Vesical fistulae--an experience from a developing country.V Raut, M Bhattacharya
Dept of Obstetrics and Gynaecology, KEM Hospital and Seth GS Medical College, Parel, Bombay, Maharashtra.
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 0008295139
Source of Support: None, Conflict of Interest: None
This study analyses patients with vesical fistulae presenting at a teaching, referral hospital over the last ten years. There were 62 cases of vesical fistulae of which 60 were obstetric in origin (44 home and 16 hospital deliveries) and 2 were following gynaecological surgery. Of the hospital deliveries which culminated in fistula formation, 8 were vaginal and 7 forceps deliveries. In one patient, lower segment caesarean section was carried out. After a thorough urological work-up, patients were subjected to standard technique of layered closure (61 by vaginal approach and one by abdominal). Repair was successful in 53 (87.09%) patients. Of the 9 failures, 4 were repeat repairs.
Keywords: Adolescent, Adult, Female, Human, Rectal Fistula, etiology,surgery,Urethral Diseases, etiology,surgery,Urinary Fistula, etiology,surgery,Vaginal Fistula, etiology,surgery,Vesicovaginal Fistula, etiology,surgery,
The urinary fistulae involving female genital tract result as infrequent complications of child-birth, pelvic disease or the treatment of pelvic disease. In developing countries like India, where hospitals and medical care are still not readily available, obstetric complications remain the leading cause of vesicovaginal fistulae.
The current study analyses patients with vesical fistulae presenting at a teaching and referral hospital in Bombay over the last ten years.
Sixty-two cases of urinary tract fistulae were referred to our department between 1981 and 1990. The age, parity, presenting symptoms of the patient and aetiology of fistulae were noted. A record was also kept of any prior surgical intervention for correction of the same.
A complete urological work-up including urinalysis, examination under anaesthesia, cystoscopy and intravenous pyelogram was performed on each patient. All but one patient was subjected to a vaginal repair using a standard technique of layered closure. Abdominal approach was preferred in only one patient with vesico-uterine fistula. In cases where the ureteric opening was in close proximity to the fistula, pre-operative ureteric catheterization was carried out. Post- operatively bladder was drained for ten days under the cover of antibiotics.
The success rate of the repair and morbidity was evaluated.
All the patients (age range: 18-37 yrs, para: 1-4) presented with incontinence of urine.
Of the sixty-two fistulae, 60 (96.77%) were obstetric in origin; 44 (73.33%) of which resulted from home deliveries and 16 from hospital deliveries [8 (13.3%) were vaginal deliveries; 7 (11.66%) forceps deliveries and 1 (1.66%) was lower segment caeserean section]. Of these 60 obstetric cases, 57 (95.0%) had history of fistulae with fresh still birth, both as sequlae of prolonged labour. The remaining two (3.33%) were following gynaecological surgery viz. abdominal hysterectomy for endometriosis and Wertheim's hysterectomy.
The types of urinary fistulae were vesico-vaginal (60), vesico-uterine (1) and urethro-vaginal (1) Five cases (8.33%) had associated recto-vaginal fistula indicating the severity of trauma.
Fifty-seven of 62 patients with fistulae had undergone primary repair performed at our hospital. Five patients had history of failed repair elsewhere; of these 3 had earlier single repair and 2 had undergone the repair twice.
Repair was successful in 53 (87.09%) cases. Of the remaining nine, 8 (12.9%) were failures, 4 of which were repeat repairs. One patient with vesicouterine fistula expired because of uncontrolled haemorrhage leading to DIC. In this patient, abdominal hysterectomy was performed followed by fistula repair. A generalized ooze was noticed from the dissected area at the base of bladder, which continued inspite of bilateral iliac ligation.
The close embryologic development and anatomic proximity of the urinary and genital organs, predisposes the urinary tract to injury during traumatic deliveries and surgery in the female pelvis.
A study of etiological factors in the 177 vesico-and urethro-vaginal fistulae that were repaired at the University of Iowa Hospitals between 1926 and 1976 showed that ¾th fistulae were related to some type of gynaecologic surgery. Most of the fistulae caused by obstetric trauma occurred prior to 1940. In developing countries like India where proper intranatal care is still not readily available, particularly in the smaller villages, obstetric complications remain the leading cause of vesico-vaginal fistula. These result either from direct trauma or from tissue necrosis of the anterior vaginal wall and bladder secondary to prolonged labour.
In our study, the incidence of vesical fistula because of difficult vaginal delivery was 86.66% (44 home deliveries and 8 hospital deliveries). The incidence of vesical fistula because of obstructed labour was 83.8% in the study conducted by Tahzib from Nigeria, another developing country.
The success rate in our study was 87.09%. The success rates reported earlier of similar cases are 90.9% and 94.2%
Our study highlights the importance of hospital delivery and need of trained and competent personnel for intra-partum care at home to minimize the chances of complications like fistulae.