VESICO-VAGINAL FISTULA

Objective: To evaluate the outcome of Vesico-vaginal Fistulae (VVF) repair by abdominal and vaginal route. Design: Interventional / clinical trial. Setting: Department of Urology, Chandka Medical College Teaching Hospital and Almas Medical Centre Larkana. Period: Feb; 2005 to Nov; 2010. Patients/Methods: After routine clinical examination and investigation, patients having Vesico-vaginal Fistulae (VVF) were selected for repair. All patients had under gone examination those anesthesia (EUA) and cystoscopy. The patients having complex fistulae or associated with urethral, ureteric and colonic involvement or with preexisting malignant pelvic pathology were excluded from the study. Patients were divided in to 02 groups on the basis of the site of the fistula and the method of repair. Group-I comprised of those patients who had low type or uncomplicated fistulae and were operated by vaginal approach. Group-II consisted of those patients who had high type or large fistulae and were operated by abdominal approach. Postoperative follow up was carried out on weekly basis for 03 to 06 months. Results: Our study included 32 cases. Group-I and II comprised of 18 and 14 patients respectively. The mean age was 34 years (ranged from 22 to 45 years). The main cause of vesico-vaginal fistulae was obstetrical in 28(87.5%) and iatrogenic gynecological (hysterectomy) in 04 (12.5%) patients. No major difficulty was experienced except in 01(0.83%) case in group-1 who had a previous failure history of repair. The mean operative time was 95 minutes (range 80 to 125 minutes) & 145 minutes (range 110 to 175 minutes) in group-1 and group-2 respectively. Peroperative blood transfusion was required in 06 (33.33%) and 13 (93%) patients of group-1 and group-II respectively. Statistically significant difference was found between these two groups (P< 0.05). Postoperative complications like wound infection occurred in 01(7.15%) of group- 1 and haematuria was present for few days in o4 (22.22%) and 05(35.5%) in group-1 and group-2 respectively. The mean hospital stay was 07 (range 5-10) days. Foleys catheter was removed at 02 week time in all cases. The success rate was achieved 15(83.33%) and in all 14 (100%) cases for group-1 and group-2 respectively and statistically no significant difference was found between two groups (P=NS). All the patients were followed up regularly except 03 (16.5%) and 05 (35.5%) patients of group-1 and group-II respectively. Long term complications like urinary stress incontinence was observed in 2 (11.1%) patients of group-I, where as small capacity bladder and stone formation was observed in 02(14.3%) of group-11 cases. Conclusions: Birth trauma is still a major cause of vesico vaginal fistula in our region. Although, there is no significant difference in outcome of different technique but interposition of tissue between suture lines have a vital role to achieve a high success rate. Further more, best chance of success achieved with first attempt of repair. Strategic approach and proper training of medical and paramedical staff is recommended.