| Autor: |
Pătrășcoiu, S., Brătilă, E., Brătilă, P., Copca, N., Stroescu, C., Hanna, A., Zamfir, R., Mischie, O. G., Popa, L., Constantin, C., Gilca, I., Pușcasu, A., Birceanu, A. |
| Předmět: |
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| Zdroj: |
Ginecologia.ro; dec2016 Supplement 1, Vol. 4, p18-18, 1/2p |
| Abstrakt: |
Introduction. Vesicovaginal fistulas are perhaps the most feared complications of female pelvic surgery. More than half of such fistulas occur after hysterectomy for benign diseases. Material and methods. 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 transvesical (extraperitoneal) approach in 14 cases. All the cases were after abdominal hysterectomy - 12 open and 2 laparoscopic. Surgical technique: The patient is positioned in a low lithotomy position with access to vagina in the sterile operative field. A vaginal mesh was inserted. We can use a midline or Pfannenstiel incision. The retropubic space is opened and the bladder is mobilized anteriorly and laterally. A midline cystotomy should be carried posteriorly down to the fistula. The fistula tract could be observed and bilateral ureteral catheters are inserted up to the level of renal pelvises. A mucosal circumferential incision was carried out 3-4 mm away from the fistula excising its tract. Minimal dissection of the bladder from the vagina is needed in order to allow a tension free suture of both the bladder and vaginal defects, which were closed separately. A Foley catheter was placed to further drain the bladder. We closed the bladder is closed in two layers, drained the Retzius space and the wound is closed in layers in a standard manner. Results. The etiology of the fistulas were in all cases after hysterectomy (12 open; 2 laparoscopic) for benign conditions. The median age was 41 years (range 33 and 58 years). In 2 cases (14.28%) we noted fistula reccurence in the first 10 days from the previous reconstruction. In both cases we did a second succesfull attempt using a combined transvesical and transabdominal approach with omental flap interposition at 2 and 3.5 months respectively. No renal unit was lost. Total operative time was aproximately 80 minutes. Blood loss was 100-150 ml.Urethral catheter was left in place for 10 days (range 8-18 days). Ureteral catheters were removed after 8 days (range 5-14 days). During a median follow-up period of 68 months (8-110 months) the patients continued to void normally, without fistula recurrence and had sterile urine cultures. The success rate after first attempt was 87.21% (12 cases from 14). The two failures were approached by transabdominal with omental flap interposition and the result was favorable without fistula reccurence. Conclusions. We should always remember that the first operation is the one most likely to succeed. Transvesical approach is feasible and familiar for urologist. Also due to the fact that the surgery is extraperitoneal, the recovery is relative quick. [ABSTRACT FROM AUTHOR] |
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