Fistula Pelvic Floor General

Urethral necrosis and proximal urethro-vaginal fistula resulting from tension-free vaginal tape.
Siegel AL
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Mar 15;.

Urethral erosion is an uncommon complication after sub-urethral sling placement using the TVT procedure. Strangulation necrosis of the entire distal urethra with a fistulous connection between proximal urethra and vagina is a devastating complication that has not been previously reported, resulting in significant morbidity and the necessity for challenging management. This is a report of a 64-year-old woman with stress urinary incontinence who underwent a TVT resulting in a large fistula between the proximal urethra and the vagina, and the necrosis of the entire urethra distal to the fistula. This problem necessitated a staged reconstruction involving three separate procedures. Initially, she underwent debridement and removal of the TVT fragments, a secondary vaginal flap urethroplasty with a labial fibro-fatty graft to restore urethral length, and a tertiary coaptive occlusive sling to restore continence.

Fournier's gangrene and its emergency management.
Thwaini A, Khan A, Malik A, Cherian J, Barua J, Shergill I, Mammen K
Postgrad Med J. 2006 Aug;82(970):516-9.

Fournier's gangrene (FG) is a rare but life threatening disease. Although originally thought to be an idiopathic process, FG has been shown to have a predilection for patients with diabetes as well as long term alcohol misuse; however, it can also affect patients with non-obvious immune compromise. The nidus is usually located in the genitourinary tract, lower gastrointestinal tract, or skin. FG is a mixed infection caused by both aerobic and anaerobic bacterial flora. The development and progression of the gangrene is often fulminating and can rapidly cause multiple organ failure and death. Because of potential complications, it is important to diagnose the disease process as early as possible Although antibiotics and aggressive debridement have been broadly accepted as the standard treatment, the death rate remains high.

Fournier gangrene: a radiologic emergency.
Piedra T, Ruiz E, Gonzalez FJ, Arnaiz J, Lastra P, Lopez-Rasines G
Abdom Imaging. 2006 Sep 1;.

Fournier's gangrene (FG) is a life-threatening, necrotizing infection involving the soft tissues of the scrotal area. Because of potential severe complications, it is important to diagnose the disease as early as possible. We present the CT findings of FG in a young male that came to the Emergency Department for genital pain and tenderness.

Sexual intercourse: an unusual cause of vesicovaginal fistula.
Singhal S, Nanda S, Singhal S
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Aug 10;.

Voluntary sexual intercourse in an adult woman with normal vagina is not a known cause of vesicovaginal fistula (VVF), though sexual abuse or sexual intercourse with young girls before reaching physical maturity can result in VVF. Postcoital VVF in an adult woman without these predisposing factors is very infrequent. A nulliparous woman who had VVF after first intercourse is presented, as it is unusual by virtue of etiology

Pregnancy in an untreated case of transverse vaginal septum with vesicovaginal fistula.
Srinath N, Misra DN
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Aug 9;.

An 18-year-old woman presented with history of cyclic hematuria, abdominal pain, and a mass in the hypogastrium. She was found to have transverse vaginal septum in the lower one-third of her vagina with congenital vesicovaginal fistula (VVF) and a dead fetus of approximately 20 weeks gestation. She underwent vaginotomy and removal of the dead fetus. Vaginal repair of VVF was carried out 3 months later.

Management of Urethrovaginal Fistula.
Pushkar DY, Dyakov VV, Kosko JW, Kasyan GR
Eur Urol. 2006 Aug 15;.

OBJECTIVES: Despite the apparent similarity, urethrovaginal fistulas (UVFs) are not identical to vesicovaginal defects. Obstetric trauma and vaginal surgery are the causes of a majority of urethrovaginal fistulas. METHODS: Careful preoperative evaluation is essential for identifying small UVFs or associated vesicovaginal fistulas and includes physical examination, cystourethroscopy, intravenous pyelography, ultrasonography, and urinalysis, but sometimes the final surgical plan can only be decided on after the patient is examined under anaesthesia with a metal sound in the urethra. Significant tissue deficit is the main characteristic of UVF repair and the minimal space present often does not allow placing any additional tissue between the urethral and vaginal walls. RESULTS: Seventy-one women (mean age, 43 yr) with UVFs have been treated in our clinic. Our results have shown successful closure of the fistula in 90.14% of patients after primary surgery and 98.59% after a second operation. Postoperative stress urinary incontinence developed in 37 patients (52.11%). We used both synthetic and autologous slings for their management. Twenty-two patients (59.46%) were cured, 12 (32.43%) were improved, and 3 remained incontinent (8.11%). The long-term results of 21 patients with mean follow-up time of 99.6 mo show no fistula recurrence. Postoperative bladder outlet obstruction (5.63%) was successfully managed by urethral dilation or urethrotomy. CONCLUSIONS: This article gives a detailed description of UVF surgical treatment. An attached DVD demonstrates one case that includes UVF primary repair, recurrent fistula repair, and surgery for continence restoration.

July

Fournier's gangrene: Report of thirty-three cases and a review of the literature.
Tahmaz L, Erdemir F, Kibar Y, Cosar A, Yalcyn O
Int J Urol. 2006 Jul;13(7):960-7.

Fournier's gangrene (FG) is an extensive fulminant infection of the genitals, perineum or the abdominal wall. The aim of this study is to share our experience with the management of this difficult infectious disease. Thirty-three male patients were admitted to our clinic with the diagnosis of FG between February 1988 and December 2003. The patient's age, etiology and predisposing factors, microbiological findings, duration of hospital stay, treatment, and outcome were analyzed. The patients were divided into two groups. The first 21 patients (Group I) were treated with broad-spectrum triple antimicrobial therapy, broad debridement, exhaustive cleaning, and then they underwent split-thickness skin grafts or delayed closure as needed. The other 12 patients (Group II) were treated with unprocessed honey (20-50 mL daily) and broad-spectrum triple antimicrobial therapy without debridement. Their wounds were cleaned with saline and then dressed with topical unprocessed honey. The wounds were inspected daily and the honey was reapplied after cleaning with normal saline. Then, the patients' scrotum and penis were covered with their own new scrotal skin. The mean age of the patients was 53.9 +/- 9.56 years (range = 23-71). The source of the gangrene was urinary in 23 patients, cutaneous in seven patients, and perirectal in three patients. The predisposing factors included diabetes mellitus for 11 patients, alcoholism for 10 patients, malnutrition for nine patients, and medical immunosuppression (chemotherapy, steroids, malignancy) for three patients. The mean duration of hospital stay was 41 +/- 10.459 (range = 14-54) days. Two patients in Group I died from severe sepsis. The clinical and cosmetic results were better in Group II than Group I. Necrotizing fasciitis of the perineum and genitalia is a severe condition with a high morbidity and mortality. Traditionally, good management is based on aggressive debridement, broad-spectrum antibiotics, and intensive supportive care but unprocessed honey might revolutionize the treatment of this dreadful disease by reducing its cost, morbidity, and mortality.

Nonoperative treatment of traumatic rectovesical fistula.
Thurairaja R, Whittlestone T
J Trauma. 2006 Jul;61(1):216-8.

June

Puborectal sling interposition for the treatment of rectovaginal fistulas.
Oom DM, Gosselink MP, Van Dijl VR, Zimmerman DD, Schouten WR
Tech Coloproctol. 2006 Jun;10(2):125-30. Epub 2006 Jun 19.

BACKGROUND: Several techniques are available for the surgical treatment of rectovaginal fistulas, however often the results are rather disappointing. Interposition of healthy, well vascularized tissue may be the key to rectovaginal fistula healing. The present study was aimed at evaluating the outcome of puborectal sling interposition in the treatment of rectovaginal fistulas.METHODS: Between 2001 and 2004, 26 consecutive patients (median age, 40.5 years; range, 15-69 years) with a rectovaginal fistula underwent a puborectal sling interposition. The etiology of the fistulas was: obstetric injury (n=11), complications after prior surgery (n=2), bartholinitis (n=4), cryptoglandular perineal abscess (n=2), inflammatory bowel disease (n=2) and idiopathic causes (n=5). The patients received a questionnaire about fecal continence (before and after surgery) and dyspareunia (after surgery).RESULTS: The median follow-up was 14 months. The recto-vaginal fistula healed in 16 (62%) of 26 patients. In patients who had undergone one or more previous repairs, the healing rate was only 31% versus 92% in patients without previous repairs (p<0.01). The median Rockwood fecal incontinence severity index score did not change as a result of the surgery. Seventeen percent of patients experienced painful intercourse before the operation; after the procedure this problem was encountered by 57% of the patients.CONCLUSIONS: The puborectal sling interposition is only successful in patients without previous repairs and in those with an uneventful postoperative course, however dyspareunia is a major drawback of this procedure.

Laparoscopic treatment of colovesical fistulas: technique and review of the literature.
Tsivian A, Kyzer S, Shtricker A, Benjamin S, Sidi AA
Int J Urol. 2006 May;13(5):664-7.

Colovesical fistula is an uncommon complication of diverticulitis. We present our technique of a laparoscopic approach for treatment of vesicosigmoid fistulas and review the available published literature. We believe that a laparoscopic approach is a feasible and advantageous alternative for the treatment of colovesical fistulas, with low morbidity and short hospital stay.

Conservative management of necrotizing fascitis in children.
Wakhlu A, Chaudhary A, Tandon RK, Wakhlu AK
J Pediatr Surg. 2006 Jun;41(6):1144-8.

BACKGROUND: Necrotizing fascitis (NF) is a severe infection of the subcutaneous tissue and fascia affecting children and adults. Conventional management includes resuscitation, aggressive debridement of necrotic tissue, and sometimes, additional measures such as hyperbaric oxygen and immunoglobulin therapy. This paper reports conservative management of 18 patients with NF with minimal morbidity and mortality. MATERIAL AND METHODS: Patients with NF admitted to our department between January 2000 and February 2004 were included in the study (N = 18). In all cases, the presentation was rapidly progressing cellulitis progressing to cutaneous gangrene between 6 and 18 hours. The patients were managed by aggressive fluid resuscitation, analgesia, broad-spectrum antibiotics, and dressing with liberal quantities of povidone iodine ointment. After separation of the gangrenous skin margins from the surrounding healthy tissue between 24 and 72 hours, dead skin and fascia were removed with forceps on the ward, the wound washed with liberal quantities of water, and the ointment dressing reapplied. This procedure was repeated until all the dead tissue had been removed. Once the wound was granulating, dressings were changed at increasing intervals until healing took place by secondary intention. RESULTS: The patients were aged between 5 days and 11 years. In all, NF began as a small boil progressing to a rapidly spreading cellulitis. None of the patients was operated during the acute stage of the infection. Blackening of the skin and separation of the edges occurred within 8-72 hours, the dead tissue was allowed to separate from the granulating base and could be removed at the bedside with minimal blood loss. Blood transfusion was required only in 2 patients where hemoglobin was < 9 gm/dL. Of the 18 patients, 6 grew group A streptococci and staphylococci in a polymicrobial wound culture, whereas the other 12 had polymicrobial flora without streptococci. The clinical course and outcomes were similar in both types of wounds. There was 1 death in the study group, and 1 patient required skin grafting. All other survivors had healing by secondary intention without disability. The period for complete epithelization varied between 3 and 8 weeks. Patients were discharged home when 70% of the wound had healed. There was extensive scarring in 3 children with NF involving the back. The other children had minimal or no scarring. None of the patients had any restriction in the movement of limbs or joints. These findings were compared with 16 retrospective patients of NF treated before January 2000 by the conventional approach of aggressive early debridement, the results of the conservative approach were superior with shorter hospital stay, lower number of blood transfusions, earlier appearance of granulation tissue, and shorter duration of complete healing. CONCLUSIONS: We conclude that the conservative management of NF offers advantages in morbidity without compromising the outcome. In our hospital setup, conservative treatment was less expensive and easily carried out. We would therefore advocate conservative management for the treatment of this condition.

May

Management of enterovaginal fistulae in a colorectal unit.
Kavanagh DO, Neary P, Dodd JD, Sheahan K, O'Donoghue D, Hyland JM
Tech Coloproctol. 2006 Mar;10(1):63-4.

Gracilis Muscle Transposition for Fistulas Between the Rectum and Urethra or Vagina.
Zmora O, Tulchinsky H, Gur E, Goldman G, Klausner JM, Rabau M
Dis Colon Rectum. 2006 Jun 6;.

PURPOSE: This study was designed to assess the efficacy of gracilis muscle transposition in repairing rectovaginal and rectourethral fistulas. METHODS: Data were retrieved from a retrospective chart review of patients who underwent gracilis muscle transposition for fistulas between the rectum and urethra/vagina. All patients had fecal diversion as a preliminary or concurrent step to fistula repair. Follow-up data were gathered from outpatient clinic visits. Success was defined as a healed fistula after stoma closure. RESULTS: Six females and three males, aged 30 to 64 years, underwent gracilis muscle transpositions from 1999 to 2005. One pouch-vaginal, three rectourethral, and five rectovaginal fistulas were repaired. The etiologies were Crohn's disease (n = 2), iatrogenic injury to the rectum during radical prostatectomy (n = 2), previous pelvic irradiation for rectal cancer (n = 2) or for cervical cancer (n = 1), recurrent perianal abscesses with fistulas (n = 1), and obstetric tear (n = 1). Seven patients underwent previous medical and surgical repair attempts. There were no intraoperative complications. Postoperative complications included perineal wound infection (n = 1) and at the colostomy closure (n = 2). There were no long-term sequelae. At a median follow-up period of 14 (range, 1-66) months since stoma closure, the fistula healed in seven patients. One patient refused ileostomy closure. One patient with severe Crohn's proctitis has a persistent rectovaginal fistula. CONCLUSIONS: Gracilis muscle transposition is a viable option for repairing fistulas between the urethra, vagina, and the rectum, especially after failed perineal or transanal repairs. It is associated with low morbidity and a good success rate. Underlying Crohn's disease and previous radiation are associated with poor prognosis.

April

Clindamycin and rifampicin combination therapy for hidradenitis suppurativa.
Mendonca CO, Griffiths CE
Br J Dermatol. 2006 May;154(5):977-8.

Summary Background Hidradenitis suppurativa (HS) is a chronic inflammatory condition affecting apocrine gland-bearing areas of the skin. There is currently no satisfactory treatment. Objectives To assess the efficacy of a 10-week course of combination clindamycin 300 mg twice daily and rifampicin 300 mg twice daily in the treatment of HS. Methods Patients who had received combination therapy with clindamycin and rifampicin for HS at one U.K. Dermatology Centre between the years 1998 and 2003 were identified from pharmacy records. Their records were analysed retrospectively. Results Fourteen patients with HS had received treatment with combination therapy. Eight of these patients achieved remission and a further two achieved remission when minocycline was substituted for clindamycin. Four patients were unable to tolerate therapy. Conclusions This small retrospective study indicates that combination therapy with clindamycin and rifampicin may be effective for HS. However, there is a need for a placebo-controlled trial.

March

Urethral diverticulum, vesicovaginal, and rectovaginal fistula repairs using a xenograft.
Agarwala N, Cohn A
Obstet Gynecol. 2006 Apr;107(4 Suppl):46S.

Rectourethral fistulae: the perineal approach.
Morey AF
J Urol. 2006 Apr;175(4):1396.

Vesicovaginal fistula: obstetric causes.
Ramphal S, Moodley J
Curr Opin Obstet Gynecol. 2006 Apr;18(2):1 47-51.

PURPOSE OF REVIEW: Obstetric fistula has a devastating impact on the lives of women in poor countries. Currently, there is an international campaign by the World Health Organisation, United Nations Population Fund and other bodies to address this problem. This article reviews recent literature and highlights the paucity of evidence-based data. RECENT FINDINGS: Articles on the pathophysiology, co-morbidities and sequelae including physical injury to 'multiorgan systems' and social consequences associated with obstetric fistula, are discussed. In particular, the devastating social, economic and psychological effects on the health and well-being, reintegration and rehabilitation are addressed. There is a need for prevalence and incidence studies to measure the extent of this problem. The creation of well-equipped fistula centres with multidisciplinary teams to evaluate patients should be the aim. Expert surgeons and optimal databases with personnel to do research will benefit patients. SUMMARY: Prevention should involve alleviation of poverty and improvement in education, maternity services and health. Research on issues such as persistent stress incontinence following fistula closure, management of reduced bladder capacity, best technique for fistula repair, role of vaginoplasty, role of early repair in selective obstetric fistula, future reproductive function, dermatological management, and social and cultural issues must be done to improve women's health.

Rectovaginal fistula after Posterior Intravaginal Slingplasty and polypropylene mesh augmented rectocele repair.
Hilger WS, Cornella JL
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan;17(1):89-92. Epub 2005 Jul 29.

Posterior Intravaginal Slingplasty and mesh augmented rectocele repairs are procedures promoted for correction of vaginal relaxation. There is little data on the complications of these procedures alone or in combination. The first report of rectovaginal fistula after Posterior Intravaginal Slingplasty with graft augmented rectocele repair is presented. A 60-year-old female developed a rectovaginal fistula 3 months after undergoing a Posterior Intravaginal Slingplasty and mesh augmented rectocele repair for prolapse. Two attempts at correcting the fistula failed and there was a recurrence of her vault prolapse. She may now require diverting colostomy and repeat repair of her vault prolapse. The case report highlights the difficulties in treating a rectovaginal fistula that developed after Posterior Intravaginal Slingplasty and mesh augmented rectocele repair for vaginal vault prolapse. More data regarding complications associated with use of these procedures is needed prior to widespread use.

February

Tension-free treatment of large perianal necrotizing fasciitis using quartet rotationplasty.
Ulkur E, Karagoz H, Celikoz B
Plast Reconstr Surg. 2006 Mar;117(3):993-6.

BACKGROUND: In the present study, the authors report their experience with quartet rotationplasty that were performed to cover large perianal defects caused by necrotizing fasciitis with no tension to the anus. METHODS: From April of 2000 to August of 2004, four patients with large perianal necrotizing fasciitis were treated with quartet rotationplasty. The average follow-up period was 10 months. RESULTS: All operations were successful. All large perianal defects were closed with quartet rotationplasty, and there was no tension on the suture lines between the flap and the anus. CONCLUSION: Quartet rotationplasty is a logical and easy means of covering large perianal defects caused by necrotizing fasciitis.

Vesicouterine fistula: a review of eight cases.
Dimarco CS, Dimarco DS, Klingele CJ, Gebhart JB
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Mar 8;.

Eight cases of vesicouterine fistula (VUF) (obstetrical etiology in six cases and inflammatory bowel disease in two) have been treated in the past 14 years. All six obstetrical cases were related to cesarean section. Both cases of colovesicouterine fistula presented acutely with watery vaginal discharge or fecaluria. Presenting complaints were vaginal urinary incontinence (five cases), hematuria (three), and vaginal discharge (two). Diagnosis was made with cystoscopy in seven cases and computed tomography in one. VUF usually was between posterior bladder and anterior uterine walls above the internal os. Of the initial treatments, six were surgical (three hysterectomies) with an abdominal (five) or transvaginal (one) approach. Mean follow up was 9 months (range, 2-24). Urinary incontinence resolved in all surgically treated patients. Two patients reporting cyclic hematuria were initially managed medically (medroxyprogesterone injections), with delayed surgical repair elsewhere. Surgical repair is the primary treatment for VUF. Successful pregnancy and cesarean delivery have been reported after VUF repair, without sequelae.

Jejuno-uterine fistula.
Duttaroy DD, Madhok BM
Eur J Obstet Gynecol Reprod Biol. 2006 Feb 3;.
Ann Intern Med. 2006 Mar 7;144(5):377-8; author reply 378-9.

Diagnosis and conservative treatment of tubercular rectoprostatic fistula.
Kumar S, Kekre NS, Gopalakrishnan G
Ann R Coll Surg Engl. 2006 Jan;88(1):26.

OBJECTIVE: To present our experience with three cases of rectoprostatic fistula with special emphasis on diagnosis and conservative management.PATIENTS AND METHODS: Three middle-aged men presented to us differently. All had spontaneous rectoprostatic fistulas. Biopsy showed tuberculosis though three consecutive urine samples for acid-fast bacilli were negative. None of the patients were immunocompromised. Their upper tracts were normal and all had a past history of pulmonary tuberculosis. They were started on antitubercular drugs and urinary diversion with or without faecal diversion. RESULTS: All fistulae healed completely within 6 weeks of starting antitubercular treatment. One patient healed with bladder neck stenosis that required bladder neck incision. Voiding was normal on 1-year follow-up. CONCLUSION: Spontaneous tubercular rectoprostatic fistulae are rare. There should be a strong clinical suspicion in endemic areas. Prostatic biopsy proves the diagnosis. Conservative management with antitubercular drugs and urinary diversion with or without faecal diversion has a high success rate and should be the first line of treatment even if urine is negative for acid-fast bacilli.

Management of radiotherapy induced rectourethral fistula.
Lane BR, Stein DE, Remzi FH, Strong SA, Fazio VW, Angermeier KW
J Urol. 2006 Apr;175(4):1382-8.

PURPOSE: An increasing number of men are being treated with BT or a combination of external beam radiation therapy and BT for localized prostate cancer. Although uncommon, the most severe complication following these procedures is RUF. We reviewed our recent experience with RUF following radiotherapy for prostate cancer to clarify treatment in these patients. MATERIALS AND METHODS: We recently treated 22 men with RUF following primary radiotherapy for adenocarcinoma of the prostate in 21 and adjuvant external beam radiation therapy following radical prostatectomy in 1. Time from the last radiation treatment to fistula presentation was 6 months to 20 years. RESULTS: Four patients underwent proctectomy with permanent fecal and urinary diversion. RUF repair in 5 patients was performed with preservation of fecal or urinary function. Six patients were candidates for reconstruction with preservation of urinary and rectal function, including 5 who underwent proctectomy, staged colo-anal pull-through and BMG repair of the urethral defect. The additional patient underwent primary closure of the rectum, BMG repair of the urethra and gracilis muscle interposition. Successful fistula closure was achieved in the 9 patients who underwent urethral reconstruction. All 8 candidates for rectal reconstruction showed radiological and clinical bowel integrity postoperatively with 2 awaiting final diverting stoma closure. CONCLUSIONS: With the increasing use of prostate BT the number of patients with severe rectal injury will likely continue to increase. Radiotherapy induced RUF carries significant morbidity and most patients are treated initially with fecal and urinary diversion. In properly selected patients good outcomes can be expected following repair using BMG for the urethral defect along with colo-anal pull-through or primary rectal repair and gracilis muscle interposition.

Fournier's Gangrene: Three Years of Experience with 20 Patients and Validity of the Fournier's Gangrene Severity Index Score.
Tuncel A, Aydin O, Tekdogan U, Nalcacioglu V, Capar Y, Atan A
Eur Urol. 2006 Feb 14;.

OBJECTIVE: To evaluate effective factors in the survival of patients with Fournier's gangrene (FG) and to determine the validity of the Fournier's Gangrene Severity Index (FGSI), which was designed for determining disease severity in these patients. METHODS: The study included 20 men with a median age of 63.5 yr treated for FG between July 2002 and June 2005. The data were evaluated about medical history, symptoms, physical examination findings, vital signs, admission and final laboratory tests, timing and extent of surgical debridement, and antibiotic treatment used. All the patients had radical surgical debridement. The FGSI, which was developed to assign a numerical score that describes the acuity of the disease, was used in our study. This index presents patients' vital signs (temperature, heart and respiratory rates) and metabolic parameters (sodium, potassium, creatinine, and bicarbonate levels, hematocrit, white blood cell count) and computes a score relating to the severity of the disease at that time. The data were assessed according to whether the patient survived or died. RESULTS: Of the evaluated 20 patients, 6 died (30%) and 14 survived (70%). The difference in age between survivors (median age, 60.0 yr) and those who died (median age, 64.5 yr) was not significant (p=0.321). The median extent of the body surface area involved in the necrotizing process in patients who survived and did not survive was 2.3% and 4.8%, respectively (p=0.001). Except for the albumin and alkaline phosphatase levels, no significant differences were found between survivors and who those died in the other admission laboratory parameters. The median admission FGSI scores for survivors and nonsurvivors were 2.0+/-2.2 and 4.0+/-3.7, respectively (p=0.331). CONCLUSIONS: The FGSI score did not predict the disease severity and the patient's survival. Metabolic parameters, predisposing factors, and extent of the disease seemed to be important risk factors for predicting FG severity and whether or not a patient survived.

January

Colouterine fistula secondary to endometriosis with associated chorioamnionitis.
Sriganeshan V, Willis IH, Zarate LA, Howard L, Robinson MJ
Obstet Gynecol. 2006 Feb;107(2):451-3.

BACKGROUND: Intestinal endometriosis may be complicated by bowel obstruction, colonic rupture, sepsis, and rarely, malignant transformation. Fistula formation is extremely rare. CASE: A 26-year-old woman presented at 16 weeks of gestation with an acute abdomen suggestive of ruptured appendicitis. Blood cultures were positive for Bacteroides fragilis. At laparotomy, she was found to have a colouterine fistula with pelvic sepsis. The resected specimens demonstrated extensive uterine adenomyosis and endometriosis of the cecum, with a fistulous tract lined by endometriosis and suppurative inflammation extending from the cecum to the uterine endometrial cavity associated with severe chorioamnionitis and endomyometritis. CONCLUSION: This case illustrates a rare complication of colouterine fistula secondary to intestinal endometriosis.

Spontaneous Intrapartum Vesicouterine Fistula.
Kaaki B, Gyves M, Goldman H
Obstet Gynecol. 2006 Feb;107(2):449-450.

BACKGROUND: Vesicouterine fistulae as an obstetrical complication have been reported only in women with a history of cesarean. We present a patient with no such history who developed a vesicouterine fistula after vaginal delivery. CASE: A 43-year-old gravida 5 at term with no history of cesarean presented in the latent phase of labor. Gross hematuria was noted intrapartum, and a foley catheter was placed. A cystogram showed an extraperitoneal bladder perforation. The patient had urinary incontinence despite Foley catheter drainage. The diagnosis of vesicouterine fistula was made by cystoscopy and fistulogram. The patient had a successful repair at 3 months. CONCLUSION: This is a rare case of a vesicouterine fistula developing during a pregnancy with no previous cesarean. Accurate diagnosis is essential because surgical repair has an excellent outcome.

Rectourethral fistula associated with two short segment urethral strictures in the anterior and posterior urethra: single-stage reconstruction using buccal mucosa and a radial forearm fasciocutaneous free flap.
Erickson BA, Dumanian GA, Sisco M, Jang TL, Halverson AL, Gonzalez CM
Urology. 2006 Jan;67(1):195-8.

INTRODUCTION: We report a novel surgical technique used to repair a rectourethral fistula associated with two short-segment urethral strictures located in the anterior and posterior segments of the urethra in a patient with prior unsuccessful repairs. TECHNICAL CONSIDERATIONS: The anterior urethral stricture was reconstructed with a ventral onlay of buccal mucosa in the exaggerated lithotomy position. In a modified prone position, the rectourethral fistula was repaired using the transrectal transsphincteric (York-Mason) technique and the posterior urethral stricture with a radial forearm fasciocutaneous free flap which was anastomosed to the inferior gluteal artery and vein. The coexistence of a rectourethral fistula and distal urethral stricture requires simultaneous repair, because the urethral pressure from the distal obstruction may compromise fistula closure. Reconstructive efforts should be tailored to minimize disruption of the urethral blood supply in patients with previous pelvic trauma. Rectal and urethral repairs should be separated by well-vascularized tissue to prevent fistula recurrence. CONCLUSIONS: The radial fasciocutaneous flap may offer the reconstructive surgeon another surgical option for complex urethral stricture and rectourethral fistula reconstruction when the local blood supply is in question. Longer follow-up and more cases are needed to further evaluate the continued use of this technique.

Vesicouterine fistula as a complication of forceps delivery: a case report.
Nouira Y, Feki W, Rhouma SB, Salah IB, Horchani A
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Nov-Dec;16(6):512-4. Epub 2005 Apr 5.

We report a case of vesicouterine fistula as a complication of forceps delivery revealed by urinary incontinence in a 68-year-old woman. Diagnosis was confirmed by examination and cystography. The treatment was a transperitoneal excision of the fistula. The literature is briefly reviewed and the treatment options are discussed.

Bulbocavernosus muscle flap in the repair of complicated vesicovaginal fistula.
Xu Z, Fu Q
Int J Urol. 2005 Dec;12(12):1037-40.

AIM: To investigate the transposition of the bulbocavernosus muscle flap for repairing complicated vesicovaginal fistulas. METHODS: Vesicovaginal fistulas were repaired via combined abdominal and perineal approaches. Through an abdominal approach, the fistula and surrounding scar tissue were excised thoroughly. A perineal incision was made between the orifices of the urethra and the vagina, dissecting until the fistula. The vaginal defect was closed through either the abdominal or the perineal approach depending upon its position. Through the abdominal approach, the bladder defect was closed in two layers with the suture lines vertical to each other. The bulbocavernosus muscle was freed through an incision between the labium majus pudendi and the labium minus pudenda, without damaging the pudendal vascular supply. The bulbocavernosus muscle flap was tunneled beneath the labium minus pudendi, and was sutured in place on the bladder wall over the fistula repair site. RESULTS: Nine patients with complicated vesicovaginal fistulas were treated using this technique. After surgery, no symptoms of vagina leakage, urinary incontinence, or urethral stricture were reported by any of the patients, and they reported normal sexual function. CONCLUSIONS: Transposition of the bulbocavernosus muscle flap is an excellent technique with low morbidity and high success rate for repairing complicated vesicovaginal fistulas.

Delayed post-traumatic prostatic-urethrorectal fistula: Transperineal rectal sparing repair - Point of technique.
Singh I, Mittal G, Kumar P, Gangas R
Int J Urol. 2006 Jan;13(1):92-4.

Abstract We describe the outcome and management of an unusual and interesting case of delayed post-traumatic prostatorectal fistula in a 40-year-old man. The fistula was repaired successfully via transperineal access without rectal or sphincteric transgression. We found the transperineal surgical approach simple, effective and useful in approaching the prostatorectal region for rectourinary fistulas. The transperineal approach is useful and should be considered in such select cases. We describe our technique that may be beneficial to many urologists.

Treatment of rectovaginal fistula: A 5-year review.
Casadesus D, Villasana L, Sanchez IM, Diaz H, Chavez M, Diaz A
Aust N Z J Obstet Gynaecol. 2006 Feb;46(1):49-51.

This paper presents a chart review of 17 patients who had been treated for rectovaginal fistula (RVF) from 1996 to 2000. In most cases (13; 76.5%), the fistula was the result of post-surgical complications. Following vaginal mucosa advancement flap repair or repair after conversion to a fourth-degree perineal laceration, 16 (94%) of the rectovaginal fistulae (during the first attempted repair or after failed treatment) were successfully treated. In all patients but one, faecal diversion was avoided. In two patients, fistulography was both a diagnostic procedure and the method of treatment.


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