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1.  Determinants of Postoperative Outcomes of Female Genital Fistula Repair Surgery 
Obstetrics and gynecology  2012;120(3):524-531.
Objective
To determine predictors of fistula repair outcomes 3 months postsurgery.
Methods
We conducted a multicountry prospective cohort study between 2007 and 2010. Outcomes, measured 3 months postsurgery, included fistula closure, and residual incontinence in women with a closed fistula. Potential predictors included patient and fistula characteristics, and context of repair. Multivariable generalized estimating equation models were used to generate adjusted risk ratios (ARR) and 95% confidence intervals (CI).
Results
Women who returned for follow-up 3 month postsurgery were included in predictors of closure analyses (n=1,274). Small bladder size (ARR 1.57; 95% CI 1.39–1.79), prior repair (ARR 1.40; 95% CI 1.11–1.76), severe scarring (ARR 1.56; 95% CI 1.20–2.04), partial urethral involvement (ARR 1.36; 95% CI 1.11–1.66), and complete urethral destruction/circumferential defect (ARR 1.72; 95% CI 1.33–2.23) predicted failed fistula closure. Women with a closed fistula at 3 month follow-up were included in predictors of residual incontinence analyses (n=1041). Prior repair (ARR 1.37; 95% CI 1.13–1.65), severe scarring (ARR 1.35; 95% CI 1.10–1.67), partial urethral involvement (ARR 1.78; 95% CI 1.27–2.48), and complete urethral destruction or circumferential defect (ARR 2.06; 95% CI 1.51–2.81) were significantly associated with residual incontinence.
Conclusions
The prognosis for genital fistula closure is related to preoperative bladder size, previous repair, vaginal scarring, and urethral involvement.
doi:10.1097/AOG.0b013e31826579e8
PMCID: PMC3437437  PMID: 22914460
2.  Current practices in treatment of female genital fistula: a cross sectional study 
Background
Maternal outcomes in most countries of the developed world are good. However, in many developing/resource-poor countries, maternal outcomes are bleaker: Every year, more than 500,000 women die in childbirth, mostly in resource-poor countries. Those who survive often suffer from severe and long-term morbidities. One of the most devastating injuries is obstetric fistula, occurring most often in south Asia and sub-Saharan Africa. Fistula treatment and care are available in many countries across Africa and Asia, but there is a lack of reliable data around clinical factors associated with the success of fistula repair surgery. Most published research has been retrospective. While these studies have provided useful information about the care and treatment of fistula, they are limited by the design. This study was designed to identify practices in care that could lead to the design of prospective and randomized controlled trials.
Methods
Self-administered questionnaires were completed by 40 surgeons known to provide fistula treatment services in Africa and Asia at private and government hospitals. The questionnaire was divided into three parts to address the following issues: prophylactic use of antibiotics before, during, and after fistula surgery; urethral catheter management; and management practices for patients with urinary incontinence following fistula repair.
Results
The results provide a glimpse into current practices in fistula treatment and care across a wide swath of geographic, economic, and organizational considerations. There is consensus in treatment in some areas (routine use of prophylactic antibiotics, limited bed rest until the catheter is removed, nonsurgical treatment for postsurgical incontinence), while there are wide variations in practice in other areas (duration of catheter use, surgical treatments for postsurgical incontinence). These findings are based on a small sample and do not allow for recommending changes in clinical care, but they point to issues for possible clinical trial research that would contribute to more efficient and effective fistula care.
Conclusions
The findings from the survey allowed us to consider clinical practices most influential in the cost, efficacy, and safety of fistula treatment. These considerations led us to formulate recommendations for eight randomized controlled trials on the following subjects: 1) Efficacy/safety of short-term catheterization; 2) efficacy of surgical and nonsurgical therapies for urinary incontinence; 3) technical measures during fistula repair to reduce the incidence of post-surgery incontinence; 4) identification of predictive factors for "incurable fistula"; 5) usefulness of urodynamic studies in the management of urinary incontinence; 6) incidence and significance of multi-drug resistant bacteria in the fistula population; 7) primary management of small, new fistulas by catheter drainage; and 8) antibiotic prophylaxis in fistula repair.
doi:10.1186/1471-2393-10-73
PMCID: PMC2995487  PMID: 21067606
3.  Risk Factors for Obstetric Fistula in Western Uganda: A Case Control Study 
PLoS ONE  2014;9(11):e112299.
Introduction
Two million women worldwide are living with genital fistula with an annual incidence of 50,000–100,000 women. Risk factors for obstetric fistula are context bound. Studies from other countries show variation in the risk factors for obstetric fistula. This study was conducted to identify risk factors for obstetric fistula in western Ugandan context.
Methods
A case control study comparing background factors of women with obstetric fistula (cases) and women without fistula (controls) was conducted in western Uganda. Data was collected using face-to-face interviews. Univariate, bivariate and multivariate analysis was conducted using Stata 12.
Results
Altogether, 420 respondents (140 cases and 280 controls) participated in the study. Duration of labour was used to form the product terms when assessing for interaction and confounding since it was one the most significant factors at bivariate level with a narrow confidence interval and was hence considered the main predictor. After adjusting for interaction and confounding, significant risk factors associated with development of obstetric fistula in western Uganda were: Caesarean section (adjusted odds ratio [AOR]  = 13.30, 95% CI  = 6.74–26.39), respondent height of 150 cm or less (AOR  = 2.63, 95% CI  = 1.35–5.26), baby weight of 3.5 kg or more (AOR  = 1.52, 95% CI  = 1.15–1.99), prolonged labour (AOR  = 1.06, 95% CI  = 1.04–1.08. A quarter of the fistulas had resulted from iatrogenic complication during caesarean section. Compared to no education, post primary level of education was protective against obstetric fistula (AOR  = 0.31, 95% CI  = 0.13–0.72) and there was no difference between respondents without education and those with primary level education.
Conclusions
Surgeons contribute to a big proportion (25%) of fistula cases hence caesarean section being a risk factor in this region. Other risk factors include; prolonged labour, weight of the baby of 3.5 kg or more, respondent height of 150 cm or less (short stature), and low or no education are risk factors for obstetric fistula in western Ugandan.
doi:10.1371/journal.pone.0112299
PMCID: PMC4234404  PMID: 25401756
4.  Non-inferiority of short-term urethral catheterization following fistula repair surgery: study protocol for a randomized controlled trial 
BMC Women's Health  2012;12:5.
Background
A vaginal fistula is a devastating condition, affecting an estimated 2 million girls and women across Africa and Asia. There are numerous challenges associated with providing fistula repair services in developing countries, including limited availability of operating rooms, equipment, surgeons with specialized skills, and funding from local or international donors to support surgeries and subsequent post-operative care. Finding ways of providing services in a more efficient and cost-effective manner, without compromising surgical outcomes and the overall health of the patient, is paramount. Shortening the duration of urethral catheterization following fistula repair surgery would increase treatment capacity, lower costs of services, and potentially lower risk of healthcare-associated infections among fistula patients. There is a lack of empirical evidence supporting any particular length of time for urethral catheterization following fistula repair surgery. This study will examine whether short-term (7 day) urethral catheterization is not worse by more than a minimal relevant difference to longer-term (14 day) urethral catheterization in terms of incidence of fistula repair breakdown among women with simple fistula presenting at study sites for fistula repair service.
Methods/Design
This study is a facility-based, multicenter, non-inferiority randomized controlled trial (RCT) comparing the new proposed short-term (7 day) urethral catheterization to longer-term (14 day) urethral catheterization in terms of predicting fistula repair breakdown. The primary outcome is fistula repair breakdown up to three months following fistula repair surgery as assessed by a urinary dye test. Secondary outcomes will include repair breakdown one week following catheter removal, intermittent catheterization due to urinary retention and the occurrence of septic or febrile episodes, prolonged hospitalization for medical reasons, catheter blockage, and self-reported residual incontinence. This trial will be conducted among 512 women with simple fistula presenting at 8 study sites for fistula repair surgery over the course of 24 months at each site.
Discussion
If no major safety issues are identified, the data from this trial may facilitate adoption of short-term urethral catheterization following repair of simple fistula in sub-Saharan Africa and Asia.
Trial registration
ClinicalTrials.gov Identifier NCT01428830.
doi:10.1186/1472-6874-12-5
PMCID: PMC3353217  PMID: 22433581
Vaginal fistula; Catheter; Non-inferiority randomized controlled trial; Surgery
5.  Factors influencing choice of surgical route of repair of genitourinary fistula, and the influence of route of repair on surgical outcomes: findings from a prospective cohort study 
Bjog  2012;119(11):1344-1353.
Objective
The abdominal route of genitourinary fistula repair may be associated with longer term hospitalisation, hospital-associated infection and increased resource requirements. We examined: (1) the factors influencing the route of repair; (2) the influence of the route of repair on fistula closure 3 months following surgery; and (3) whether the influence of the route of repair on repair outcome varied by whether or not women met the published indications for abdominal repair.
Design
Prospective cohort study.
Setting
Eleven health facilities in sub-Saharan Africa and Asia.
Population
The 1274 women with genitourinary fistula presenting for surgical repair services.
Methods
Risk ratios (RRs) and 95% confidence intervals (95% CIs) were generated using log-binomial and Poisson (log-link) regression. Multivariable regression and propensity score matching were employed to adjust for confounding.
Main outcome measures
Abdominal route of repair and fistula closure at 3 months following fistula repair surgery.
Results
Published indications for abdominal route of repair (extensive scarring or tissue loss, genital infibulation, ureteric involvement, trigonal, supratrigonal, vesico-uterine or intracervical location or other abdominal pathology) predicted the abdominal route [adjusted risk ratio (ARR), 15.56; 95% CI, 2.12–114.00]. A vaginal route of repair was associated with increased risk of failed closure (ARR, 1.41; 95% CI, 1.05–1.88); stratified analyses suggested elevated risk among women meeting indications for the abdominal route.
Conclusions
Additional studies powered to test effect modification hypotheses are warranted to confirm whether the abdominal route of repair is beneficial for certain women.
doi:10.1111/j.1471-0528.2012.03461.x
PMCID: PMC3470701  PMID: 22900837
Developing countries; genitourinary fistula; observational study; propensity score; route of repair; surgery
6.  Factors influencing urinary fistula repair outcomes in developing countries: a systematic review 
We reviewed literature examining predictors of urinary fistula repair outcomes in developing country settings, including fistula and patient characteristics, and peri-operative factors. We searched Medline for articles published between January 1970 and December 2010, excluding articles that were 1) case reports, cases series or contained 20 or fewer subjects; 2) focused on fistula in developed countries; and 3) did not include a statistical analysis of the association between facility or individual-level factors and surgical outcomes. Twenty articles were included; 17 were observational studies. Surgical outcomes included fistula closure, residual incontinence following closure, and any incontinence (dry vs. wet). Scarring and urethral involvement were associated with poor prognosis across all outcomes. Results from randomized controlled trials examining prophylactic antibiotic use and repair outcomes were inconclusive. Few observational studies examining peri-operative interventions accounted for confounding by fistula severity. We conclude that a unified, standardized evidence-base for informing clinical practice is lacking.
doi:10.1016/j.ajog.2012.02.006
PMCID: PMC3398205  PMID: 22475385
Developing countries; obstetric fistula; surgical outcomes; systematic review
7.  Quality care in vesico-vaginal obstetric fistula: case series report from the regional hospital of Maroua-Cameroon 
The World Health Organization (WHO) proposes a successful closure rate for first repair of vesico-vaginal obstetric fistula to be at 85% in each facility, with the continence achievement among the closed cases at 90 %. We are reporting the vesico-vaginal obstetric fistula outcome at the provincial hospital of Maroua-Cameroon from 2005 to August 2007. Among the overall 32 patients with vesico-vaginal fistula operated, 25 patients were at their first operation. The complete closure of vesico-vaginal fistula (VVF) was 23/25 (92%) and among the 23 patients with complete closure 17(74%) had good continence. When we consider only the 25 patients who were at their first operation, the overall closure of VVF was 23/25 (92%) and among them 17/23 (74%) were continent. Large lesion, bladder neck lesions, vaginal adherence and rigid margin are associated with failure/incontinence. These factors must be taken into consideration when preparing patients for surgery or when assigning them to a surgeon within the surgical team.
PMCID: PMC2984323  PMID: 21120005
Obstetric fistula; closure; continence; Cameroon
8.  Transperineal Management for Postoperative and Radiation Rectourethral Fistulas 
The Journal of urology  2012;189(3):966-971.
Purpose
The rectal sphincter preserving transperineal approach has been increasingly used successfully. We analyzed our experience with this surgical approach. A secondary aim was to evaluate the surgical outcome of energy ablative rectourethral fistulas without a concomitant interposition muscle flap.
Materials and Methods
We identified all patients with rectourethral fistula who underwent rectal sphincter preserving transperineal repair from 1998 to 2011. Re-approximation of the urethral mucosa, posterior anastomotic urethroplasty or partial/total prostatectomy with urethrovesical anastomosis was performed for urinary closure. The fistula cohort was divided into 2 groups, including postoperative and energy ablative fistulas, respectively. Success after perineal rectourethral fistula repair was defined as resolution after the first attempt at repair.
Results
A total of 23 patients underwent rectal sphincter preserving, transperineal rectourethral fistula repair. In the postoperative fistula cohort the fistula was successfully resolved in all 10 patients. A dartos interposition muscle flap was used in 2 of 10 patients. In the energy ablative cohort the fistula was successfully closed in 8 of 13 patients. An interposition muscle flap was not placed in 8 patients with an energy ablative fistula, of whom success was achieved in 5. Two of the 5 patients with an energy ablative fistula and a successful outcome without a concomitant interposition muscle flap had urinary extravasation, necessitating temporary catheterization.
Conclusions
Rectal sphincter preserving transperineal repair is a successful surgical method to repair postoperative and energy ablative rectourethral fistulas. An interposition muscle flap should be considered in the setting of energy ablative rectourethral fistulas to increase successful outcomes.
doi:10.1016/j.juro.2012.08.238
PMCID: PMC3570634  PMID: 23009867
urethra; rectum; fistula; surgical flaps; reconstructive surgical procedures
9.  Randomized controlled trial of minimally invasive surgery using acellular dermal matrix for complex anorectal fistula 
AIM: To compare the efficacy and safety of acellular dermal matrix (ADM) bioprosthetic material and endorectal advancement flap (ERAF) in treatment of complex anorectal fistula.
METHODS: Ninety consecutive patients with complex anorectal fistulae admitted to Anorectal Surgical Department of First Affiliated Hospital, Xinjiang Medical University from March 2008 to July 2009, were enrolled in this study. Complex anorectal fistula was diagnosed following its clinical, radiographic, or endoscopic diagnostic criteria. Under spinal anesthesia, patients underwent identification and irrigation of the fistula tracts using hydrogen peroxide. ADM was securely sutured at the secondary opening to the primary opening using absorbable suture. Outcomes of ADM and ERAF closure were compared in terms of success rate, fecal incontinence rate, anorectal deformity rate, postoperative pain time, closure time and life quality score. Success was defined as closure of all external openings, absence of drainage without further intervention, and absence of abscess formation. Follow-up examination was performed 2 d, 2, 4, 6, 12 wk, and 5 mo after surgery, respectively.
RESULTS: No patient was lost to follow-up. The overall success rate was 82.22% (37/45) 5.7 mo after surgery. ADM dislodgement occured in 5 patients (11.11%), abscess formation was found in 1 patient, and fistula recurred in 2 patients. Of the 13 patients with recurrent fistula using ERAF, 5 (11.11%) received surgical drainage because of abscess formation. The success rate, postoperative pain time and closure time of ADM were significantly higher than those of ERAF (P < 0.05). However, no difference was observed in fecal incontinence rate and anorectal deformity rate after treatment with ADM and ERAF.
CONCLUSION: Closure of fistula tract opening with ADM is an effective procedure for complex anorectal fistula. ADM should be considered a first line treatment for patients with complex anorectal fistula.
doi:10.3748/wjg.v16.i26.3279
PMCID: PMC2900719  PMID: 20614483
Acellular dermal matrix; Surgery; Transsphincteric complex fistula
10.  Modified Plug Repair with Limited Sphincter Sparing Fistulectomy in the Treatment of Complex Anal Fistulas 
Frontiers in Surgery  2014;1:17.
Purpose: New technical approaches involving biologically derived products have been used to treat complex anal fistulas in order to avoid the risk of fecal incontinence. The least invasive methods involve filling out the fistula tract with fibrin glue or introduction of an anal fistula plug into the fistula canal following thorough curettage. A review shows that the new techniques involving biologically derived products do not confer any significant advantages. Therefore, the question inevitably arises as to whether the combination of a partial or limited fistulectomy, i.e., of the extrasphincteric portion of the fistula, and preservation of the sphincter muscle by repairing the section of the complex anal fistula running through the sphincter muscle and filling it with a fistula plug produces better results.
Methods: A modified plug technique was used, in which the extrasphincteric portion of the complex anal fistula was removed by means of a limited fistulectomy and the remaining section of the fistula in the sphincter muscle was repaired using the fistula plug with fixing button.
Results: Of the 52 patients with a complex anal fistula, who had undergone surgery using a modified plug repair with limited fistulectomy of the extrasphincteric part of the fistula and use of the fistula plug with fixing button, there are from 40 patients (follow-up rate: 77%) some kind of follow-up informations, after a mean of 19.32 ± 6.9 months. Thirty-two were men and eight were women, with a mean age of 52.97 ± 12.22 years. Surgery was conducted to treat 36 transsphincteric, 1 intersphincteric, and 3 rectovaginal fistulas. In 36 of 40 patients (90%), the complex anal fistulas or rectovaginal fistulas were completely healed without any sign of recurrence. None of these patients complained about continence problems.
Conclusion: A modification of the plug repair of complex anal fistulas with limited fistulectomy of the extrasphincteric part of the fistula and use of the plug with fixing button seems to increase the healing rate in comparison to the standard plug technique.
doi:10.3389/fsurg.2014.00017
PMCID: PMC4287161  PMID: 25593941
anal fistula; plug repair; sphincter sparing fistulectomy; fistula plug; biological plug
11.  Risk Factors of Postoperative Pancreatic Fistula in Curative Gastric Cancer Surgery 
Journal of Gastric Cancer  2013;13(3):179-184.
Purpose
Postoperative pancreatic fistula is a dreadful complication after gastric cancer surgery. The purpose of this study is to evaluate the actual incidence and risk factors of postoperative pancreatic fistula after curative gastrectomy for gastric cancer.
Materials and Methods
A total of 900 patients who underwent gastrectomy for gastric cancer (laparoscopic gastrectomy, 594 patients; open gastrectomy 306 patients) were enrolled between January 2009 and December 2010. Clinical outcomes, including postoperative pancreatic fistula grade based on the International Study Group on Pancreatic Fistula, were investigated.
Results
Overall, the postoperative pancreatic fistula rate was 3.3% (30/900) (1.5% in laparoscopic gastrectomy versus 6.9% in open gastrectomy, P<0.001). Patients who underwent D2 lymphadenectomy, total gastrectomy, splenectomy or distal pancreatectomy showed higher postoperative pancreatic fistula rates (4.7%, 13.8%, 13.6%, or 57.1%, respectively, P<0.001). Patients with postoperative pancreatic fistula had higher morbidity (46.7% versus 13.1%, P<0.001), delayed gas out (4.9 days versus 3.8 days, P<0.001), belated diet start (5.8 days versus 3.5 days, P<0.001) and longer postoperative hospital stay (13.7 days versus 6.8 days, P<0.001). On the multivariate analysis, total gastrectomy (odds ratio 9.751, 95% confidence interval: 3.348 to 28.397, P<0.001), distal pancreatectomy (odds ratio 7.637, 95% confidence interval: 1.668 to 34.961, P=0.009) and open gastrectomy (odds ratio 2.934, 95% confidence interval: 1.100 to 7.826, P=0.032) were the independent risk factors of postoperative pancreatic fistula.
Conclusions
Laparoscopic gastrectomy had an advantage over open gastrectomy in terms of the lower postoperative pancreatic fistula rate. Total gastrectomy and combined resection, such as distal pancreatectomy, should be performed carefully to minimize postoperative pancreatic fistula in gastric cancer surgery.
doi:10.5230/jgc.2013.13.3.179
PMCID: PMC3804677  PMID: 24156038
Stomach cancer; Gastrectomy; Pancreatic fistula; Risk factors
12.  Iatrogenic genitourinary fistula: an 18-year retrospective review of 805 injuries 
International Urogynecology Journal  2014;25(12):1699-1706.
Introduction and hypothesis
Genitourinary fistula poses a public health challenge in areas where women have inadequate access to quality emergency obstetric care. Fistulas typically develop during prolonged, obstructed labor, but providers can also inadvertently cause a fistula when performing obstetric or gynecological surgery.
Methods
This retrospective study analyzes 805 iatrogenic fistulas from a series of 5,959 women undergoing genitourinary fistula repair in 11 countries between 1994 and 2012. Injuries fall into three categories: ureteric, vault, and vesico-[utero]/-cervico-vaginal. This analysis considers the frequency and characteristics of each type of fistula and the risk factors associated with iatrogenic fistula development.
Results
In this large series, 13.2 % of genitourinary fistula repairs were for injuries caused by provider error. A range of cadres conducted procedures resulting in iatrogenic fistula. Four out of five iatrogenic fistulas developed following surgery for obstetric complications: cesarean section, ruptured uterus repair, or hysterectomy for ruptured uterus. Others developed during gynecological procedures, most commonly hysterectomy. Vesico-[utero]/-cervico-vaginal fistulas were the most common (43.6 %), followed by ureteric injuries (33.9 %) and vault fistulas (22.5 %). One quarter of women with iatrogenic fistulas had previously undergone a laparotomy, nearly always a cesarean section. Among these women, one quarter had undergone more than one previous cesarean section.
Conclusions
Women with previous cesarean sections are at an increased risk of iatrogenic injury. Work environments must be adequate to reduce surgical error. Training must emphasize the importance of optimal surgical techniques, obstetric decision-making, and alternative ways to deliver dead babies. Iatrogenic fistulas should be recognized as a distinct genitourinary fistula category.
doi:10.1007/s00192-014-2445-3
PMCID: PMC4234894  PMID: 25062654
Cesarean section; Genitourinary fistula; Hysterectomy; Iatrogenic; Ureteric injury
13.  Guided Treatment Improves Outcome of Patients with Enterocutaneous Fistulas 
World Journal of Surgery  2012;36(10):2341-2348.
Background
The present study was designed to evaluate the effects of guided treatment of patients with an enterocutaneous fistula and to evaluate the effect of prolonged period of convalescence on outcome.
Methods
All consecutive patients with an enterocutaneous fistula treated between 2006 and 2010 were included in this study. Patient information was gathered prospectively. Treatment of patients focused on sepsis control, optimization of nutritional status, wound care, establishing the anatomy of the fistula, timing of surgery, and surgical principles. Outcome included spontaneous and surgical closure, mortality, and postoperative recurrence. The relationship between period of convalescence and recurrence rate was determined by combining the present prospective cohort with a historical cohort from our group.
Results
Between 2006 and 2010, 79 patients underwent focused treatment for enterocutaneous fistula. Cox regression analysis showed that period of convalescence related significantly with recurrence of the fistula (hazard ratio 0.99; 95 % confidence interval 0.98–0.999; p = 0.04). Spontaneous closure occurred in 23 (29 %) patients after a median period of convalescence of 39 (range 7–163) days. Forty-nine patients underwent operative repair after median period of 101 (range 7–374) days and achieved closure in 47 (96 %). Overall, eight patients (10 %) died.
Conclusions
Prolonging period of convalescence for patients with enterocutaneous fistulas improves spontaneous closure and reduces recurrence rate.
doi:10.1007/s00268-012-1663-4
PMCID: PMC3465546  PMID: 22669399
14.  Successful Treatment of Rectovaginal Fistula Complicating Ulcerative Colitis With Infliximab: A Case Report and Review of the Literature 
Rectovaginal fistula is a rare complication of ulcerative colitis (UC) regardless of surgical history of rectum. Various surgical treatment modalities for the closure of rectovaginal fistula have been developed, but a radically curative therapy remains to be developed. Recently, infliximab, the chimeric anti-human tumor necrosis factor alpha (TNF-α) antibody, has been largely applied for the treatment of inflammatory bowel disease (IBD), and a few reports have shown its partial effectiveness in the management of rectovaginal fistulas associated with UC. In the present report, we describe the successful management of a rectovaginal fistula, following the stapled ileo-anal canal anastomosis in a UC patient, by administration of infliximab. The patient was a 40-year-old female, initially diagnosed as UC (total colitis type) at the age of 15. She received a restorative proctocolectomy at the age of 22, and developed a rectovaginal fistula at the eighth postoperative day. The surgical treatment of the fistula was repeated four times during the 10-year period, but it recurred in intervals ranging between 2 months and 5 years after the operation. The last recurrence occurred at the age of 32, but the surgical repair was considered difficult and a conservative management was indicated. At the age of 40, infusions of infliximab were started. Four weeks after the first infusion, drainage from the fistula was evidently reduced, and 2 weeks later, the fistula was completely closed. Thereafter, no recurrence of the fistula is observed, as confirmed by the abdominal magnetic resonance imaging (MRI) and the barium-enema study. From the present case, we concluded that infliximab may be an effective strategy for the management of fistulas associated with UC.
doi:10.14740/jocmr1987w
PMCID: PMC4217757  PMID: 25368705
Ulcerative colitis; Rectovaginal fistula; Anti-human tumor necrosis factor alpha antibody
15.  Laparoscopic fistula excision and omentoplasty for high rectovaginal fistulas: a prospective study of 40 patients 
Aim
The aim of this study is to prospectively evaluate 40 patients with a high rectovaginal fistula treated by a laparoscopic fistula division and closure, followed by an omentoplasty.
Patients and methods
Forty patients with a rectovaginal fistula, between the middle third of the rectum and the posterior vaginal fornix, resulting from different causes (IBD, iatrogenic and birth trauma) were treated by a laparoscopic excision of the fistula and insertion of an omentoplasty in the rectovaginal septum. The patients completed the gastrointestinal quality of life index questionnaire (GIQLI) and the Cleveland Clinic incontinence score (CCIS). All tests were performed at regular intervals after treatment.
Results
In 38 (95%) patients with a median age of 53 years (range 33–72), the surgical procedure was feasible. In two patients, the fistula was closed without an omentoplasty, and a diverting stoma was performed. The median follow-up was 28 months (range 10–35). Two patients (5%) developed a recurrent fistula. In one patient, the interposed omentum became necrotic and was successfully treated laparoscopically. In another patient, an abscess developed, which needed drainage procedures. The mean CCIS was 9 (range 7–10) before treatment and 10 (range 7–13) after treatment (p = 0.5 Wilcoxon). The median GIQLI score was 85 (range 34–129) before treatment and 120 (range75–142) after treatment (p = 0.0001, Wilcoxon).
Conclusions
Laparoscopic fistula excision combined with omentoplasty is a good treatment modality with a high healing rate for high rectovaginal fistulas and an acceptable complication rate.
doi:10.1007/s00384-011-1259-8
PMCID: PMC3197910  PMID: 21701809
Omentoplasty; Omentum; Laparoscopic fistula excision; Rectovaginal fistulas; Rectovaginal septum
16.  Depression among women with obstetric fistula, and pelvic organ prolapse in northwest Ethiopia 
BMC Psychiatry  2013;13:236.
Background
The prevalence of depression is not well studied among women with pelvic floor disorders. Hence, this study aimed to determine the prevalence of depression and its associated factors among women with pelvic floor disorders.
Methods
A cross-sectional study was conducted among 306 women with one or more of the advanced pelvic floor disorders who attended at the gynaecologic outpatient clinic of Gondar university referral hospital in the six months data collection period. Women who complained of urinary or faecal incontinence or protruding mass per vagina were assessed and staged accordingly. Eligible women i.e. those with advanced pelvic organ prolapse or obstetric fistula were included consecutively. A structured questionnaire was used to obtain socio-demographic data and medical histories for all consenting women. Interviews were done by a female midwife nurse. Depression measures were obtained using the Beck’s Depression Inventory (BDI) tool administered by the midwife nurse after intensive training. Data were entered into a computer using Epi Info version 3. 5.3, and then exported to SPSS version 20 for analysis. Multiple logistic regressions were fitted and Odds ratios with 95% confidence intervals were calculated to identify associated factors.
Results
Of the 306 women interviewed, 269 had advanced pelvic organ prolapse (stages 3 and 4), 37 had obstetric fistula. All four women (100%) with both faecal and urinary incontinence, 97.0% those with urinary incontinence due to obstetric fistula and 67.7% of those with advanced pelvic organ prolapse (stages 3 and 4) had symptoms of depression. Depression was significantly associated with age 50 years or older (P < 0.01), marital status (P < 0.05), history of divorce (p < 0.01), self perception of severe problem (P < 0.05), and having stage 3 pelvic organ prolapse (P < 0.01).
Conclusion
Women with advanced pelvic organ prolapse, and obstetric fistula had high prevalence of depressive symptoms. A holistic management approach, including mental health care is recommended for women having such severe forms of pelvic floor disorders.
doi:10.1186/1471-244X-13-236
PMCID: PMC3849390  PMID: 24070342
Depression; Pelvic organ prolapse; Obstetric fistula; Ethiopia
17.  Management of urethrocutaneous fistula after hypospadias surgery – An experience of thirty-five cases 
Introduction:
The commonest complication following hypospadias repair is occurrence of urethrocutaneous fistula. The smaller fistulas (<2 mm) are easier to close with a simple closure whereas larger ones (>2 mm) with good vascular surrounding skin require a local skin flap closure for avoiding overlapping suture lines. For the recurrent/larger fistulas with impaired local surrounding skin - incidence of recurrence is significantly reduced by providing a waterproofing interposition layer.
Aims:
To study the effect of size, location, number of fistulas and surrounding tissues in selecting the procedure and its outcome. To identify various factors involved in the recurrence and to formulate a management in the cases where recurrence has occurred.
Patients and Methods:
This study of 35 cases of urethrocutaneous fistula repair was done from July 2006 to May 2009 to achieve better results in fistula management following hypospadias surgery.
Statistical analysis used:
X2 test and Fisher's exact test.
Results:
The overall success rate for fistula repair at first attempt was 89% with success rates for simple closure, layered closure and closure with waterproofing layer being 77%,89% and 100%, respectively. The second attempt success rate at fistula repair for simple closure and closure with waterproofing layer were 33% and 100%, respectively. At third attempt the two recurrent fistulas were managed by simple closure with a waterproofing interposition layer with no recurrence. All the waterproofing procedures in this study had a success rate of 100%.
Conclusions:
The treatment plan for a fistula must be individualized based on variables which has an effect on the outcome of repair and to an extent dictates the type of repair to be performed. The significantly improved success rates with the addition of a waterproofing layer suggests the use of this interposition layer should be done at the earliest available opportunity to prevent a reccurence rather than to reserve it for future options.
doi:10.4103/0970-0358.81456
PMCID: PMC3111134  PMID: 21713169
Hypospadias; tunicavaginalis; urethrocutaneous fistula; waterproofing layer
18.  Treatment Strategies in 135 Consecutive Patients with Enterocutaneous Fistulas 
World Journal of Surgery  2008;32(3):445-453.
Background
Enterocutaneous fistulas (ECF) pose a major challenge to every gastrointestinal (GI) surgeon. Based on earlier studies, a standardized treatment guideline was implemented. The focus of the present study was to assess that guideline and determine prognostic factors for outcome of patients with ECF, and to define a more detailed therapeutic approach including the convalescence time before restorative surgery.
Methods
All patients with ECF treated between 1990 and 2005 were included. Management consisted of controlling Sepsis, Optimization of nutritional state, Wound care, assessment of fistula Anatomy, Timing of surgery, and Surgical strategy (the SOWATS guideline). Prognostic factors were assessed by way of multiple logistic regression analysis.
Results
A total of 135 patients were treated at our unit. Overall closure was achieved in 118 patients (87.4%). Restorative operations for fistula closure were performed after a median of 53 days (range: 4–270 days). Restorative operations were successful in 97/107 patients (90.7%). Thirteen patients (9.6%) died. An abdominal wall defect was the most predominant negative prognostic factor for spontaneous closure (odds ratio [OR] = 0.195, confidence interval [CI] 0.052–0.726, p = 0.015). A strong relation was found between preoperative albumin level and surgical closure (p < 0.001) and mortality (p < 0.001).
Conclusions
Application of the SOWATS guideline allowed a favorable outcome after a short convalescence period. Abdominal wall defects and preoperative hypoalbuminemia are important prognostic variables.
doi:10.1007/s00268-007-9371-1
PMCID: PMC2248608  PMID: 18175171
19.  Pancreatic Fistula Rates After 462 Distal Pancreatectomies: Staplers Do Not Decrease Fistula Rates 
Introduction
Pancreatic fistula is a major source of morbidity after distal pancreatectomy (DP). We reviewed 462 consecutive patients undergoing DP to determine if the method of stump closure impacted fistula rates.
Methods
A retrospective review of clinicopatologic variables of patients who underwent DP between February 1994 and February 2008 was performed. The International Study Group classification for pancreatic fistula was utilized (Bassi et al., Surgery, 138(1):8–13, 2005).
Results
The overall pancreatic fistula rate was 29% (133/462). DP with splenectomy was performed in 321 (69%) patients. Additional organs were resected in 116 (25%) patients. The pancreatic stump was closed with a fish-mouth suture closure in 227, of whom 67 (30%) developed a fistula. Pancreatic duct ligation did not decrease the fistula rate (29% vs. 30%). A free falciform patch was used in 108 patients, with a fistula rate of 28% (30/108). Stapled compared to stapled with staple line reinforcement had a fistula rate of 24% (10/41) vs. 33% (15/45). There is no significant difference in the rate of fistula formation between the different stump closures (p=0.73). On multivariate analysis, BMI>30 kg/m2, male gender, and an additional procedure were significant predictors of pancreatic fistula.
Conclusions
The pancreatic fistula rate was 29%. Staplers with or without staple line reinforcement do not significantly reduce fistula rates after DP. Reduction of pancreatic fistulas after DP remains an unsolved challenge.
doi:10.1007/s11605-008-0636-2
PMCID: PMC3806097  PMID: 18704597
Distal pancreatectomy; Pancreatic fistula
20.  Risk of Fecal Diversion in Complicated Perianal Crohn’s Disease 
The purpose of the study was to determine the overall risk of a permanent stoma in patients with complicated perianal Crohn’s disease, and to identify risk factors predicting stoma carriage. A total of 102 consecutive patients presented with the first manifestation of complicated perianal Crohn’s disease in our outpatient department between 1992 and 1995. Ninety-seven patients (95%) could be followed up at a median of 16 years after first diagnosis of Crohn’s disease. Patients were sent a standardized questionnaire and patient charts were reviewed with respect to the recurrence of perianal abscesses or fistulas and surgical treatment, including fecal diversion. Factors predictive of permanent stoma carriage were determined by univariate and multivariate analysis. Thirty of 97 patients (31%) with complicated perianal Crohn’s disease eventually required a permanent stoma. The median time from first diagnosis of Crohn’s disease to permanent fecal diversion was 8.5 years (range 0–23 years). Temporary fecal diversion became necessary in 51 of 97 patients (53%), but could be successfully removed in 24 of 51 patients (47%). Increased rates of permanent fecal diversion were observed in 54% of patients with complex perianal fistulas and in 54% of patients with rectovaginal fistulas, as well as in patients that had undergone subtotal colon resection (60%), left-sided colon resection (83%), or rectal resection (92%). An increased risk for permanent stoma carriage was identified by multivariate analysis for complex perianal fistulas (odds ratio [OR] 5; 95% confidence interval [CI] 2–18), temporary fecal diversion (OR 8; 95% CI 2–35), fecal incontinence (OR 21, 95% CI 3–165), or rectal resection (OR 30; 95% CI 3–179). Local drainage, setons, and temporary stoma for deep and complicated fistulas in Crohn’s disease, followed by a rectal advancement flap, may result in closing of the stoma in 47% of the time. The risk of permanent fecal diversion was substantial in patients with complicated perianal Crohn’s disease, with patients requiring a colorectal resection or suffering from fecal incontinence carrying a particularly high risk for permanent fecal diversion. In contrast, patients with perianal Crohn’s disease who required surgery for small bowel disease or a segmental colon resection carried no risk of a permanent stoma.
doi:10.1007/s11605-006-0029-3
PMCID: PMC1852374  PMID: 17436140
Fecal diversion; Crohn’s disease; Perianal abscesses; Fistulas
21.  Obstetric Fistula in Burundi: a comprehensive approach to managing women with this neglected disease 
Background
In Burundi, the annual incidence of obstetric fistula is estimated to be 0.2-0.5% of all deliveries, with 1000–2000 new cases per year. Despite this relatively high incidence, national capacity for identifying and managing obstetric fistula is very limited. Thus, in July 2010, Medecins Sans Frontieres (MSF) set up a specialised Obstetric Fistula Centre in Gitega (Gitega Fistula Centre, GFC), the only permanent referral centre for obstetric fistula in Burundi. A comprehensive model of care is offered including psychosocial support, conservative and surgical management, post-operative care and follow-up. We describe this model of care, patient outcomes and the operational challenges.
Methods
Descriptive study using routine programme data.
Results
Between July 2010 and December 2011, 470 women with obstetric fistula presented for the first time at GFC, of whom 458 (98%) received treatment. Early urinary catheterization (conservative management) was successful in four out of 35 (11%) women. Of 454 (99%) women requiring surgical management, 394 (87%) were discharged with a closed fistula, of whom 301 (76%) were continent of urine and/or faeces, while 93 (24%) remained incontinent of urine and/or faeces. In 59 (13%) cases, the fistula was complex and could not be closed. Outcome status was unknown for one woman. Median duration of stay at GFC was 39 days (Interquartile range IQR, 31–51 days).
The main operational challenges included: i) early case finding and recruitment for conservative management, ii) national capacity building in obstetric fistula surgical repair, and iii) assessing the psychosocial impact of this model.
Conclusion
In a rural African setting, it is feasible to implement a comprehensive package of fistula care using a dedicated fistula facility, and satisfactory surgical repair outcomes can be achieved. Several operational challenges are discussed.
doi:10.1186/1471-2393-13-164
PMCID: PMC3765123  PMID: 23965150
Obstetric fistula; Comprehensive management; Operational research; Burundi
22.  The Versatility of the Tongue Flap in the Closure of Palatal Fistula 
Aims Tongue flaps were introduced for intraoral reconstruction by Lexer in 1909. A retrospective study was performed in the Department of Oral and Maxillofacial Surgery, S.D.M. College of Dental Sciences (Dharwad, India), to assess the use of tongue flap in closure of palatal fistula.
Material and Methods A total of 40 patients treated for palatal fistulas were included in this study from the period of January 1, 2000, to January 1, 2007; fistulas present in anterior and midpalate were considered. Patients' preoperative photographs, clinical records, and preoperative speech analysis were recorded. Following completion of fistula closure, patients were assessed over 6 months to check flap viability, fistula closure, residual tongue function, aesthetics, and speech impediment.
Results A total of 40 (24 male and 16 female) patients with palatal fistulas were treated with tongue flap in our study. Six patients were 4 to 6 years old, three were 7 to 10 years old, and 22 were 11 to 20 years old, which accounts for 68% of study subjects. There were nine patients 21 to 30 years old. In the early postoperative period, we encountered bleeding in one patient and sloughing in one patient. There are three recurrences, and two flaps were detached; all remaining cases showed satisfactory healing, and donor site morbidity was minimal. No speech deficits were evident.
Conclusion Tongue flaps are used in cleft palate surgery because of their excellent vascularity, and the large amount of tissue that they provide has made tongue flaps particularly appropriate for the repair of large fistulas in palates scarred by previous surgery.
doi:10.1055/s-0032-1313352
PMCID: PMC3578650  PMID: 23997859
tongue flap; palatal fistula; speech intelligibility; hyper nasality; nasal emission; complication
23.  Urogenital fistulae: A prospective study of 50 cases at a tertiary care hospital 
Urology Annals  2010;2(2):67-70.
Introduction:
The misfortunate incident of formation of a urogenital fistula remains a major challenge for surgical urologists worldwide. Such fistulae may not be a life-threatening problem, but surely the women face demoralization, social boycott and even divorce and separation. The fistula may be vaginal, recto-vaginal or a combination of the two. The World Health Organization (WHO) has estimated that in the developing nations, nearly 5 million women annually suffer severe morbidity with obstetric fistulae being the foremost on the list. The objective of our study was to enunciate the patient demography, patient profile, incidence, type of surgery, as well as the long-term outcomes encountered in the management of all types of genital fistulae at a tertiary care centre.
Materials and Methods:
50 consecutive patients, attending the outpatient department with urogenital fistulae, were studied during the period of 5 years from July 2005 to July 2009. All female patients with complaints of urinary incontinence and fecal incontinence and dribbling, patients having a history of obstructed labor, radiotherapy, instrumental delivery, foreign body or trauma and with a history of hysterectomy (abdominal/ vaginal) and lower segment caesarean section (LSCS) were included. A thorough urological examination included a dye study using methylene blue, Renal function tests, X-ray KUB and intravenous urography (IVU). Cystoscopy along with examination under anaesthesia (EUA) were done to assess the actual extent of injury. All patients were subjected to appropriate surgical interventions via the same combination of surgeons . Post operatively, prophylactic antibiotics were administered to all patients and patients were managed till discharge and followed thereafter via regular outpatient visits for a period of 3 years.
Results:
Age of patients ranged from 21 to 40 years. 64% patients hailed from rural areas, 76% were from the lower socio-economic strata, 40% illiterate and 69% were short Statured. Vesico vaginal fistulae (VVF) was seen in 64% cases of which 50% were due to obstructed labor, 19% cases post LSCS and 31% cases post total abdominal hysterectomy (TAH). 68% of urogenital fistulae were between 1 to 3 cms. We obtained a 75% cure rate in UVF, 87.5% cure rate in RVF while a 93.75% cure rate was observed in patients with VVF. 76% of all patients were cured while 8% had a recurrence, probably due to the large size of fistula.
Conclusion:
Genital fistula is preventable, yet it remains a significant cause of morbidity among females of reproductive age group. Despite facilities available, certain conditions like physical, social, economic, illiteracy, and a very casual attitude towards maternal health and children birth practices limit utilization of services for women. It is important that the modern health care providers should be aware of these aspects, so that they can recognize services that are appropriate and acceptable to the people. Thus, one must agree that in cases of urogenital fistulae, "prevention is better than cure".
doi:10.4103/0974-7796.65114
PMCID: PMC2943683  PMID: 20882157
Obstructed labor; urogenital fistulae; vesico vaginal fistula
24.  Surgical repair of genital fistulae — analysis of 62 cases in a tertiary hospital 
Objectives
To determine the etiology of genital fistulae and the outcome of treatment.
Methods
A total number of 62 women with genital fistulae were managed during the period of January 2001 to December 2007. Fifty seven cases were urogenital and five cases were rectovaginal fistulae. They were analyzed with regards to the age, parity, etiology, mode of treatment and outcome. The route of repair was individualized according to the appropriate access of fistulae.
Results
Obstetric complications were the leading cause (79.03) of genital fistula. Majority (78.94%) of urogenital fistulae were treated surgically through vaginal route. Out of 57 cases of urogenital fistulae, 51 cases were repaired successfully in the first attempt and three patients were cured at the second repair. The overall cure rate achieved was 94.8%. All of the five rectovaginal cases were closed after a single attempt.
Conclusions
A high percentage of patients with genital fistulae can be repaired by the experience of surgeon, team work and meticulous surgery with conventional approach.
doi:10.1007/s13224-010-0070-8
PMCID: PMC3394610
genital fistulae; recto-vaginal fistula (RVF); vesico-vaginal fistula (VVF)
25.  Gracilis muscle interposition with primary rectal without urethral repair for moderate sized rectourethral fistula caused by brachytherapy for prostate cancer: a case report 
Introduction
There is a 0.16% chance of a rectourethral fistula after prostate brachytherapy monotherapy using Palladium-103 or Iodine-125 implants. We present an unusual case report of a rectourethral fistula following brachyradiotherapy monotherapy for prostate adenocarcinoma. It was also associated with unusual management of the fistula.
Case presentation
A 58-year-old Caucasian man underwent brachyradiotherapy monotherapy as definitive treatment for verified intracapsular prostate adenocarcinoma receiving 56 Iodine-125 implants using a transrectal ultrasound-guided technique. The patient started to complain of severe perineal pain and mild rectal bleeding 15Â months after brachyradiotherapy. A biopsy of mucosa of his anterior rectal wall was performed. A moderate sized rectourethral fistula was confirmed 23Â months after implantation of Iodine-125 seeds. Laparoscopic sigmoidostomy and suprapubic cystostomy were then performed. Long-term cortisone applications in combination with 30 sessions of hyperbaric oxygen therapy, and antibacterial therapies were initiated due to necrotic infection. A gracilis muscle interposition to create a partition between the patient's rectum and urethra in conjunction with primary rectal repair but without urethral repair were performed 6 months later. The 3cm rectal defect was repaired via a 3cm-long horizontal perineal incision. The 1.5cm urethral defect just below the prostate was not repaired. The patient underwent an optic internal urethrotomy 3Â months later for a 1.5cm-long urethral stricture. Several planned preventive urethral buginages were performed to avoid urethral stricture recurrence. At 12Â months postoperatively, there were no signs of a fistula and cancer recurrence. He now has a normal voiding and anal continence.
Conclusion
Severe rectal pain, bleeding, and local anterior necrotic proctitis are predictors of a rectourethral fistula. Urinary and fecal diversion is the first-step operation. Gracilis muscle interposition in conjunction with primary rectal repair but without urethral reconstruction is one of the reconstructive surgery options for moderate 2cm to 3cm rectourethral fistulas. Internal urethrotomy is a procedure for postoperative urethral strictures of 1.5cm in length.
doi:10.1186/1752-1947-6-323
PMCID: PMC3485089  PMID: 23009550
Brachytherapy; Gracilis interposition; Prostate cancer; Radiotherapy; Rectal repair; Rectourethral fistula

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