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Clinical evaluation of genito-urinary fistula Rashida T Companywala, Mina Bhattacharya, VN PurandareDepartment of Obstetrics and Gynaecology, K.E.M. Hospital and Seth G.S. Medical College, Parel, Bombay-400 012., India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 722603
Clinical evaluation of 50 cases of genito-urinary fistula from January 1969 to March 1917 is presented. In 84% of the cases the aetiological factor was obstetric injury while in 12% it followed hysterectomy. Sixty per cent of the patients had come within one year of the development of symptoms. Eighty per cent of the cases were operated upon by vaginal route while 14% were operated upon by abdominal route and 6% by pereineo-abdominal route. The operative management is discussed. The success rate was 72%. The literature on this subject is reviewed.
Although genito-urinary fistulae are becoming less frequent as a result of improved obstetric practice, the surgery of such fistulae holds a fascination of its own, for Marion Sim [7] has quoted: "No branch of surgery calls for greater resource, never is the patient so sorely tried, and never is the success more dependant on the exercise of constant care both during operation and even more perhaps during the anxious days of convalescence. But never is the reward greater."
Fifty cases of genito-urinary fistulae operated upon during January, 1969 to March 1977 at the K.E.M. Hospital, Bombay, are reported in this paper. All these patients were between the ages of 20 and 50 years except for one who was 70 years old. Majority of the patients were in the reproductive age group, only 8 being menopausal. All of them had borne one or more children. Thirty cases had come with symptoms of less than one year's duration, of which 15 were operated upon within 3 months of the development of the fistula. Four patients had come as late as 10-20 years after the development of the fistula. [Table 1] details the aetiological factors in our patients. The largest group was that following obstetrical injuries, the commonest cause being prolonged labour with consequent ischaemic necrosis. The entire group following obstetrical injuries had been delivered elsewhere. One patient had small, multiple vesico-vagina; fistulae associated with bladder stones. [Table 2] gives the types of fistulae observed in the present series. In 14 cases, the repair (abdominal in 9 and vaginal in 5) had been attempted before they came to us. The surgical procedures used by us are listed in [Table 3]. The vaginal surgery was done with the patient in lithotomy position in 38 cases and in the knee-chest position in 2 cases. The repair was done by the "flap-splitting" technic. Intestinal catgut (3-0) was used for suturing in 39 cases and nylon sutures were used in one case. The latter were removed on the 21st day. In one patient with a large fistula at the bladder neck, fibres of levator ani were brought under the bladder neck as an additional support. Recto-vaginal fistula repair was done simultaneously in 2 cases. In the 3rd case, the colostomy was followed by rectovaginal fistula repair only. Vesico-vaginal repair was attempted after the healing of recto-vaginal fistula repair and closure of colostomy. Additional drainage was provided by suprapubic cystostomy in 8 cases. Five patients were operated upon by abdominal route while 3 required both abdominal and vaginal approach for a complete repair. Extra-peritoneal approach was used in 1 case while in the remaining 9 cases the operation was performed by transperitoneal, transvesical route. Two cases of uretero-vaginal fistulae were operated upon by abdominal route. Small bowel was injured accidently while opening the abdomen in 1 case because of multiple adhesions. In one patient who had vesical calculus, fistula re-occurred due to recurrence of vesical calculi;thus fistula was again repaired successfully by vaginal route. All these patients were on continuous bladder drainage for 2-3 weeks postoperatively. Prophylactic urinary antibiotics along with intravaginal antibiotic suppositories were given to all the cases. Flushing of catheter was done as and when necessary. Alternate acidification and alkalinisation was carried out in a few cases.
The overall success rate of genitourinary fistulae was 72% 36 cases-[Table 4]. All those who had fistulae following hysterectomy healed well thus giving a success rate of 100% in Gynaecological cases. Among the 42 Obstetric cases healing was observed in 29 cases only. The repair was also successful in 1 patient having fistulae due to vesical calculi. Among those who were previously operated upon, the success was only 57% as against those who were operated upon for the first time in whom the success rate was 78%. Cases of uretero and vaginal fistula were successfully repaired. Two of these cases in which recto-vaginal fistula was repaired simultaneously, healed well. Three patients developed stress incontinence, in the present series. There was no mortality in our series.
Operative success of vesico-vaginal fistula depends not only on the skill of the surgeon but depends on a number of other factors such as the aetiology, the size and situation of the fistula and the post-operative care provided to the patient. Obstetric trauma remains a major aetiological factor in the development of genito-urinary fistulae in the developing countries. A complication of gynaecological surgery accounted for 80% of fistulae in Moir's [4],[5] series, 92% in Masse [3] et at series and 80% in Falk's [2] series. In the Indian literature, cases following obstetric injury accounted for 95% in Devi's [1] series, 97%, in Rao [6] et at series and 96% in Singh's' series. In our series, 84 % were following obstetric trauma. In addition to the skill and experience of the surgeon, healing of the fistulae depends on the condition and the response of the tissue surrounding it. Repeated attempts at repair of the fistula reduce the prospects of a successful repair because with each unsuccessful attempt the amount of scar tissue increases. The overall success rate in our series is 72%, it being 100% in gynaecological cases but only 69% in obstetric cases. This shows that there is a wide area of pressure necrosis and resultant fibrosis in cases of fistulae following obstetric injury which impairs healing inspite of an adequate mobilisation and meticulous postoperative care. Rao, [6] in his series of 297, cases had success rate of 86% with the first attempt repair. In Singh [8] series of 270 cases the success rate was 88.2%. In Devi [1] series of 500 cases the success rate was 84%. In Moir's [4],[5] series of 431 cases, and Yennen and Babuna [9] series of 195 cases the success rate was 90% and 76% respectively. The number of attempts made previously for repair affects the result, the success rate being 57% in previously attempted repair cases as against 78% in first attempt repair cases.
We thank Dr. C. K. Deshpande, Dean, K.E.M. Hospital and Seth G.S. Medical College for allowing us to publish the hospital data.
[Table 1], [Table 2], [Table 3], [Table 4]
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