lower urinary tract fistulas jianhong zhou. historic perspectives earliest evidence of a...

Lower Urinary Tract Fistulas

Jianhong zhou

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

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 the twentieth century.

EPIDEMIOLOGY AND ETIOLOGY

• Obstetric Fistulas– Obstructed labor – follow cesarean delivery of peripartum hystere

ctomy ,hemorrhage, and surgical inexperience

• Gynecologic Fistulas– total abdominal hysterectomy—80%– urologists and colorectal, vascular, and gener

al surgeons—20%

PRESENTATION AND INVESTIGATION

• Gross hematuria or abnormal intraperitoneal fluid accumulation noted during or after surgery

• urinary incontinence or persistent vaginal discharge presenting 7 to 21 days after surgery

• unexplained fever; hematuria; recurrent cystitis or pyelonephritis; vaginal, suprapubic, of flank pain; and abnormal urinary stream

PRESENTATION AND INVESTIGATION

• Complete physical examination – speculum examination of the vagina – Urine should be examined microscopically and culture

d • Further office evaluation

– cystourethroscopy– intravenous urogram permit the physician to localize t

he fistula• Office testing-- distinguish between fistulas invol

ving the bladder or ureters– Instillation of methylene blue or sterile milk into the bla

dder stains vaginal swabs

CONSERVATIVE MANAGEMENT

• Various conservative or minimally invasive therapies are available for vesicovaginal and ureterovaginal fistulas

• Various conservative or minimally invasive therapies are available for vesicovaginal and ureterovaginal fistulas.

• Ureterovaginal fistula is confirmed, recommended initial management is ureteral stenting

TIMING OF SURGICAL REPAIR

• early repair of vesicovaginal fistulas requires diagnosis of the fistula within 72 hours of the injury.

• Once infection and induration have occurred, a 3-to 6-month waiting period

PRESURGICAL MANAGEMENT

patients waiting surgical repair need considerable psychological support

• the use of tampons, perineal pads• Perineal care • vaginal or oral estrogen • In malnourished patients • not be performed during menstruation

SURGICAL REPAIR

• Vaginal Repair of Vesicovaginal Fistula