Obstetric fistula (OF), although virtually eradicated from the developed world, has a number of unique features that make this topic worthy of the attention of practitioners of pelvic surgery anywhere. A discussion of the steps of repair of OF is useful to all pelvic surgeons because of the relative difficulty of repair of OF compared with other types of vesicovaginal fistula (VVF). The etiology of OF is wide-field ischemia.1 OF injuries tend to be much larger, with more tenuous vascular supply, and located in physiologically more important anatomic areas when compared with fistulae seen in wealthy countries.2 Therefore, if one can appreciate the basic principles of OF repair, all will apply to the much simpler problem of postoperative VVF as seen in the West. The techniques of OF repair also are well employed in the challenging area of postirradiation fistulae, which share some features with OF. Figures 36-1 and 36-2 demonstrate longitudinal and vaginal views of large circumferential VVFs that demonstrate some of the complexity of these types of fistula.
Longitudinal view of circumferential fistula.
Large circumferential vesicovaginal fistula. A. Vaginal view with metal dilator in urethra. B. Vaginal view of circumferential fistula.
Box 36-1 Master Surgeon’s Corner
Fistulas in the developed world more commonly present as posthysterectomy vesicovaginal fistulas. The usual location of the fistula after hysterectomy is in the supratrigonal region of the bladder.
Retrograde filling the bladder with indigo carmine– or methylene blue–dyed sterile solution can help confirm fistula location.
Use of stay sutures placed away from the fistula and dilation of the fistula with insertion of a pediatric Foley catheter can aid in dissection.
REPAIR OF THE OBSTETRIC FISTULA
Generalized material on the generic approach to OF has been published in symposia3 and surgical manuals.4
By tradition, many surgeons impose a mandatory waiting period between injury and attempted repair. However, these beliefs are not supported with randomized, prospective data. Subjectively, most practitioners of OF repair would base a decision of timing of surgery on the condition of the patient and the appearance of the tissues at clinical examination. As would be the case with any major pelvic reconstruction, the patient should be assessed for nutritional status and general medical fitness for surgery. It is quite common in OF to see patients present for care in an advanced state of malnutrition. These patients can require long periods of rehabilitation prior to the safe performance of fistula repair. Since OF results most commonly from regional ischemia, it is also not uncommon to encounter patients for whom the process of sloughing of necrotic tissue is not yet complete. In these cases, fistula repair should not be attempted ...