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An introduction to Obstetric
       Fistula surgery


      Brian Hancock
        MD.FRCS.FRCOG
Obstructed Labour




Prolonged pressure of the babies head
crushes the base of the bladder against
the back of the pubis
Causes of wetness post delivery
• Ischaemic necrosis to the bladder and
  vagina due to prolonged labour ( 90%)

• Accidental damage to the Bladder or
  Ureter at Caesarean section or
  hysterectomy for ruptured uterus (10%)
The Vesico Vaginal Fistula
1-2 million in
  Africa

Wet for life.

High skill
Low tech surgery

Dramatic results
The Cause.

         Unrelieved obstructed labour




Urban poverty. Lack of   Remote dwellings.No
free medical care.       Transport. No hospitals
Three stages of delay for
    Caesarean section.

• Delay deciding to get help

• Delay getting to hospital

• Delay in Hospital
Result




A hole between the Vagina and Bladder (VVF)
Effect of a VVF

She will be incontinent of
urine for life

She will become a social
outcast unless she can find a
skilled surgeon
Vesico-Vaginal Fistula is



More than a hole in the bladder

 The whole body is damaged
The Obstetric Fistula Injury Complex
 Primary damage

      Vagina, Uterus.

      Urethra, Bladder,Ureter.

      Rectum

      Nerve damage

      Pelvic Floor Muscle damage
The Obstetric Fistula Injury complex.
   Secondary damage

         Social outcast. Depression. Suicide.

         Malnutrition

         Foot Drop. Contractures. Deformity

         Bladder stones. Renal damage

         Dermatitis.

         Infertility.
Can all patients with VVF be cured?


                                   easy
                                   25%



    intermediate
        50%
                                   difficult
                                    25%




One quarter are easy with near 100% success
One half are intermediate in difficultly, 80% success for
an expert
One quarter are very difficult, 50% success rate for an
expert.
Results of VVF surgery
1100 cases in Uganda in 10 years

       Inoperable   Fail
          3%        10%
                           Stress
                           17%



 Dry
70%
Why are so few repairs done?
Surgery thought to be difficult
               but 25% are quite easy
Results thought to be poor.
               but 100% success for easy cases
No teaching in post graduate curriculum
               but simple books are available
Lack of special instruments
               but they are not needed for easy cases
No specialist nursing care
               but nursing care is very easy
Many cases can be repaired under
        basic conditions




   Lira. Uganda     Kamuli. Uganda
Further progress is best made by apprenticeship
       with one of the master surgeons.




  Kees Waaldijk                     Dr Mulu
    Katsina                        Addis Ababa
     Nigeria                         Ethiopia
Understanding the nature of VVF




The commonest site for ischaemic
injury is the junction of the bladder and
urethra. In severe cases the whole of
the anterior vaginal wall and bladder
base are lost and the urethra is
separated from the bladder.
Diagnosis is made by,


• History taking

• Examination

• No special investigations required
History taking
Wet all the time?

Leaking faeces as well? ( 5-10%)

How long wet?

Which delivery caused the problem?

Did the baby survive?

How born? CS or Vaginal Delivery?

Has repair been attempted before?

Social history.
Some demographic facts from 1000 cases in
               Uganda

• Mean age was 26 years

• Mean duration of fistula was 6 years

• 50% were primiparous

• Only 33% of patients with a fistula delivered vaginally, the rest had a
caesarean section.

• 12% of women who developed a fistula after LSCS had a live baby
In contrast to 4% in those delivering vaginally.

• 13% had already had at least one attempt at repair.
Examination
Inspection.     For signs of wetness.

Palpation by VE. ( don’t forget abdo exam first)

Is there any vaginal stenosis?

Can a defect be felt in the anterior vaginal wall.? If
so, what is its site, size and mobility.

Can the cervix be felt? Is the vagina shortened?

If in doubt expose the anterior wall with a
speculum.
Examination in Left Lateral position
Dye test for a hidden fistula




  The last swab to be removed is blue
Two simple cases




Both fistulae are about three cm from the external urethral orifice
Difficult fistulas. Not for a beginner




 This high juxta cervical fistula has a
 ureteric opening on its margin
Another troublesome case




This high fistula extends into an open cervical canal.
Equipment for fistula repair




Tilting table        Good quality scissors
                      forceps and needle
                            holder.
Selection of cases for beginners
The fistula must be small mobile and accessible.
Spinal anaesthesia
Principles of repair

Adequate exposure sometimes with
an episiotomy

Flap splitting technique.

Mobilise enough healthy bladder to
close without tension.

Protection of ureters

Excision of scar.
A simple juxta-urethral fistula




  It is small mobile and accessible; an
           ideal beginners case
The posterior margin   The anterior vaginal
has been mobilised     flap has been elevated
A small rim of scar is
                         Suture started at the margins.
 excised around the
   fistula margin
Single layer closure with 2 zero catgut, dexon or vycril
After the bladder has been closed perform
a dye test with 50 ccs of dilute methylene blue
Vaginal pack and
Closure of vagina with
                         suture for catheter
  absorbable sutures
Basic post operative
care for VVF patients.
The reality
• Nurses will be in short supply

• Post op care must be kept as simple as
  possible.

• Patients and their carers must often take
  responsibility for their own care.
The essentials.
 The patient must be



  Dry

  Drinking

  Draining
Ensure free drainage at all
              times
• Options.

     • Closed drainage into a bag.



     • Free drainage into a basin or bucket
A practical method of drainage



The patient is nursed flat
For 24 hours post spinal

Allow oral fluids freely

Watch the dripping into the bucket.
Closed drainage


This is a very
  high tech
  system.
Problems with closed drainage



What happens to this
bag in the night?
A BLOCKED CATHETER
        is an emergency
Signs
         Urine flow stops.

         Patients feels a full bladder

         Wet Bed due to leak through the urethra or repair

Action
         Look to exclude kinked catheter

         Irrigate to clear obstruction

         Change Catheter.
Kinked Catheters
                    big trouble ahead.



The patient is lying on the
catheter

The catheter is kinked

The urine is concentrated.
A blocked catheter
Drinking

• Drinking up to 4
  litres a day is
  essential to ensure
  a good output of
  clear urine
Early mobilisation
Up with a bucket on day
  two.
Good for patient morale
Avoids Pressure sores
  and DVT risk.
Low nursing care.
Patients must continue to
  Drink ++++.
Other aspects of post op care.




  Daily perineal washing is essential.
  At first by the nurse then by the patient or carer.
After day two, the patient can be largely self caring until
the catheter comes out. The patient stays in bed if the are
ureteric catheters but these rarely need to be retained for
more than 48 hours.
Some happy patients.
Further reading

•Practical Obstetric Fistula Surgery .

       Brian Hancock and Andrew Browning

•Step by Step Surgery of Vesico Vaginal Fistula.

       Kees Waaldijk

Both obtainable from Teaching Aids at Low Cost. (TALC)
Box 49,St Albans, Herts, AL1 5TX, UK. (info@talcuk.org)

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An introduction to Obstetric Fistula surgery

  • 1. An introduction to Obstetric Fistula surgery Brian Hancock MD.FRCS.FRCOG
  • 2. Obstructed Labour Prolonged pressure of the babies head crushes the base of the bladder against the back of the pubis
  • 3. Causes of wetness post delivery • Ischaemic necrosis to the bladder and vagina due to prolonged labour ( 90%) • Accidental damage to the Bladder or Ureter at Caesarean section or hysterectomy for ruptured uterus (10%)
  • 4. The Vesico Vaginal Fistula 1-2 million in Africa Wet for life. High skill Low tech surgery Dramatic results
  • 5. The Cause. Unrelieved obstructed labour Urban poverty. Lack of Remote dwellings.No free medical care. Transport. No hospitals
  • 6. Three stages of delay for Caesarean section. • Delay deciding to get help • Delay getting to hospital • Delay in Hospital
  • 7. Result A hole between the Vagina and Bladder (VVF)
  • 8. Effect of a VVF She will be incontinent of urine for life She will become a social outcast unless she can find a skilled surgeon
  • 9. Vesico-Vaginal Fistula is More than a hole in the bladder The whole body is damaged
  • 10. The Obstetric Fistula Injury Complex Primary damage Vagina, Uterus. Urethra, Bladder,Ureter. Rectum Nerve damage Pelvic Floor Muscle damage
  • 11. The Obstetric Fistula Injury complex. Secondary damage Social outcast. Depression. Suicide. Malnutrition Foot Drop. Contractures. Deformity Bladder stones. Renal damage Dermatitis. Infertility.
  • 12. Can all patients with VVF be cured? easy 25% intermediate 50% difficult 25% One quarter are easy with near 100% success One half are intermediate in difficultly, 80% success for an expert One quarter are very difficult, 50% success rate for an expert.
  • 13. Results of VVF surgery 1100 cases in Uganda in 10 years Inoperable Fail 3% 10% Stress 17% Dry 70%
  • 14. Why are so few repairs done? Surgery thought to be difficult but 25% are quite easy Results thought to be poor. but 100% success for easy cases No teaching in post graduate curriculum but simple books are available Lack of special instruments but they are not needed for easy cases No specialist nursing care but nursing care is very easy
  • 15. Many cases can be repaired under basic conditions Lira. Uganda Kamuli. Uganda
  • 16. Further progress is best made by apprenticeship with one of the master surgeons. Kees Waaldijk Dr Mulu Katsina Addis Ababa Nigeria Ethiopia
  • 17. Understanding the nature of VVF The commonest site for ischaemic injury is the junction of the bladder and urethra. In severe cases the whole of the anterior vaginal wall and bladder base are lost and the urethra is separated from the bladder.
  • 18. Diagnosis is made by, • History taking • Examination • No special investigations required
  • 19. History taking Wet all the time? Leaking faeces as well? ( 5-10%) How long wet? Which delivery caused the problem? Did the baby survive? How born? CS or Vaginal Delivery? Has repair been attempted before? Social history.
  • 20. Some demographic facts from 1000 cases in Uganda • Mean age was 26 years • Mean duration of fistula was 6 years • 50% were primiparous • Only 33% of patients with a fistula delivered vaginally, the rest had a caesarean section. • 12% of women who developed a fistula after LSCS had a live baby In contrast to 4% in those delivering vaginally. • 13% had already had at least one attempt at repair.
  • 21. Examination Inspection. For signs of wetness. Palpation by VE. ( don’t forget abdo exam first) Is there any vaginal stenosis? Can a defect be felt in the anterior vaginal wall.? If so, what is its site, size and mobility. Can the cervix be felt? Is the vagina shortened? If in doubt expose the anterior wall with a speculum.
  • 22. Examination in Left Lateral position
  • 23. Dye test for a hidden fistula The last swab to be removed is blue
  • 24. Two simple cases Both fistulae are about three cm from the external urethral orifice
  • 25. Difficult fistulas. Not for a beginner This high juxta cervical fistula has a ureteric opening on its margin
  • 26. Another troublesome case This high fistula extends into an open cervical canal.
  • 27. Equipment for fistula repair Tilting table Good quality scissors forceps and needle holder.
  • 28. Selection of cases for beginners The fistula must be small mobile and accessible.
  • 30. Principles of repair Adequate exposure sometimes with an episiotomy Flap splitting technique. Mobilise enough healthy bladder to close without tension. Protection of ureters Excision of scar.
  • 31. A simple juxta-urethral fistula It is small mobile and accessible; an ideal beginners case
  • 32. The posterior margin The anterior vaginal has been mobilised flap has been elevated
  • 33. A small rim of scar is Suture started at the margins. excised around the fistula margin
  • 34. Single layer closure with 2 zero catgut, dexon or vycril
  • 35. After the bladder has been closed perform a dye test with 50 ccs of dilute methylene blue
  • 36. Vaginal pack and Closure of vagina with suture for catheter absorbable sutures
  • 37. Basic post operative care for VVF patients.
  • 38. The reality • Nurses will be in short supply • Post op care must be kept as simple as possible. • Patients and their carers must often take responsibility for their own care.
  • 39. The essentials. The patient must be Dry Drinking Draining
  • 40. Ensure free drainage at all times • Options. • Closed drainage into a bag. • Free drainage into a basin or bucket
  • 41. A practical method of drainage The patient is nursed flat For 24 hours post spinal Allow oral fluids freely Watch the dripping into the bucket.
  • 42. Closed drainage This is a very high tech system.
  • 43. Problems with closed drainage What happens to this bag in the night?
  • 44. A BLOCKED CATHETER is an emergency Signs Urine flow stops. Patients feels a full bladder Wet Bed due to leak through the urethra or repair Action Look to exclude kinked catheter Irrigate to clear obstruction Change Catheter.
  • 45. Kinked Catheters big trouble ahead. The patient is lying on the catheter The catheter is kinked The urine is concentrated.
  • 47. Drinking • Drinking up to 4 litres a day is essential to ensure a good output of clear urine
  • 48. Early mobilisation Up with a bucket on day two. Good for patient morale Avoids Pressure sores and DVT risk. Low nursing care. Patients must continue to Drink ++++.
  • 49. Other aspects of post op care. Daily perineal washing is essential. At first by the nurse then by the patient or carer.
  • 50. After day two, the patient can be largely self caring until the catheter comes out. The patient stays in bed if the are ureteric catheters but these rarely need to be retained for more than 48 hours.
  • 52. Further reading •Practical Obstetric Fistula Surgery . Brian Hancock and Andrew Browning •Step by Step Surgery of Vesico Vaginal Fistula. Kees Waaldijk Both obtainable from Teaching Aids at Low Cost. (TALC) Box 49,St Albans, Herts, AL1 5TX, UK. (info@talcuk.org)