Postoperative management
Fluid balance
Nursing care of patients who have undergone urogenital fistula repair is of critical importance, and obsessional postoperative management may do much to secure success. As a corollary, however, poor nursing may easily undermine what has been achieved by the surgeon. Strict fluid balance must be kept, and an adequate daily fluid intake should be maintained until the urine is clear of blood. Haematuria is more persistent following abdominal surgery than vaginal procedures, and intravenous fluid is therefore likely to be required for longer in these patients.
Bladder drainage
Continuous bladder drainage in the postoperative period is crucial to success, and nursing staff should check catheters hourly throughout each day, to confirm free drainage and check output. Bladder irrigation and
Figure 13
A Martius labial fat graft may often be necessary to fill dead space suction drainage are not recommended. Views differ as to the ideal type of catheter. The calibre must be sufficient to prevent blockage, although whether the suprapubic or urethral route is used is to a large extent a matter of individual preference. The author's usual practice is to use a 'belt and braces (suspenders)' approach of both urethral and suprapubic drainage initially, so that if one becomes blocked free drainage is still maintained. The urethral catheter is removed first, and the suprapubic retained, and used to assess residual volume, until the patient is voiding normally.
The duration of free drainage depends on the fistula type. Following repair of surgical fistulas, 12 days is adequate. With obstetric fistulas up to 21 days' drainage may be appropriate, and following repair of radiation fistulas 21-42 days are required. If there is any doubt about the integrity of the repair it is wise to carry out dye testing prior to catheter removal. Where a persistent leak is identified free drainage should be maintained for 6 weeks.
Mobility and thromboprophylaxis
The biggest problem in ensuring free catheter drainage lies in preventing kinking or drag on the catheter. Restricting patient mobility in the postoperative period helps with this, and some advocate continuous bed rest during the period of catheter drainage. If this approach is chosen patients should be looked on as being at moderate to high risk for thromboembolism, and prophylaxis must be employed (see Chapter 4).
Figure 14
The vaginal or vulval skin is closed with interrupted sutures to cover the fat graft
Figure 15
Transvesical fistula repair. After its mobilization from the overlying bladder wall, the vagina has been closed with a single layer of inverting interrupted sutures. The Figure shows the bladder being closed with a similar layer of interrupted sutures, picking up the vagina also to close dead space. A continuous suture will be inserted into the urothelium for haemostatic purposes
Antibiotics
Antibiotic cover is advised for all intestinovaginal fistula repairs. If prophylactic antibiotics are not used at urogenital fistula repair, catheter urine specimens should be collected for culture and sensitivity every 48 hours; only symptomatic infection need be treated in the catheterized patient.
Transperitoneal transvesical repair. A midline split is made in the vault of the bladder, and is extended downwards in a racquet shape around the fistula
Figure 16
Transperitoneal transvesical repair. A midline split is made in the vault of the bladder, and is extended downwards in a racquet shape around the fistula
Bowel management
If patients are restricted to bed following urogenital fistula repair, a laxative should be administered to prevent excessive straining at stool. Following abdominal repair of an intestinovaginal fistula patients should either have a nasogastric tube inserted or be restricted to nil by mouth until they are passing flatus; the majority prefer the latter approach. Once oral intake is allowed, or following vaginal repair of a rectovaginal fistula, a low-residue diet should be administered until at least the fifth postoperative day. Some authorities advocate total parenteral nutrition throughout the first week postoperatively for all intestinovaginal fistulas. Enemas and suppositories should be avoided, although a mild aperient such as dioctyl sodium (docusate sodium) is advised to ease initial bowel movements.
Subsequent management
On removal of catheters most patients will feel the desire to void frequently, since the bladder capacity will be functionally reduced after being relatively empty for so long. In any case it is important that the bladder does not become overdistended, and hourly voiding should be encouraged and fluid intake limited. It may also be necessary to wake patients once or twice during the night for the same reason. After discharge from hospital patients should be advised gradually to increase the period between voiding, aiming to achieve a normal pattern by 4 weeks postoperatively. Tampons, pessaries, douching and penetrative sex should be avoided until 3 months postoperatively.
Figure 17
Transperitoneal transvesical repair. The fistulous track is excised and the vaginal or cervical defect closed in a single layer; the bladder is then closed in either one or two layers. An omental interposition graft may also be inserted, particularly when the technique is used for the repair of radiation fistula
Bibliography
Bladou F, Houvenaeghel G, Delpero J, Guerinel G (1995) Incidence and management of major urinary complications after pelvic exenteration for gynecological malignancies, J Surg Oncol 58:91-6.
Chassar Moir J (1967) The vesico-vaginalfistula. London: Bailliere.
Emmert C, Köhler U (1996) Management of genital fistulas in patients with cervical cancer, Arch Gynecol Obstet 259: 19-24.
Hamlin R, Nicholson E (1969) Reconstruction of urethra totally destroyed in labour, BMJ 2:147-50.
Hawley P, Burke M (1985) Anal sphincter repair. In: Henry M, Swash M, editors. Coloproctology and the pelvic floor. Pathophysiology and management. London: Butterworth; pp. 252-8.
Hilton P (1997) Fistulae. In: Shaw R, Souter W, Stanton S, Gynaecology. Edinburgh: Churchill Livingstone; pp. 779-801.
Hilton P (1997) Post-operative urogenital fistulae are best managed by gynaecologists in specialist centres, Br J Urol, 80 (suppl. 1):35-42.
Hilton P (1998) Urodynamic findings in patients with urogenital fistulae, Br J Urol, 81:539-42.
Hilton P (2000) Bladder drainage. In: Stanton SL, Monga AK, editors. Clinical urogynaecology. Edinburgh: Churchill Livingstone; 541-50.
Hilton P, Ward A (1998) Epidemiological and surgical aspects of urogenital fistulae: a review of 25 years experience in Nigeria, Int Urogynecol J, 9:189-94.
Hudson C (1968) Malignant change in an obstetric vesico-vaginal fistula. Proc Roy Soc Med, 61:121-4.
Jonas U, Petri E (1984) Genitourinary fistulae. In: Stanton S, editor. Clinical gynecologic urology, St Louis: CV Mosby; pp. 238-55.
Kelly J, Kwast B (1993) Epidemiologic study of vesico-vaginal fistula in Ethiopia, Int Urogynecol J 4:278-81.
Figure 18
Ureteric re-implantations. Where the bladder cannot easily be mobilized sufficiently, a psoas hitch may allow reimplantation without tension
Kiricuta I, Goldstein A. (1972) The repair of extensive vesicovaginal fistulas with pedicled omentum: a review of 27 cases, J Urol 108:724-7.
Lawson J (1972) Vesical fistulae into the vaginal vault, Br J Urol 44:623-31.
Lawson J (1978) The management of genito-urinary fistulae, Clin Obstet Gynaecol 6:209-36.
Lawson J, Hudson C (1987) The management of vesico-vaginal and urethral fistulae. In Stanton S, Tanagho E, editors, Surgery for female urinary incontinence. Berlin: Springer; pp. 193-209.
Lee R, Symmonds R, Williams T (1988) Current status of genitourinary fistula, Obstet Gynec 71:313-19.
Parks A, McPartlin J (1971) Late repair of injuries of the anal sphincter, Proc Roy Soc Med 64:1187-9.
Sultan A, Kamm M, Hudson C, Bartram C (1994) Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair, BMJ 308:887-91.
Waaldijk K (1989) The surgical management of bladder fistula in 775 women in Northern Nigeria. MD Thesis, University of Amsterdam.
White A, Buchsbaum H, Blythe J, Lifshitz S (1982) Use of the bulbocavernosus muscle (Martius procedure) for repair of radiation-induced recto vaginal fistulas, Obstet Gynecol 60:114-18.
World Health Organization (1989) The prevention and treatment of obstetric fistulae: a report of a Technical Working Group. Geneva: WHO.
Yeates W (1987) Uretero-vaginal fistulae. In: Stanton S, Tanagho E, editors. Surgery for female urinary incontinence, Berlin: Springer, pp. 211-17.
Zacharin R (1988) Obstetric fistula. Vienna: Springer.
Figure 19
For high ureteric injury the Boari-Ockerblad technique may be appropriate, utilizing a flap of bladder wall to fill the deficiency
Figure 20
Repair of a low rectovaginal fistula. After the lesion has been converted into a widely mobilized. The rectal wall is closed using a continuous suture
'complete perineal tear', the tissues are
Figure 21
The 'overlapping' technique of sphincter repair
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