Surgical management of genitourinary fistula.

OBJECTIVE To determine the commonest cause of genitourinary fistulae and evaluate the experience of the surgical management. The study was carried out at the Urology Department, Jinnah Postgraduate Medical Centre (JPMC), Karachi. METHODS Twenty two patients were operated including 14 of Vesicovaginal Fistula (WF), and 8 of Ureterovaginal Fistula (UVF). In one patient of WF fistula was extending up to proximal urethra. Out of 14 WF cases, 9 patients underwent transvaginal repairs, 1 extraperitoneal transvesical repair and 1 transperitoneal repair. Three urinary diversions including 1 Mitrofanoff and 2 ileal conduits were also made. Ureteroneocystostomy was done in cases of UVF with adjuvant procedures in 3 cases including Psoas Hitch in 1 and Boari's flap in 2 patients. RESULTS The mean age was 35 (range 21-50) years. WF due to obstetric causes was seen in 71.4% patients while 28.6% developed WF secondary to gynaecological procedures. Majority of (91%) WF were repaired successfully in the first attempt in patients subjected to the procedure (78.6% cases of WF). There was only one recurrence in transvaginal repair, which was successfully treated with extraperitoneal transvesical approach in second attempt, thus augmenting the success rate to 100%. However 3 (21.4%) cases of WF required urinary diversion as there was complete loss of sphincter mechanism in one case, in which fistula was extending up to the urethra, and in two cases of complex WF with complete loss of posterior bladder wall surrounded by extensive scarring. All cases of UVF were successfully treated with ureteroneocystostomy alone or with adjuvant procedure in 37.5% cases. CONCLUSION Uncomplicated WF can be successful repaired transvaginally by refreshing the fistulous edges without excising it. Transabdominal route should be reserved for complicated WF. Ureteroneocystostomy with antireflux mechanism with or without adjuvant procedure is the treatment of choice for UVF resulting from complete transaction or ligation of ureter.