Thomas J.I.P. Raassen, Carrie Ngongo, Marietta Mahendeka · Thomas J.I.P. Raassen, Carrie Ngongo,...
Transcript of Thomas J.I.P. Raassen, Carrie Ngongo, Marietta Mahendeka · Thomas J.I.P. Raassen, Carrie Ngongo,...
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Iatrogenic Urogenital Fistulas
Thomas J.I.P. Raassen, Carrie Ngongo, Marietta Mahendeka
GMNHC 2015, Mexico City October 18 - 21
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MESSAGE
l Iatrogenic fistulas are a separate group l All cadres of service providers are
involved l Training needs to be improved l Alternatives for CS need to be used
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BACKGROUND
l From June 1994 – September 2012, 5.959
VVF/RVF-repairs l In over 65 hospitals in Eastern Africa and Asia l 805 Iatrogenic Fistulas, which is 13,2%
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PATHOPHYSIOLOGY
An Iatrogenic Genitourinary Fistula is a fistula between bladder/ureter and uterus/cervix/vagina, resulting from surgery performed by a medical person
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IATROGENIC FISTULAS
3 Types l Uretero-(cervico)-vaginal fistulas l Vault fistulas
l Vesico-(utero)-cervico-vaginal fistulas
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OPERATIONS
l Caesarean Section (CS)
l CS/Hysterectomy for ruptured uterus
l Hysterectomy for gynecological reasons
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RISK FACTORS
l Prior uterine operations, especially CS l Endometriosis l Cervical myoma l Prior pelvic radiation l Inexperienced operators l Difficult circumstances in our setting
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URETERO-(CERVICO)-VAGINAL FISTULAS
PATHOPHYSIOLOGY
This is a lesion to the distal ureter during CS, CS/hysterectomy for ruptured uterus, or hysterectomy for gynecological reasons
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URETERO-CERVICO- VAGINAL FISTULA
Dr. Kees Waaldijk
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URETERO-(CERVICO)-VAGINAL FISTULAS
l Post CS alone 138 (50,6%) l Post Ruptured Uterus, Repaired 16 (5,8%) l Post Ruptured Uterus, Hysterectomy 57 (20,9%) (Obst) 211 l Post Hysterectomy (Gyn) 62 (22,7%) 62 Total 273
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PRIOR LAPAROTOMY
l C-section x 1 20 l C-section x 2 9 l C-section x 3 2
Total 31 (11,6%)
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OPERATOR l Specialist 26 l Registrar 9 l Medical Officer 145 (53,1%) l AMO/CO 93 (34,1%)
Total 273
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VAULT FISTULAS
PATHOPHYSIOLOGY The vault fistula is a connection between
the bladder and the apex of the vagina (vault) and it occurs after total abdominal hysterectomy. It borders on the anterior edge of the vaginal scar
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VAULT FISTULA
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VAULT FISTULAS 2 GROUPS l Post Total Abdominal Hysterectomy 95
for gynecological indication l Post CS/Hysterectomy for ruptured 86 uterus, obstetric indication
Total 181
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PRIOR LAPAROTOMY
l CS once 20 l CS twice 4 l CS thrice 3 l Others 4 Total 31 (17,1%)
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OPERATOR l Specialist 48 (26,4%) l Registrar 8 l Medical Officer 95 (52,5%) l AMO/CO 30
Total 181
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VESICO-UTERO/CERVICO- VAGINAL FISTULAS(VCVF)
PATHOPHYSIOLOGY This fistula is an accidental bladder injury (cut or suture) during a Caesarean Section, which is less than 3 cm
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VCVF
Dr. Kees Waaldijk
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VCVF 351
l Obstetric Origin 349
l Gynecological 2 Total 351
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VCVF 349
Obstetric l Live birth 210(60%) l Stillbirth 139(40%)
Total 349
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PRIOR LAPAROTOMY
Alive Stillborn Total l CS once 76 32 108 l CS twice 23 7 30 l CS thrice 3 3
Total 102 39 141(40,2%) l (48,6%) (28,1%)
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OPERATOR
l Specialist 4 l Registrar 5 l Medical Officer 234 (66,7%) l AMO/CO 108 (30,8%)
Total 351
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IATROGENIC FISTULAS
3 TYPES l Uretero-CVF 273 l Vault Fistulas 181 l Vesico-CVF 351
Total 805
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CONCLUSIONS RECOMMENDATIONS
l In my series 13,2% of the women have iatrogenic fistulas
l Iatrogenic fistulas are a separate group l All cadres of service providers are involved l Women with previous CS are at an increased
risk of iatrogenic fistula
l Most operations are performed by Med. Off.
and AMO’s/CO’s
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CONCLUSIONS RECOMMENDATIONS
l Training needs to be better. MO’s/AMO’s must perform CS under supervision, before they are posted to hospitals
l Prevention: Do not use blunt, but sharp dissection between bladder and uterus (Tancer, Hilton)
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CONCLUSIONS RECOMMENDATIONS
l Alternatives for CS need to be used, like
Vac. Extr., Destructive Delivery for dead babies and Symphysiotomy
l Early Detection and Catheter Treatment l Access: Improve the accessibility for
pregnant women to free maternity services
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Thank you