lower urinary tract fistulas jianhong zhou. historic perspectives earliest evidence of a...
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Lower Urinary Tract Fistulas
Jianhong zhou
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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
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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.
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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%
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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
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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
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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
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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
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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
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SURGICAL REPAIR
• Vaginal Repair of Vesicovaginal Fistula