| Abstract|| |
A retrospective review of 120 patients diagnosed to have lower genito-urinary fistulae, over a period of 42 years, was performed. The patients were seen at the University Maternity Hospital or the Zahrawi Maternity Hospital, Damascus, Syria. The majority of the patients, particularly in the early part of this period, had obstetrical causes (90.5%), mainly due to obstructed labour, difficult and traumatic forceps deliveries, ruptured uterus and bladder and/or lower segment caesarean section (LSCS). Less frequently encountered gynecological causes, in the same early period, were due to total abdominal hysterectomy (TAH), Wertheim radical hysterectomy (WRH), anterior vaginal repair, sling operation and other causes (9.5%). However, in the later part of this study, the main causes became gynecological (57%) with obstetric causes contributing in only 43% of the cases. Urinary fistulae still represent a major problem in Syria and reflect a sub-optimal level of training of undergraduate and postgraduate students and poor socio-economic conditions. The overall cure rate was 77%. It is hoped that with better hospital care, improvement in the quality of medical practice and the socio-economic status in the country, the incidence of genito-urinary fistulae will be reduced.
Keywords: Vesico-vaginal fistula, Vesico-urethro-vaginal fistula, Vesico-uretero-vaginal fistula, Iatrogenic fistula, Syria
|How to cite this article:|
Pharaon S. Lower Genito-urinary Fistulae. Saudi J Kidney Dis Transpl 2007;18:643-7
| Introduction|| |
A urinary fistula is a traumatic opening between the urinary tract and the outside.  The problems related to urinary vaginal fistulae date back to antiquity. J. Marion Sims is generally recognized as having made many of the major contributions to this field.  Fistulae are commonest in developing countries because of the higher incidence of obstetric complications. In contrast, iatrogenic fistulae, consequent on extensive gynecological surgery or radio-therapy, are mainly found in the developed countries,  where obstetric fistulae have almost disappeared.  Fistulae are still far from being rare in Syria. This is a personal survey of cases dealt with during the last four decades. The study indicates the etiology of the urinary fistulae, shows the change in the causative factors through the study period and the results of their repair. At the end, some suggestions are mentioned about surgical repair and about how to minimize their occurrence.
| Patients, Methods and Results|| |
A total of 125 cases with various types of genito-urinary fistulae (vesico-vaginal, vesicourethro-vesical, uretero-vaginal and vesicouretero-vaginal fistulae) were encountered during the study period. Five cases were referred to a urologist colleague for repair. Of the remaining 120 cases, six needed to be repaired twice; thus, 126 operations were performed during this period (1964-2005).
Route of repair
The vaginal route was used in 107 operations (85%); the abdominal or the vaginal-and-then abdominal routes were used in 19 operations (15%). Total cure (both anatomical and functional) was achieved in 97 operations (77%) and failure was noted in 29 cases (23%). The results of repair according to the route used were as follows: the vaginal route, cure in 86 operations (80%) and failure in 21 (20%); the abdominal and vaginal-then-abdominal routes, cure in 11 operations (58%) and failure in eight (42%) [Table - 1].
Etiology of the genito-urinary fistulae
The causes were obstetrical in 91 cases (76%) and gynecological in 29 cases (24%) [Table - 2].
The study period was divided into three phases: phase 1, 1964 to 1979; phase 2, 1980 to 1997 and phase 3, 1998 to 2005. Analysis of the causes during the three consecutive periods, showed a progressive change. During the first phase, (1964-79) 90.5% of the cases had obstetric causes with only 9.5% having gynecologic causes. In the second phase, (1980-1997) 73% had obstetric causes while 27% had gynecologic causes. In the third phase, (19982005), 43% had obstetric causes while 57% had gynecologic causes. Thus, there was a steady decrease in the obstetrical causes and a parallel increase in the gynecologic causes.
| Discussion|| |
Our study shows that the majority of the cases of genito-urinary fistulae are of obstetrical origin (76%). Most of them were due to difficult, protracted and frequently neglected vaginal deliveries that took place at home by certified or traditional midwives. Unfortunately, the certified midwives cause more problems than the traditional ones, because of indiscriminate use of oxytocics, either intra-muscularly or by i.v. drip, in home deliveries. Many of these unfortunate patients arrived to hospital in shock, either delivered or not yet. Difficult forceps deliveries (frequently with forceful rotation and traction) were popular among the older generation of accoucheurs, but are now much less popular among younger obstetricians. These days, more and more caesarean sections are carried out and fistulae are encountered either after the first CS or after a repeat one. Most of them occur when the bladder is pushed down vigorously with the finger and this maneuver frequently results in trauma to the bladder with hematoma formation that ends with sloughing and a late vesico-vaginal fistula formation. A few cases of vesico-vaginal and vesico-uretero-vaginal fistulae were also noted after LSCS that resulted from unwary suturing of the lower segment and inadvertent inclusion of the bladder wall and/or the distal end of the ureter. Destructive operations on the dead fetus used to be practiced, in the past, relatively safely by the experienced older-generation obstetricians. Over time, the younger generation, who are less experienced in carrying out such procedures, caused formidable tears in the genitourinary tract. Hopefully, this form of traumatic practice will fade away soon.
Primary and repeat LSCSs are now on the increase in Syria. The rates of primary LSCS vary from 10% to 35% in general and private hospitals respectively and the rates of repeat LSCS vary from 50% to 100%. Cases of postLSCS vesico-vaginal and vesico-utero-vaginal fistulae are increasingly seen and are usually due to blunt and heavy-handed pushing down of an adherent bladder. Vesico-vaginal fistula, after a simple total abdominal hysterectomy and/or anterior vaginal repair, frequently reflects lack of experience of the young surgeons, most of whom did not have sufficient and methodic tutoring during their obstetric and gynecological training. Some of these young doctors are home-made but the largest bulk of them are the massive product of the less brilliant graduates who had been sent to the exSoviet Union hospitals where they had inadequate and leisurely training and were too hurriedly and prematurely sent back home to be bestowed with senior posts. The mere fact that genito-urinary fistulae are not a rarity in a certain area of the world betrays major defects in the health-care system. These should be dealt with in a frank, objective and unbiased way. Unless such measures are taken earnestly, no reduction in the rate of these regrettable iatrogenic disasters would be noted. The overall success rate in repairing these fistulae in this series compares well with those of other third world countries. Elkins, in the USA, reported a 95% closure rate. Arrowsmith,  in the USA too, reported a closure rate of 94.9%. Chassar Moir (1956) reported a cure rate of 98.0%.  Husain et al,  reported a success rate of 63% in Eritrea. Our results lay in between those from the developed countries and the third world. These variations apparently reflect differences in the nature and extent of the fistulae; obstetrical ones are usually due to massive blunt trauma and result in more scarring and necrosis of tissues. It is hoped that special centers would be founded in general hospitals, where devoted and motivated doctors take care of such patients. We think that the vaginal approach is the more appropriate one; it is easier and needs shorter postoperative convalescence and care and carries the advantage that no abdominal scar is left behind.
Comments on repair techniques
Fistulae should not be repaired before all sloughing, edema and inflammatory reactions have subsided (3-6 months for obstetric cases and lesser for gynecologic ones). With the lapse of time, more and more cases were increasingly dealt with per vaginam, with successful results. Mid-line episiotomy incisions or Schuchardt incisions were resorted to only when the introitus was narrow or after CS and these gave better exposure and easier maneuvering. Only sharp dissection of the vaginal and vesical layers, with scalpel and/or scissors, was used. The author believes that, sharp dissection, in general, is the safer way of separating tissues and this especially applies to fistulae, as blunt dissection would only result in tear and trauma to the already-traumatized edges. NorthSouth adequate dissection of the bladder edges from the vagina is recommended, as the bladder edges should be sutured tension free. Continuous (running) sutures are easier, speedier and more watertight than interrupted ones. Usually the bladder is stitched in two layers. The first row should not include the vesical mucosa. Chromic catgut was used in the early years but recently Vicryl 00 is used and is more reliable. After closure, it is appropriate to inject diluted Methylene Blue solution or any other dye into the bladder to ascertain that the suture is watertight. Before closure of the vaginal wall, it is much safer to put 3 or 4 U-shaped mattress sutures (Vicryl No.1) in order to obliterate the widely dissected space between bladder and vagina. Any redundant and fibrotic vaginal tissue is trimmed. Indwelling Foley's catheter is left for 12-14 days and the patient is usually kept in hospital for a few days after removal of the catheter. Most of the cases had an IVP before and after operation, especially when the vesical tear was transverse and/or reached near one or two of the ureteric orifices on the trigone. On occasional cases, when the ureteric orifice was close to the edge of the fistula, the ureter was stented upwards and the stent's lower end was left in the bladder and removed later by cystoscopy. Urine culture before surgery and appropriate antibiotic therapy before and after operation are important. For anyone planning to work on fistulae, it is highly recommended to study and refer to Chassar Moir's detailed and most helpful lucid description of the surgical repair, postoperative draining and care in his wonderful monograph. 
The overall success rate in our series was 77%. With more experience and improvement of hospital care and conditions, this rate could be raised. Unfortunately, some of the extensive and devastating fistulae prove intractable even for the best surgeons. It is, therefore, hoped that an earnest endeavor is made so that genito-urinary fistulae would not happen, which is a better goal to look for. This cannot be reached unless the whole health-care system is drastically revised, which requires a true treatment of the local social, economic and educational status of the whole population.
| Conclusion|| |
Genitourinary fistulae are a sensitive parameter of the social, economic and medical conditions in a certain population. In underdeveloped countries, they are unfortunately frequent and of the worst degrees and nature. In developed countries, they form a rarity and they are usually smaller, easier to handle and probably have some justification for their occurrence in exceptionally difficult cases. Some arguments may arise as to who should take care of the genito-urinary fistulae; the urologist or the gynecologist? We believe that the obstetrician-gynecologists are much more at home when dealing with pelvic organs, be it genital or urinary and they generally prefer the vaginal approach, which is easier, safer and carries less discomfort. Urologists nearly always prefer and select the abdominal route. Close cooperation between the two of them, especially in high genito-urinary fistulae gives better results.
To conclude, it is hoped that a local multidisciplinary committee would be organized in every country of the third world that acts to prevent or at least to minimize the occurrence of any genito-urinary fistulae in the female, to cure them when they occur and to fulfill the scope that an obstetrician-gynecologist would not see more than one or two cases in a lifetime.
To the memory of Prof. Dr. M. M. Barmada (1916-1999), Professor of Obstetrics and Gynecology at Damascus University Maternity Hospital.
| References|| |
|1.||Novak's gynecology, 12 th ed. Williams and Wilkins: 1988. p. 638,. |
|2.||Kittel WC, cited in Buchsbaum and Schmidt's Gynecologic and Obstetric Urology. W. B. Saunders Co: 1978. p. 267. |
|3.||Chassar Moir J. The vesico-vaginal Fistula, 2nd ed, Bailliere Tindall and Cassell: London; 1967. p. 7. |
|4.||Lawson J, cited in Clinics in Obstetrics and Gynaecology. W.B. Saunders Ltd: April 1978. p. 210., |
|5.||Elkins TE. Surgery for the obstetric vesicovaginal fistula: A review of 100 operations in 82 patients. Am J Obstet Gynecol 1994;170:1108-20. [PUBMED] |
|6.||Arrowsmith SD. Genitourinary reconstruction in obstetric fistulas. J Urol 1994;152:403-6. [PUBMED] |
|7.||Chassar Moir J. Am J Obstet Gynecol 1956;71:471, cited in Buschsbaum and Schmidt's Gynecologic and Obstetric Urology, p. 273 |
|8.||Hussain A, Johnson K, Glowacki CA, et al. Surgical management of complex obstetric fistula in Eritrea. J Womens Health(Larchmt) 2005;14:839-44. |
Diab Building, Parliament Street, Damascus
[Table - 1], [Table - 2]