to Obstetric Trauma Pelvic Floor Repair Surgical Essentials - AGES

AGES
Pelvic Floor
Symposium &
Workshop XII
2011
to
Obstetric Trauma
Pelvic Floor Repair
Surgical Essentials
14
is often standardized between patients. Identification of pathology
and knowing how to respond to it is paramount to completing the
procedure.
This lecture will define and describe the incidence of common
bladder disorders. A video will be shown that highlights proper
indications, equipment, and technique for performing diagnostic
cystoscopy.
RECOMMENDED READING:
1. Ostergard’s Urogynecolgy and Pelvic Floor Dysfunction. Lippincott
Williams & Wilkins; Sixth ed (July, 2007).
2. Lotze P. Video: Diagnostic Cystoscopy (2010) – available on
YouTube.
AUTHOR AFFILIATION: Peter Lotze, MD, FACOG; Fellowship
Director, Urogynecology and Pelvic Reconstructive Surgery Women’s
Pelvic Health & Continence Center Clinical Assistant Professor,
Division of Urogynecology, Dept of OB/Gyn UTHSC-Houston; Baylor
College of Medicine Houston, Texas, USA.
Session 6 / 1210-1230
Vaginal closure of lower genitourinary
tract fistula
Goh J
Obstetric fistula is the most common fistulae world-wide. Most
commonly, it is due to prolonged obstructed labour with pressure
necrosis, subsequent sloughing of the affected tissue and formation
of the fistula. Obstetric genito-urinary fistulae may also occur from
operative deliveries.
In prolonged obstructed labour, the lower urinary tract is at
risk with the fetal presenting part compressing the vagina and
bladder/urethra against the back of the pubic symphysis. The
fetal presenting part often also causes urethral obstruction and
the distending bladder is placed at further risk of injury. There
is also a risk to the rectum from pressure necrosis but the rates
are much lower. Unrepaired fourth degree tears also cause faecal
incontinence.
A high degree of suspicion is required for early detection and hence
early intervention and counselling. Immediate management usually
depends on the nature of injury. If a fistula is detected in the first
few days following delivery, treatment options include prolonged
catheterisation. Spontaneous closure of the fistula may occur with
prolonged catheterisation. If the fistula is detected early and is not
due to pressure necrosis, early surgical closure is another option
if the fistula site has little/no inflammation or infection. Once the
fistulous tract is established and epithelialised, little is gain with
prolonged catheterisation in hope of spontaneous closure.
Various investigations are available. For fistulae in the bladder/
urethra, an examination may be all that is required. If the fistula
is large, the defect is palpated or visualised during a vaginal
examination. A dye test may be performed with instillation of dilute
dye into the bladder via a catheter. Imaging is usually required to
diagnose a ureteric fistula. A urethrocystocopy may also be used as
a diagnostic tool.
Timing of surgical management of the bladder or urethral fistula
would depend on the nature of the injury, previous history, time
of diagnosis from injury, the condition of tissue around the fistula
(eg infected, inflamed). Surgery for urinary fistulas is fraught with
a number of controversies. Foremost are the timing of closure of
the fistula (early or delayed) and the route of repair (vaginal or
abdominal). Other controversies include the surgical techniques, use
of grafts and length of catheterisation.
There are a number of basic principles of fistula repair. These include:
• Prophylactic antibiotics
• Adequate exposure
• Cannulation of the ureters if indicated
• Mobilisation of the bladder from the vagina
• Haemostasis
• Tension free closure of the bladder and testing the closure for
example, with diluted methylene blue solution
• Postoperative bladder drainage
In vaginal repair of fistulae, the flap-splitting technique is usually
used. For upper vaginal fistulas, this technique is preferable to
the Latzko as it does not shorten the vagina. Adequate exposure
during surgery is achieved by optimisation of the patient’s position
(eg Trendelenburg, inclination depending on site of the fistula),
good lighting, experienced assistants and often division of vaginal/
perineal scarring to allow access to the fistula.
Anatomical distortion may alter the site of ureteric orifices. It is
essential to exclude ureteric involvement, especially in the large
fistula, very scarred fistula and fistula near the trigone. Where
ureters are near or involved with the fistula, cannulation is vital to
reduce the risk of ureteric obstruction from oedema around the
surgical site or ureteric incorporation into the repair
Apart from the obvious injuries in the genital and urinary tract,
genital tract fistulae particularly following prolonged obstructed