful condition involving mental, social, marital, and financial repercussions.

OBJECTIVE

The objective of this study is to systematically evaluate etiology, clinical presentation, diagnosis, the timing of repair, and perform a meta-analysis evaluating the success rate of various treatment modalities with respect to time taken to seek treatment.

SEARCH STRATEGY

We performed a critical review of PubMed/Medline, Embase, and the Cochrane Library in April 2020 according to the PRISMA statement. Seventeen studies were included in the final analysis and all were retrospective in design.

SELECTION CRITERIA

Each article was rated by the evidence-based medicine levels of evidence scale and the Methodological Index for Nonrandomized Studies scale for assessment of bias among nonrandomized studies.

MAIN RESULTS

Of the 799 fistulae reported in 17 studies, endoscopic management was done in 35.6% (12 studies), whereas surgical management was preferred in 85.6% fistulae (15 studies). The pooled success of endoscopic stenting was 32% (95% confidence interval [CI]: 7-64) and 100% (95% CI: 98-100) in operated patients. Patients who underwent stenting within 2 weeks (20%), 2-6 weeks (21%), and >6 weeks (40%) had pooled success rates of 95% (95% CI: 87-100), 46% (95% CI: 0-100), and 20% (95% CI: 1-49), respectively. Patients who underwent surgical management <6 weeks (15.9%) and >6 weeks (22%) of diagnosis had pooled success rates of 100% (95% CI: 99-100) and 100% (95% CI: 99-100), respectively.

CONCLUSIONS

Stent placement as early as <6 weeks (preferably < 2 weeks) had better outcomes as compared to >6 weeks. Proceeding to surgery regardless of timing in cases of stent failure seems to be a feasible option.