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Dr Amita Jain Treats Complex Fistulas
- 1. Dr. Amita Jain Consultant Urogynaecologist Medanta Institute of Kidney & Urology Medanta -The Medicity Gurgaon, Haryana -122001, INDIA
- 2. Female Genital Fistula(FGF) is a socially debilitating problem with important medicolegal implications. In the developing nations, nearly 5 million women annually suffer severe morbidity with obstetric fistulae being the foremost on the list. (WHO 1991) Around > 2 million women living with fistula, with approximately 50,000 to 100,000 cases occurring annually, mostly in Africa, Asia, and the Arab world. Stanton C et al, Int J Gynaecol Obstet 2007, 99:S4-S9. The unmet need for fistula repair is estimated to be as high as 99%. Ahmed S et al, Int J Gynaecol Obstet 2007, 99:S1-S3. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 3. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 4. • 74 years • C/O Involuntary leakage of urine with coughing, sneezing & change in posture • Co - morbidities Old age (Postmenopausal) Past multiple surgeries - Wertheim’s hysterectomy followed by Radiotherapy – carcinoma cervix 1986 - Laparotomy - intestinal obstruction 1990 - Repeated urethral dilatation - retention of urine 2008 - Abdominal Sacrocolpopexy - vaginal vault prolapse March 2010 Hypertension Hypothyroidism Osteoarthritis DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 5. General & Neurological Examination: normal POPQ Aa +2.0 Gh 7 Ap -3 Ba +1.0 Pb 3.5 Bp -3 C -5 TVL 7 D 0 STAGE III CYSTOCELE Urethral Hypermobility + Stress leak + DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 6. SENSATION RESULTS LEAK POINT PRESSURES SENSATION Bladder filling First Sensation 110 cc 10 cmH2O Strong Desire 280 cc 11 cmH2O Max Cyst Capacity 280 cc 15 cmH2O Bladder filling Pabd Pdet 1 156 cc 13 cmH2O 10 cmH2O 2 248 cc 10 cmH2O 7 cmH2O 3 276 cc 10 cmH2O 11 cmH2O Pdet DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 7. Total bladder capacity 281cc Peak flow rate 7ml/s Pdet at peak flow 15 cmH2O Average flow rate 3 ml/s Residual Urine 0 ml Opening Pdet 9 cmH O DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 8. Braided Suture Piercing bladder wall DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 9. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited Blind pit at Ant. Vaginal wall ( ? healed fistula opening) Negative Three Swab Test
- 10. Suture Removal 3 weeks Cystocele Repair & Midurethral Sling Placement DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 11. Peak Flow Rate 15 ml/s Average Flow Rate 7 ml/s Voided Volume 267 ml Voided Time 24 s Flow Time 24 s Post Void Residual 150 cc DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 12. • Able to hold & void herself • Fully continent ( Pads not required) • Clean Intermittent Self Catheterisation (3 times a day) DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 13. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 14. • 54 years • Recurrent UTI • On & off pinkish foul smelling vaginal discharge 1.5 yrs • Past Surgical History - Lap Hysterectomy 2 yrs back (Menorrhagia cause ? fibroid uterus) - Cholecystectomy 20 yrs back - Incisional hernia repair 16 yrs back • Co-morbidities - Hypertension 3-4 months - Diabetes Mellitus 3-4 months DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 15. Per speculum: - Black colored material at the apex of vaginal vault - Foul smelling black to brown dirty discharge soiling the walls of vaginal vault DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 16. Impression: Low Rectovaginal fistula DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 17. A black colored ? Suture at the apex of vaginal vault DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 18. On removal – black brown colored infected material drained. Communicating path traced through a probe. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 19. Abdominal Repair DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 20. Vaginal opening traced DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 21. No communicating path into sigmoid colon or rectum DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 22. Edges of Vaginal opening freshened up & closed DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 23. No foul smell discharge Not a single episode of UTI DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 24. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 25. • • • • 54 years Pain in left loin – 1 month Continuous urinary leakage – 1 month H/O present illness month - D & C for menorrhagia 4 months back. - f/b Vaginal hysterectomy with left oophorectomy after one - C/O continuous significant vaginal bleeding in postop - re-evaluated after 2 weeks & some stiches were put through vaginal route - developed high grade fever after 2 days f/b urinary incontinence • Past H/O - Tubal ligation 30 yrs back • No Co - morbidities DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 26. Findings: Moderate Left sided Hydroureteronephrosis with dilatation of left ureter in its entire extent with abrupt cut off at distal end, which appears to merge with vaginal stump DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 27. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 28. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 29. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 30. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 31. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 32. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 33. Abrupt cut off at 2 cm distance from left ureteric orifice DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 34. Post Hysterectomy Iatrogenic Left Ureteric Trauma with Vesico-vaginal fistula DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 35. Left Percutaneous Nephrostomy 4 weeks Cystoscopy + O’Conner’s VVF Repair* + Left Ureteric Reimplantation (stented) [ discharged on POD 5 with SPC in situ] “The best approach for complex fistulas is transabdominal using the O'Connors bivalve technique.” O'Connor VJ et al. Suprapubic closure of vesicovaginal fistula. J Urol. 1973;109:51–4. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 36. At 2 Weeks Findings: •Well maintained bladder outline •No leak DJ Stent removal done DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 37. Normal KFT Normal findings of DTPA Scan and USG Whole Abdomen DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 38. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 39. • 31 years • Continuous urinary leakage per vaginum for 2 year • Past Surgical History - MTP with tubal ligation (continous leakage in postop) - Hysterectomy with reimplantation of right ureter - Cystoscopy (0.5 cm sized fistula inferomedial to left ureteric orifice, right ureteric orifice not seen) + LRGP + LDJS - 2 failed attempts of vaginal repair of VVF - LRGP + Left Laser endoureterotomy + Laser fulgration of VVF • No Co-morbidities DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 40. USG KUB: B/L Chronic Renal Parenchymal Disease KFT: Bld Urea 93 mg/dl S. Creatinine 4.76 mg/dl Hb 8 g/dl Urine C/S: E Coli >10 cfu/ml DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 41. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited Impression: B/L contracted Kidneys, Re-implantation of right ureter ? into bowel (dilated 8 mm), DJ Stent on left side, 4 mm sized focal defect in posterior wall of UB communcating to vaginal stump (fluid in endovaginal canal)
- 42. Renal Transplantation after Fistula Repair DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 43. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 44. • 52 years • Continuous urinary leakage per vaginum for 2 year • Large bed sore over sacrum • Past History - Received multiple courses of chemoradiation for Ca Cervix (grade III) diagnosed in 1999 - Multiple cystoscopies for gross hematuria in 2009 - Cystoscopic fulgration & angioembolisation in Aug 2009 - Admitted in ICU for septicemia - on catheter removal at discharge noticed continuous leakage of urine • No Co-morbidities DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 45. Left small sized kidney Right normal sized kidney No Ureterovaginal fistula/ no ureteric stricture DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 46. Frozen Large Pelvis Vesico-vaginal fistula DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 47. Small capacity bladder Fluffy tissue inside Patchy inflammation Supratrigonal large irregular hole at left side of posterior wall DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 48. Urinary Diversion ( Transverse Colonic Urinary Conduit) DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 49. POD3 Myelosuppresion with pancytopenic sepsis B/L Parotitis with right parotid abscess Respiratory failure with Metabolic Acidosis Acute Renal Failure with Dyselectrolytemia Liver Dysfunction with Hypoalbuminemia Paralytic ileus POD 11 Anastomotic leakage Conservative Management in ICU by Multidisciplinary Team DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 50. Went home on full recovery after 6 weeks Doing well at 2years 6 months DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 51. Obstretical fistulas are associated with high incidence of recurrence and failure rates due to their large size and presence of ischaemic tissues. Arrow SS et al, Obstet Gynecol Surv. 1996;51:568–74. Postsurgical fistulas are result of more direct and localised trauma to otherwise healthy tissue, so having better results after repair. Hadley HR. Vesicovaginal fistula. Curr Urol Rep. 2002;3:401–7. DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 52. To date improvements in health care facilities may have led to change in etiological aspect of FGF. Surgical correction is still a great challenge and requires a team approach for better results. “Prevention is better than cure". THANKS DR AMITA JAIN Confidential & Proprietary. Any use of this material without prior permission is strictly prohibited
- 53. Medanta Institute of Kidney & Urology Dr. Amita Jain Urogynaecology Clinic 12th Floor, OPD Wing, Medanta -The Medicity Gurgaon, Haryana -122001, INDIA Tel: +91 124 4141 414 info@medanta.org www.medanta.org MOB. +91-9871136110 http://www.urogynecologistindia.in/ http://amitajainurogynaecolgist.blogspot.in/ http://www.linkedin.com/mbox?displayMBoxItem=&itemID=I225857003_75