Our study represents the review of the case histories of 56 patients admitted to or discharged from National Medical Center with diagnosis of urinary fistula, from January 1.959. through end of 1963.
The causes of these fistulas were analysed and methods of management were reviewed. Particular attention was paid to those patients in whom surgical repair of the fistula was carried out and an attempt was made to evaluate the factors responsible for success of repair.
Of 56 cases of urinary fistulas studied, 26 were the result of obstetric dystocia and 16 were associated with abdominal operations including Wertheim´s operation and in. the remainder of the cases the lesion were related to chemical cauterization for treatment of prolapse of uterus and TB. These cases were compared with Dr. Ruseel´s 74 cases, which besides ordinary obstetrical fisseries -tulas also included urinary fistula due to radium therapy and vaginal operations, where as in our no such cases were seen.
Six of the fistulas healed spontaneously. One was an obstetrical fistula while others five were fistula which occurred as the result of radical operation for cervical cancer. In 36 patients operative -procedure were-carried out on 45 occasions. These operations were mostly designed to close the fistulous opening by the vaginal approach but in 15 cases abdominal approach was used.
In 2f+ cases of large fistulas The ureteral orifices were found either at the edge of the fistula or near to it. In most of those cases extensive scar formation with poor circulation was found. Of these 20 cases eight were discharged as inoperable, five were operated by interposition of uterus or Martius operation in comb; nation with layer to layer closure after insertion of ureter catheter. In .the remaining 7 cases the fistulas were so large and fibrosis were so extensive that it was impossible to make sufficient mobilization of the surrounding tissue to make suture without tension.
Operation was carried out in 36 cases´ complete cure were 21, in complete cure in 4 cases where urinary incontinence followed after the operation despite closure of fistula, failure in 11 cases.
Certain general principles for management of vesicovaginal fistula were described.
1) Complete urologic study and diagnosis.
2) Elimination of infection before and after operation.
3) Optimal time of operation about 6 months after fistula developed.
4) For good operative result it is very important to make good exposure of vaginal tract, to make complete excision of scar tissue, -to make sufficient mobilization and suture always to apply sutures in healthy tissue without tension
5) Continuous, effective postoperative bladder drainage for days should be carried out to allow solid healing of bladder wound.
|