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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
labour may result in a number of other complications including psychological, orthopaedic, reproductive, sexual and pelvic floor dysfunction. Although the surgical treatment of genitourinary fistulas addresses the physical defect, a holistic approach is required. Program Abstracts Saturday 4 June third, 2.5 cm lateral to the middle third, and 0.9 cm lateral to the distal third of the ligament. Segments of a video will be shown to highlight this anatomy. The benefit of lighted ureteral catheters will be demonstrated. REFERENCES: 1. Browning A, Fentahum W, Goh JTW. The impact of surgical treatment on the mental health of women with obstetric fistula. BJOG 2007, 114: 1439-41. 2. Goh JTW, Sloane KM, Krause HG, Browning A, Akhter S. Mental health screening in women with genital tract fistulae. BJOG 2005; 112: 1328-30. 3. Goh JTW, Browning A, Berhan B, Chang A. Predicting the Risk of Failure of Closure of Obstetric fistula and Residual Urinary Incontinence Using a Classification System. Int Urogynecol J 2008; 19: 1659-1662. 4. Murray C, Goh J, Fynes M, Carey M. Continence outcome following delayed primary obstetric genital fistula repair at a fistula hospital. BJOG 2002; 109: 827-832. AUTHOR AFFILIATION: Judith Goh FRANZCOG, PhD, CU. Urogynaecologist, Greenslopes Private Hospital, Brisbane, Australia. RECOMMENDED READING: 1. TeLinde’s Operative Gynecology. Lippincott Williams & Wilkins; Tenth ed. (April, 2008) 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 8 / 1610-1630 Pelvic sidewall and paravaginal anatomy Lotze P The trend toward both minimally invasive incontinence surgery as well as mesh kits have made knowledge of the anatomy of the Space of Retzius increasingly important. Although surgeons have focused on select targeted tissues (e.g. sacrospinous ligament), neighbouring structures represent potentially significant risk for complications if injured. Those structures may include visceral structures, such as the bladder and rectum, as well as major nerves and blood vessels in the region. Segments of a video on the Space of Retzius will attempt to demonstrate some of these structures. Minimally invasive surgery in the abdomen such as laparoscopic hysterectomies and sacrocolpopexies have also become more frequent. The subsequent dissection and use of electrical energy such as bipolar cautery can increase the risk of ureteral injury. The course of the pelvic ureter from its entry point at the pelvic brim to its location in the Cardinal ligament becomes increasingly important to know as a result. In general, the ureter – lateral to the uterosacral ligament – can be found approximately 4 cm lateral to the proximal 15
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Page 5 and 6: Welcome We are pleased to present o
Page 7 and 8: Day 2 Saturday 4 June 2011 Adelaide
Page 9 and 10: Program Abstracts Friday 3 June Ses
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Page 15: REFERENCES: 1. Abrams P, Cardozo L,
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