| Autor: |
Pătrășcoiu, S., Brătilă, E., Brătilă, P., Copca, N., Stroescu, C., Zamfir, R., Mischie, O. G., Popa, L., Rosulescu, C., Prie, I., Poenaru, R., Constantinica, V., Gurau, C. |
| Předmět: |
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| Zdroj: |
Ginecologia.ro; dec2016 Supplement 1, Vol. 4, p17-17, 1/2p |
| Abstrakt: |
Introduction. Vesicovaginal fistulas are perhaps the most feared complications of female pelvic surgery. Ideally the majority of VVFs should be amenable by transvaginal repair. The relative advantages of vaginal repair compared to an abdominal approach are quick convalescence and return to normal activities; approach is not compromised by multiple prior abdomino-pelvic surgeries, minimal blood loss and postoperative pain. The main disadvantages of the transvaginal approach include the relative lack of familiarity of the vaginal cuff anatomy to many urologists, the difficulty in exposing high or retracted fistulae located near the vaginal cuff. The situation is even more difficult if there is no apical prolapse or we have to deal with a narrow vagina. The abdominal approach is advantageous in several situation such as fistulas located high at the vaginal cuff, when reimplantation is necessary or when other intraabdominal pathology require repair. In our experience, large, complex or recurrent VVF are best approached abdominally as well. Material and methods. We present a retrospective study based on the personal experience in the field of major urologic surgery on a period of almost 10 years. During Jan 2008 - July 2016 I operated 34 VVFs in two major hospitals in Bucharest - Fundeni Clinical Institute and ”Saint Mary” Clinical Hospital.We used the combined transvesical and transabdominal approach in 8 cases. Surgical technique: The patient is positioned in a low lithotomy position with access to vagina in the sterile operative field. We can use a midline or Pfannenstiel incision. The retropubic space is opened and the bladder is mobilized anteriorly and laterally. Pouch of Douglas, vaginal apex and the entire bladder should be exposed. The bowels are packed away to keep it out the operative field. A midline cystotomy should be carried posteriorly down to the fistula. The fistulous tract is excised by circumscribing the bladder portion, dissecting it down to the vaginal wall and removing it by a circumscribing incision in the vagina. The edges of the vaginal wall are freed up by sharp dissection to permit adequate mobilization for closure in a tension free manner.Well vascularized tissue should remain for closure of bladder and vagina.Vagina is closed with separate absorbable suture. An interpositional flap of greater omentum is highly recommended. The flap is secured 1 to 2 cm distally beyond the excised VVF tract. Urethral catheter and lond ureteral mono-J stents are placed, sometimes a suprapubic tube could be usefull. Bladder is closed in two layers. Retzius space and peritoneal cavity are drained. The wound is closed in layers in a standard manner. Results. The etiology of the fistulas were 5 cases (62.5%) after hysterectomy (3 open - abdominal; 2 laparoscopic); 3 cases (37.5%) after radiotherapy and Wertheim operation (2 open; 1 laparoscopic).In two cases we performed ureteral reimplantation due to the fact that fistula tract was in close proximity of the ureteric orifice. In one case we performed preoperative nephrostomy drainage in order to preserve the renal unit. No fistula reccurence was noted. No renal unit was lost. Mean operative time was aproximately 120 min (range between 80 and 200 min). Mean blood loss was 150 ml (range between 100-600 ml). Mean hospital stay was 14 days (range between 12-22 days). During a median follow-up period of 72 months (3-116 months ) the patients continued to void normally, without fistula recurrence and had sterile urine cultures. Conclusions. We should always remember that the first operation is the one most likely to succeed. You always should select an approach with which you feel confortable. The combined approach transvesical and transperitoneal represents a feasible technique especially for large fistulae located high in a deep narrow vagina, in failures after other approaches and also when we need to perform ureteral reimplantation.The key to the operation is the mobilization [ABSTRACT FROM AUTHOR] |
| Databáze: |
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