Dr. Preeti Yadav is a young gynaecologist with a keen interest in uro-gynaecology and at addressing socio-economic aspect of disease process along with surgical and medical management. She is a graduate and postgraduate from the prestigious Maulana Azad Medical College, New Delhi, and is also a trained laparoscopic surgeon. She has several publications in journals of national and international repute. Apart from routine clinical work,
Objective: To study aetiology and management of complicated genital fistulae and to evaluate the outcome of the treatment.
Methods: This observational study enrolled patients with complicated genital fistulae from September 2008 to August 2018 at Sant Parmanand Hospital, Delhi. Patients underwent a reparative surgery or ureteric stenting after a detailed preoperative workup. Patients were followed up for the assessment of outcomes.
Results: A total of 16 patients were recruited: Ten (62.5%) patients had fistulae secondary to gynaecological surgeries (seven laparoscopic and three abdominal hysterectomies) and six (37.5%) patients had obstetric fistulae. At a mean follow-up of 5.8 years among obstetric fistulae and 7.3 years among post-operative fistulae, 100% success rate was maintained with the first attempt of reparative surgery or ureteric stenting. There were no major complications. Two patients had recurrent urinary tract infections, and one patient had transient urinary incontinence for 4 weeks.
Conclusions: The study demonstrates that complicated genital fistulae occur more commonly secondary to gynaecological surgeries as compared to obstetric complications in a contemporary cohort from a metropolitan city. A 100% success rate of reparative surgery could be achieved with a transperitoneal approach. Good outcome in ureteric fistulae can be achieved with conservative approach, after proper case selection.
Keywords: Complicated genital fistula · Urogenital fistulae · Laparoscopic hysterectomy · Vaginal hysterectomy · Obstetric fistulae
Genital fistula is an abnormal communication between genital tract and urinary or intestinal tract. This is an incapacitating and crippling condition and may socially outcast a healthy woman.
Although the global burden of the disease is not exactly known, it is estimated at 3 million worldwide, with the addition of 30,000 to 130,000 new cases per year [1]. The prevalence of 1.5–1.7 per 1000 women has been estimated by national community-based survey in Ethiopia [2] and Bangladesh [3].
Genital fistulae can occur because of obstetric complications, gynaecological procedures and trauma. Even in expert hands, urinary tract injuries are known to occur during gynaecological procedures. The incidence as well as the aetiology of genital fistulae shows geographical variation. In developed part of world, two-third of the urogenital fistulae are iatrogenic following gynaecological surgeries for benign pathologies. The remaining are due to advanced malignancy, radiotherapy, congenital and obstetric complication [4]. In high-income countries, less than 20% are obstetric fistulae, with most of them following obstetric intervention (caesarean section, caesarean hysterectomy, instrumental delivery) and not because of obstructed labour. Up to 70% of all surgical fistulae are associated with hysterectomy [5]. In contrast to this, obstetric fistulae (1.1 per 1000 births) [6] due to unassisted and unsafe practices constitute the majority of unrepaired fistulae in developing countries. Fistulae occurring due to obstetric complications are more complex, with cultural, socio-economic, physical and geopolitical contributors.
Genital fistulae anatomically could be urogenital or genito-intestinal fistulae, the former being more common. Currently, no universally accepted classification of fistula is available. However, studies have identified factors that could help in predicting unsuccessful fistula closure [7, 8] based on which 12–25% of all fistulae are classified as complicated genital fistulae. These are characterized by size more than 3 cm, trigonal involvement, fistula secondary to malignancy or radiotherapy, loss of vaginal tissue leading to its shortening, involvement of urethra, ureter or bowel and when surgical approach is difficult.
The reparative surgeries for complicated genital fistulae do not always result in successful outcome. As suggested by the statistics, the huge burden of the condition and unmeasurable suffering caused by genital fistulae to otherwise healthy women, deserves utmost attention. The operative implications as well as conservative approach such as ureteric stenting deserve analysis for improving outcomes.
Observational study was carried out at Department of Gynaecology and Urology, Sant Parmanand Hospital, Delhi, India, from September 2008 to August 2018 after approval from the institutional ethics committee. During this period, 16 patients with complicated genital fistulae who were managed by a team of specialized doctors, comprising gynaecologists and urologists, were recruited. Previous case records of patients were studied, and patients were followed till the end of study.
Preoperative workup consisted of
detailed history, review of the delivery or operative notes, clinical
examination, Moir’s test to confirm the leak and site of leak and
routine laboratory investigations including hemogram, renal function
test and urine examination with culture/ sensitivity. Retrograde
pyelogram, barium meal follow through, barium enema, MRI (magnetic
resonance imaging) and CECT (contrast-enhanced computed tomography) were
carried out wherever required. If present, urinary tract infection was
treated before the procedure. Wherever required, examination under
anaesthesia was performed in the same setting just before the surgery.
All patients were planned for surgery or stenting after written informed
consent with proper counselling, bowel preparation and peri-operative
antibiotic cover. Regional anaesthesia was preferred. The approach was
decided keeping in mind the ease of performing the procedure.
1. To study the aetiology and management of complicated genital fistulae in a multi-super-speciality city hospital
2. To evaluate the surgical approach for reparative surgery and their outcome.
The smell of urine or faeces and inability to stay dry is humiliating, rendering a patient both physically and psychologically distressed. Every effort should be made to prevent genital fistulae. The majority of obstetric fistulae are preventable by a simple yet difficult-to-achieve solution, that is, health care for all [9]. Concurrently, immediate access to health care should be ensured for timely management of fistulae already occurred.
There exists a geographical variation in aetiology of genital fistulae. In contrast to developing countries, where obstetric fistulae remain more common, surgery and radiation are major contributors in the developed world. We encountered less of obstetric fistulae (37.5%) as our institute mainly caters to middle socio-economic strata of urban population.
Similar trends were shown by Venkatramani et al. in Indian population where 58.6% were gynaecological fistulae [10]. All obstetric fistulae in our study were referred from peripheral centres, with at least four being iatrogenic. No patient was less than 20 years old, and only two of the six obstetric fistulae resulted from difficult delivery, both developing massive fistulae. This is unlike the series reported by Goswami et al. [11] who reported 37.7% patients less than 20 years age and almost 50% fistulae following difficult delivery in an illiterate and low socio-economic population. Two post-abortion fistulae were encountered, implicating that all women in need of abortion must be referred to appropriate healthcare centre, as abortions by untrained personnel carry a high risk of complications.
Ten cases of post-surgical genital fistulae were treated in the study period, all following hysterectomy (seven abdominal and three laparoscopic) for benign uterine disorders. The literature shows that incidence of post-hysterectomy fistulae varies depending on the approach [10]. The lowest is with transvaginal (0.2:1000), followed by transabdominal (1:1000) and laparoscopic procedures (2.2:1000) [12]. This is consistent with the present data, where none of the fistulae followed vaginal approach and laparoscopy was twice more commonly associated with genital fistulae as compared to abdominal approach. Further, the occurrence of fistula was associated with intraoperative haemorrhage and possible excessive use of electrocautery. We encountered five isolated and one combined ureteric injuries. Five were following laparoscopic approach, supporting the fact that the ureteric injuries are six times more common in laparoscopic as compared to open hysterectomy [12].
Recently, Paul Hilton has proposed the concept of retrogressive evolution of surgical practice (pertaining to teaching and training in gynaecology and workforce planning, inappropriate audit and operational research in obstetrics), to explain the increasing rate of iatrogenic urogenital fistulae [13]. The inadequate training might be a reason for rise in incidence of iatrogenic gynaecologic fistulae, as more and more hysterectomies are performed laparoscopically, by newly trained surgeons. This problem is amenable to rectification if the trainer and the trainee toil together, with the aim of achieving minimal complication rate, intraoperative recognition and repair of injury.
All the genitourinary fistulae in our study were approached transperitoneally, as complex fistulae involving ureter, large part of bladder and urethra require more difficult surgeries for their treatment [14]. Although laparoscopic approach for repair is an option, we found transperitoneal approach for complicated genital fistulae offers wider inspection, better dissection and excellent results. The ano-vagino-cuteneous fistula was repaired through perineal approach. The faecal fistulae were also repaired abdominally except one post-hysterectomy high rectovaginal fistula in a very obese patient with previous multiple abdominal surgeries. This patient also had colostomy and big para-stomal hernia. Fistula was repaired vaginally using by converting high fistula to complete perineal tear. The colostomy closure and hernia repair followed 3 months later.
The success rate in our study was 100% in the first attempt. The success rate for primary surgical repair ranges from 88 to 93% and decreases with each successive attempt [1]. Goswami et al. [6] reported an overall success rate of 75.55%. The successful repair of complex genital fistulae can be achieved, provided repair principles such as careful dissection of planes, adequate haemostasis and proper repair in separate planes are kept in mind [15]. Omental interposition in between the planes gives the best possible results as advocated by Turner Warwick [10, 16].
The limitation of the study is that many patients were referred from other centres. Also the patient cohort in this study may not be representative of the whole community as India comprises of heterogeneous population.
Out of 16, 62.5% (10) fistulae were secondary to
surgery for gynaecological conditions and the rest 37.5% (6) were
obstetric fistulae. All patients were literate and belonged to middle
socio-economic strata, except one with massive vesicovaginal fistula
(VVF) belonging to low socioeconomic background. The age of patients
varied from 20 to 45 years with a mean of 40.5 years. The mean age for
obstetric fistulae was 28 years, in contrast to 49 years for
post-operative fistulae. The duration symptoms ranged from 5 days to 5
years.
All the obstetric fistulae were referred patients. Two
resulted from difficult deliveries, with both having fatal neonatal
outcomes. One of them started having urinary leak, 3 weeks after
caesarean section for obstructed labour, eventually developing
subsymphyseal fistula presenting after 1 year. Abdominal repair of the
fistula with O’Connor’s approach (transperitoneally approaching fistula
through bladder) with bladder neck reconstruction was carried out. The
other woman presented 10 years after she had difficult instrumental
vaginal delivery resulting in massive VVF. Total abdominal hysterectomy
was performed to optimally repair the fistula. After a follow-up of 2.5
and 7 years, respectively, both remain continent. A patient with
uretero-vaginal fistula had developed continuous dribbling of urine on
tenth post-operative day after emergency lower segment caesarean
section. She presented 4 months after surgery with a small left uretero-
vaginal fistula 4 cm from uretero-vesical junction, which was managed
by double J (DJ) ureteric stenting for 12 weeks. Patients remain dry
henceforth.
Two of the obstetric fistulae developed following
procedures for abortion. One had underwent dilatation and evacuation for
missed abortion an year before and presented with secondary infertility
and complaint of watery leaking with ammoniacal odour during
intercourse. Post-coital test revealed no sperms despite normal semen
analysis, and Moir’s test was negative. Multiple small VVF (four in
number) were seen on cystoscopy and vaginoscopy. Abdominal repair with
O’Connor’s approach was carried out. Patient had a successful pregnancy 3
years later and remained continent on follow-up. Another young patient
with secondary infertility and persistent vaginal discharge had
undergone dilation and evacuation 18 months before. On diagnostic
hysteroscopy, bowel lumen was seen. Laparotomy was performed, and a 5-mm
colouterine fistula was repaired successfully.
One
ano-cutaneo-vaginal fistula was encountered in a young patient 10 days
after delivery, following faulty episiotomy repair. Perineal excision of
fistulous tract and layered closure was carried out successfully. In
our study, all the post-operative gynaecological fistulae resulted
post-hysterectomy. Laparoscopic hysterectomy accounts for seven of them
and three secondary to total abdominal hysterectomy. All hysterectomies
were performed for benign uterine pathology. The mean duration of onset
of symptoms was 9.3 days post-surgery. Total laparoscopic hysterectomy
(TLH) and laparoscopic-assisted vaginal hysterectomy (LAVH) were
implicated in five and two cases of fistulae, respectively. One of the
five patients who underwent TLH presented 5 days post-operatively with
urinary leak and septic shock. After resuscitation, she was diagnosed to
have uretero-vaginal with associated vesicovaginal fistula. Three
months of conservative management was followed by abdominal VVF repair
by O’Conor’s approach with ureteric re-implantation and psoas hitch. Out
of five patients who had total laparoscopic hysterectomy, three were
diagnosed to have uretero-vaginal fistula. Two of them were managed with
abdominal ureteric re-implantation and psoas hitch. The third patient
of uretero-vaginal fistula following TLH underwent successful
conservative management with DJ stenting.
Another patient who
had uretero-vaginal fistula following LAVH was managed similarly with DJ
stenting. Both conservatively managed patients remain dry till date.
One uretero-vaginal fistula was formed after TAH which was repaired by
ureteric re-implantation. Two of the patients developed urinary leak due
to multiple inaccessible VVF near vault few days following TLH and
total abdominal hysterectomy (TAH), respectively. Both were repaired
through modified O’Conor’s technique transperitoneally with omental
reposition. Intraoperative haemorrhage was noted in the operative notes
of primary surgery in five out of six uretero-vaginal fistulae (Tables
1, 2).
Two patients had rectovaginal fistulae (RVF), one each
following TAH and LAVH. The former was obese and underwent colostomy
with RVF repair vaginally with paediatric laparoscopic instruments, as
the site of fistula was difficult to access. The other patient had
faecal incontinence 3 weeks after LAVH. Operative notes revealed use of
cautery on posterior vaginal wall to achieve haemostasis. RVF repair was
performed abdominally, and colostomy was performed.
Adequate
hydration with daily fluid intake of 3 to 5 litres was maintained in all
patients, and prophylactic antibiotics were continued for 5 days. All
patients had indwelling three-way urethral catheter for 14 days to
ensure continuous urinary drainage. No patient underwent suprapubic
catheter insertion.
Patients with obstetric fistulae and
post-operative fistulae underwent a mean follow-up of 5.8 years and 7.5
years, respectively. All patients (including the three patients managed
conservatively with DJ stenting) remained dry on follow-up, without
needing a repeat procedure. The complications encountered included
recurrent urinary tract infections and abdominal pain. One patient had
urinary incontinence lasting 4 weeks following catheter removal due to
small capacity bladder, improved on medical management. Two patients who
presented with infertility conceived and delivered successfully.
Conflict of interest All the co-authors declare that there is no conflict of interest.
Human Participants It is an observational study involving human participants.
Informed consent Informed consent was taken from each participant.
