VVF/UVF Flashcards
classification WHO
simple single less than 4cm VVF closing mechanism not involved no circumferential defect minimal tissue loss ureters not invovled first attempt repair
WHO complex fistula
as well as failed previous repair radiation fistula intravaginal ureters recto vaginal fstiula, cervicla fistula mutiple
questions on cystosscopy
diagnosis are ureters involved quality of tissues repair classify fistulad foreign bodies, sutures, mesh, stones probes and bougies biopsy estimate bladder volume
put foley catheter in vagina
operative technique
the dissection spltting technique circumferential incision split from bladder define edges tension free closure interrupted 2 layer martius fat pad
may need stent ureters
optimal timing of repair
early is less than 3 weeks
late is more than 3 months
no evidence in literature of success rate difference between these
usually at least 2 months from first leak post hysterectomy
from first day of irradiation leak wait 6 months
main question is when tissues are ready to be repaired
rate of spontaneous closure
very small, 13% of cases for very small <1cm with catheter in
martius fat pad blood supply
This flap receives a blood supply from both external and internal pudendal arteries.
two techniques
splitting technique
excision technique - vaginal skin excised- may shorten vagina
risk of fistula following hysterectomy
0.1-4%
higher with hysterectomy malignant disease
initial management fistula
Attention should be given as appropriate to skin care, nutrition, rehabilitation, counselling and support prior to, and following, fistula repair
tissue care - incontinence
initial management fistula
Attention should be given as appropriate to skin care, nutrition, rehabilitation, counselling and support prior to, and following, fistula repair
tissue care - incontinence
duration of catheter
Ensure that the bladder is continuously drained following fistula repair until healing is confirmed (expert opinion suggests: 10–14 days for simple and/or postsurgical fistulae;
14–21 days for complex and/or post-radiation fistulae).
Weak
diagnosing urethro vaginal fistulae
clincial examination three swab test cystoscopy VCUG.US CT or MRI
principles of urethra vaginal fistula surgery
idenfication fistula plane between vaginal wall and urethra closure urethra watertight interposition tissue closure vaginal wall
complications urethra vaginal fistula repair
SUI 50% may require sling
urethral stenosis 5.6%
complications urethra vaginal fistula repair
SUI 50% may require sling
urethral stenosis 5.6%
advantages of psoas hitch and boari flap 3
fixation bladder above iliac for tension free
submucosal tunnel for anti reflux
implantation into immobilised part of bladder to prevent kinking during filling and emptying
distance for psoas hitch
5-8cm above UO , above this boari flap can be used
blood supply ureter
Medial in the proximal part
Posterior in mid portion
Lateral in distal portion
The abdominal portion of the ureter is supplied mainly by arterial branches medially from the main renal arteries
however, this segment may be uncommonly supplied by branches arising from the abdominal aorta or gonadal arteries.
These branches approach the ureters medially and divide into ascending and descending branches, forming a longitudinal anastomosis on the ureteral wall
The mid-ureter is supplied by branches arising posteriorly from the common iliac arteries
The blood supply to the distal ureter comes laterally from the superior vesical artery, a branch of the internal iliac artery.
psoas hitch procedure
supra inguinal hockey stick incision
divide inferior epigastric and medial um ligament
divide round ligament female
mobilise spermatic cord male
find ureter over common iliacs or behind where umbilical joins IAA
transect ureter
ligate distal stump
mobilise ureter superiorly, stay suture 6 olock, careful blood supply comming laterally
fill bladder
dissect peritoneum over bladder
mobilise bladder - may need divide contralateral medial um ligament
stay sutures
open bladder 3-4 cm oblique incision
out finger in and see if can reach cranially to psoas, if not for boari flap
interrupted stay sutures whole thickness detrusor to psoas tendonw above iliacs and femoral branch GF nerve
do not tie
submucosal tunnel
oval window at bladder end to avoid stenosis neo orifice
bring ureter into tunnel
fix bladder
spatulate ureter 12 oclock
suture achor 5 and 7 oclock
interrupted 6/0 sutures monocryl
achor sutures at entrace to tunnel
stent
close bladder two layers 5/0 and 4/0 monocryl
suprapubic catheter
drain
