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Lower Urinary Tract Fistulas

Women’s Hospital, School of Medicine, Zhejiang University. Lower Urinary Tract Fistulas. Jianhong Z hou. HISTORIC PERSPECTIVES. Earliest evidence of a vesicovaginal fistula was reported in the mummified remains by Derry (1935) Noted a large vesicovaginal fistula

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Lower Urinary Tract Fistulas

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  1. Women’s Hospital, School of Medicine, Zhejiang University Lower Urinary Tract Fistulas JianhongZhou

  2. HISTORIC PERSPECTIVES • Earliest evidence of a vesicovaginal fistula was reported in the mummified remains by Derry (1935) • Noted a large vesicovaginal fistula • Concluded that the presence of a severely contracted obstructed labor

  3. HISTORIC PERSPECTIVES • Zacharin (1988) states that de Mercado first used the term fistula instead of the usual term rupture. • The discovery of antibiotics and the development of general and regional anesthesia contributed significantly to the surgical treatment of vesicovaginal fistulas in thetwentieth century.

  4. EPIDEMIOLOGY AND ETIOLOGY • Obstetric Fistulas • Obstructed labor • follow cesarean delivery of peripartum hysterectomy ,hemorrhage, and surgical inexperience • Gynecologic Fistulas • total abdominal hysterectomy—80% • urologists and colorectal, vascular, and general surgeons—20% • the accepted incidence of fistula formation after pelvic surgery is 0.1 to 2%

  5. EPIDEMIOLOGY AND ETIOLOGY • Other Causes • Radiation therapy, malignancy, trauma, foreign bodies, infections, pelvic inflammation, and inflammatory bowel disease

  6. EPIDEMIOLOGY AND ETIOLOGY

  7. PRESENTATION ANDINVESTIGATION • Gross hematuria or abnormal intraperitoneal fluid accumulation noted during or after surgery • (Vesicovaginal fistula classically presents with unexplained continuous urinary leakage from the vagina after a recent operation) • urinary incontinence or persistent vaginal discharge presenting 7 to 21 daysafter surgery • unexplained fever; hematuria; recurrent cystitis or pyelonephritis; vaginal, suprapubic, of flank pain; and abnormal urinary stream

  8. PRESENTATION ANDINVESTIGATION • Complete physical examination • speculum examination of the vagina • Urine should be examined microscopically and cultured • Further office evaluation • cystourethroscopy • intravenous urogram permit the physician to localize the fistula • Office testing-- distinguish between fistulas involving the bladder or ureters • Instillation of methylene blue or sterile milk into the bladder stains vaginal swabs

  9. CONSERVATIVE MANAGEMENT • Various conservative or minimally invasive therapies are available for vesicovaginal and ureterovaginal fistulas • Ureterovaginal fistula is confirmed, recommended initial management is ureteral stenting

  10. Ureteral Stenting

  11. TIMING OF SURGICAL REPAIR • early repair of vesicovaginal fistulas requires diagnosis of the fistula within24-48hours of the injury. • Once infection and indurations have occurred, a3-to 6-monthwaiting period

  12. PRESURGICAL MANAGEMENT patients waiting surgical repair need considerable psychological support • use of tampons, perineal pads • Perineal care • vaginal or oral estrogen • In malnourished patients • not be performed during menstruation

  13. SURGICAL REPAIR • Vaginal Repair of Vesicovaginal Fistula

  14. SURGICAL REPAIR

  15. SURGICAL REPAIR

  16. Women’s Hospital, School of Medicine, Zhejiang University Thank You !

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