Obstetrical vaginal fistulae surgical approach · Post. op. follow-up ... Follow-Up Evaluation . of...

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Obstetrical Obstetrical vaginal vaginal fistulae fistulae : : surgical surgical approach approach C C - - H Rochat, MD H Rochat, MD Geneva Geneva

Transcript of Obstetrical vaginal fistulae surgical approach · Post. op. follow-up ... Follow-Up Evaluation . of...

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ObstetricalObstetrical vaginal vaginal fistulaefistulae::surgicalsurgical approachapproach

CC--H Rochat, MDH Rochat, MDGenevaGeneva

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PrevalencePrevalence

estimatedestimated : 2 : 2 miomiowomenwomen worldwideworldwideAfricaAfrica, , AsiaAsia, , SouthSouthAmericaAmerica–– SubSub--saharansaharan AfricaAfrica: :

2/1000 2/1000 deliveriesdeliveries

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ProblemProblem

AbandonnedAbandonned fromfromtheirtheir familiesfamiliesCoCo--morbiditymorbidity–– InfectionsInfections–– BladderBladder stonesstones–– InfertilityInfertility

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AetiologyAetiology

ObstructedObstructed labour because labour because ofof::––EarlyEarly childbirthchildbirth––LackLack ofof accessabilityaccessability ofof

skilledskilled attendentsattendentsmedicalmedical facilitiesfacilities

––LackLack ofof educationeducation

–– POVERTYPOVERTY

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DefinitionDefinition 11

Tissue destruction Tissue destruction secondarysecondary to to thethe prolongedprolonged pressure pressure ofof thetheheadhead duringduring obstructedobstructed labour labour

((ischaemicischaemic laesionlaesion))

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DefinitionDefinition 22

Tissue Tissue lacerationlaceration duringduringinstrumental instrumental deliverydelivery, , CaesarianCaesarian

section or section or CaesarianCaesarianhysterectomyhysterectomy

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ConsequencesConsequences

Communication Communication betweenbetween thethebladderbladder//urethraurethrawithwith thethe vaginavaginaCommunication Communication betweenbetween rectum rectum andand vaginavagina

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Simple Simple fistulafistula

NonNon--fibroticfibrotic tissuetissueEasyEasy to to accessaccess

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ComplexComplex fistulafistula

FibroticFibrotic tissuetissueLossLoss ofof tissuetissueUrethralUrethral involvmentinvolvment(transsection/destruction)(transsection/destruction)RetractedRetracted bladderbladderAberrant tractAberrant tractPreviousPrevious failedfailed surgerysurgery

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TanguietaTanguieta case case seriesseries

HospitalHospital northernnorthern BeninBenin9 9 urologicalurological missions missions sincesince 19941994SinceSince 1996 1996 specificspecific visitsvisits for for surgicalsurgical fistulafistula repairrepair

obstetricalobstetrical fistulaefistulaeN = 101N = 101

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Case Case seriesseries 1996 1996 –– 20022002n=101n=101

20 (19.8)20 (19.8)LossLoss to to followfollow--upup n (%)n (%)

30 (29.7)30 (29.7)PreviousPrevious attemptattempt for for fistulafistula repairrepair n (%)n (%)

3.0 (0.13.0 (0.1--15)15)DurationDuration ofof urinaryurinary incontinence incontinence -- yearsyears((medianmedian, range), range)

2.9 (12.9 (1--11)11)ParityParity n (n (medianmedian, range), range)[33 [33 firstfirst deliverydelivery]]

27.9 (1527.9 (15--63)63)Age y (Age y (medianmedian, range), range)

BaselineBaseline datadata

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Case Case seriesseries 1996 1996 -- 20022002

Complications Complications atat thethe timetime ofof deliverydelivery–– perinatalperinatal mortalitymortality: 98%: 98%–– RupturedRuptured uterusuterus: 10%: 10%

SectioSectio rate: 40%rate: 40%

Maternal mortalityMaternal mortality??

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Case Case seriesseries 1996 1996 -- 2002 2002 LocalisationLocalisation

7% 20%

24%

40%

5%4% urethral

trigonal

supratrigonal

combined

recto-vaginal

no data

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Case Case seriesseries 1996 1996 -- 2002 2002 LocalisationLocalisation

39 (38.6)39 (38.6)SupratrigonalSupratrigonal n (%)n (%)

60 (59)60 (59)Trigonal n (%)Trigonal n (%)

35 (34.7)35 (34.7)UrethralUrethral n (%)n (%)

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Localisation Localisation ofof combinedcombined FistulaeFistulae

4 (10)4 (10)CompleteComplete InvolvementInvolvement n (%)n (%)

12 (30)12 (30)Trigonal Trigonal + + SupratrigonalSupratrigonal n (%)n (%)

24 (60)24 (60)UrethralUrethral + Trigonal n (%)+ Trigonal n (%)

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Case Case seriesseries 1996 1996 –– 20022002SurgicalSurgical approachapproach

76%

21%

3%

vaginalabdominalcombined

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Case Case seriesseries 1996 1996 –– 20022002SurgicalSurgical techniquetechnique

12 (11.9)12 (11.9)CutaneousCutaneous graftgraft n (%)n (%)

32 (31.7)32 (31.7)MartiusMartius graftgraft n (%)n (%)

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Case Case seriesseries 1996 1996 –– 20022002OutcomesOutcomes

13 (16)Stress incontinence

Complications n (%)

4 (67)60 (74)Success rate n (%) *

RVFn = 6

VVFn = 81

* Urinary diversion (uretero – sigmoidostomie) in 4 cases of 101 patients

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SurgicalSurgical tipstips

ExtendedExtended Trendelenburg positionTrendelenburg positionScott Scott retractorretractorHeadlightHeadlightSharp Sharp scissorsscissorsSuture Suture materialmaterial

PostPost opop followfollow--upupCave: Cave: obstructedobstructed cathetercatheter !!

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Martius Flap

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FollowFollow--UpUp

Evaluation Evaluation ofof possible stress possible stress incontinenceincontinenceUrinaryUrinary infectioninfectionCouncellingCouncelling for future for future pregnancypregnancy((ceasarianceasarian sectiosectio))

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PreventionPreventionAccess to Access to prenatalprenatal care care andandeducationeducationMedicalMedical infrastructureinfrastructure

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ConclusionsConclusions

MajorityMajority ofof fistulaefistulae cancan bebe treatedtreated by by vaginal vaginal approachapproachIn 35% In 35% ofof cases cases thethe urethraurethra isisinvolvedinvolvedEpisiotomyEpisiotomy notnot mandatorymandatoryMartiusMartius flapflap preferablepreferable for for urtehralurtehralsuspension suspension andand tissue interpositiontissue interpositionCarefullCarefull followfollow--upup mandatorymandatory

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ReferencesReferencesVesicoVesico--vaginal fistula. What is an obstetric fistula?vaginal fistula. What is an obstetric fistula?Safe Mother. 1999;(27):4, 8. Safe Mother. 1999;(27):4, 8. TheThe challenge challenge ofof vesicovesico--vaginalvaginal fistulafistula. . PopuliPopuli 2001; 28(1): 122001; 28(1): 12--1515OjanugaOjanuga OD, OD, EkwempuEkwempu CC. An investigation CC. An investigation ofof sociomedicalsociomedical riskrisk facorsfacors associatedassociatedwithwith vaginal vaginal fistulafistula in in NorthernNorthern Nigeria. Nigeria. WomenWomen HealthHealth 1999; 28:1031999; 28:103--116116JH JH NaudeNaude. Reconstructive . Reconstructive urologyurology in in thethe tropical tropical andand developingdeveloping worldworld: a : a personalpersonalperspective. BJU International 2002; 89 (perspective. BJU International 2002; 89 (supplsuppl 1): 311): 31--3636

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