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One hundred thirty patients with urinary fistulas had been admitted in the Gynecological Ward of the National Medical Center, Seoul, during 13 years, from the beginning of 1959 through the end of 1971, of which 109 patients were actually submitted to the surgical treatment. A review of these cases indicated that complete investigation of the urinary tract should precede repair, since these abnormal communications appeared in many varieties and might be multiple. Anatomic as well as etiologic considerations were important in diagnosis. The causes of these fistulas were analysed and methods of management were reivewed. Particular attention was paid to those patients in whom surgical repair of the fistula was undertaken and an attempt was made to evaluate the factors responsible for success of repair. The results of clinical observations were summarized as follows: 1. Seventy five out of 130 patients were obstetric fistula and more than half of them belonged to the second decade(50.7%), while in 55 of the non-obstetric fistula cases the greatest incidence was observed to be in the fourth decade(47.3%). 2. Presumed etiologic agents of the fistula showed 75 out of 130 patients were caused by various types of obstetric operation and large numbers were found in prolonged labor with or without forceps delivery and craniotomy. Etiologic agents of non-obstetric fistula could be divided into 26 of hysterectomy either simple or radical, 19 of chemical cauterization for total uterine prolapse with strong acid by laymen, 3 of genito-urinary tuberculosis, 2 of irradiation after hysterectomy due to ovarian cancer and 5 others. 3. The majority of patients, both obstetric and non-obstetric, belinged to vesicovaginal fistula, comprising 72.3%. As for the ureterovaginal variety, 17 patients consisted of 15 non-obstetric and only 2 obstetric. 4. The fistulas of less than 2cm in diameter could be found most frequently both obstetric and non-obstetric. It was our general concept that the size did not influence as much as the location of fistulas. 5. In 89 of 109 patients, various types of baginal approach were undertaken with 73(82%) patients of success. Twenty patiens, all of ureterovaginal variety as well as technically difficult patients were submitted to abdominal precedures with 18 patients(90%) of success. The combined, abdominal and vaginal approach was performed for 2 cases of complicated vesicovaginal variety with 2 patients of success. Six of 109 patients had to be resorted to various types of diversion with 5 patients of success. Nine of 130 fistulas healed spontaneously. All spontaneously healed fistulas occured as the results of surgical trauma, 3 of radical hysterectomy, 4 of abdominal total hysterectomy and 2 of subtotal hysterectomy. 6. In 109 patients operarive procedures were carried out on 137 occasions. Final cure rate of surgical repair was decreased by the number of surgical attempts made. But it seemed to be worthwhile to try repeated attempts, even more that 5 times in some selected cases, with patience and deliberated evaluation. 7. Obstetric fistulas were usually poor outcome(80.3%) than non-obstetric(89.5%), because most of them 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. In the present series, overall success was 91 of 109 patients, or 83.5% of the whole, during 13 years. 8. Genito-urinary infection was the most common complication and E. coli was the most common causative organism of urinary infection. 9. Unobstructed postoperative urinary catheter drainage was of primary importance.
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