Well, I'm really happy to introduce a colleague of mine that I've gotten to know over the past few years. He did his urogyne training at Hamelin, Worldwide Fistula Fund helped support him. He was the first urogyne fellow from the Hamelin system. Dr. Fikada Ienichu is an obstetrician, gynecologist, and a subspecialty trained urogynecologist. He's currently an assistant professor in the Department of Obstetrics and Gynecology at Yaketet 12 Hospital Medical College in Ethiopia and serves as the medical advisor to the International Fistula Alliance and Fistula Foundation. He does a lot of capacity building at sites throughout Africa. I've gotten to know him through the International Society of Fistula Surgeons. He continues to help train and mentor new urogynes through the urogyne program at Hamelin and at McKelley University up in Tigray. We approached him to see if he would... He's a FIGO trained and does FIGO training of fistula surgeons. He is a superb surgeon. I saw he did live surgery when we were in DACA in December, unbelievable cases. He's here today, hopefully he'll get on, to present a VVF repair, also discussing in fairly good detail the principles of a surgical repair. He put this together for us in advance. We're going to hear him speak. In some countries, most of these fistulas are caused by obstetric injuries, but in most regions, atherogenic fistulas are becoming very common. I will not go into the details of the pathophysiology and management of obstetric fistulas, but I'll focus on what defines a simple vesico-vaginal fistula. Some of the attributes of simple vesico-vaginal fistulas are as follows. Simple ones are simple VVFs are very easy to access, and basically this means they are very easily visible during procedure and will be accessible by common surgical instruments for vaginal procedures. Simple VVFs are communication of the bladder, the posterior wall of the bladder, with the vagina. But the circumferential injury, which is a complete discontinuation of the lower hematopoietic tract, should not be present if a fistula is supposed to be a simple vesico-vaginal fistula. And in simple VVFs, the ureters open well inside the bladder, and they're far away from the fistula repair matrix. And simple VVFs should not also involve the continence mechanism. This is basically the urinary bladder neck and the proximal urethra, and there should not be also significant scarring. And the simple VVFs are usually single, and they are in the midline and are small in size. And most fistula surgeons agree that a maximum diameter of the fistula less than two centimeters defines what is a small vesico-vaginal fistula. And after mobilization of tissue in a simple VVF, there should not be significant loss of urinary bladder tissue loss. And if there had been a previous repair, this makes the fistula complex. When it comes to surgical principles of repair of genital urinary fistulas, there is a step-by-step evidence-based recommendations, but what I'm going to discuss is based on the recommendation of experienced fistula surgeons. And this is also following the emphasis on the vaginal route of repair, which is preferable by most surgeons, but most of these principles also hold true for the abdominal route of repair. So the first is optimal tissue mobilization. And what we mean by optimal tissue mobilization is you always, as a fistula surgeon, always have to properly identify tissues, basically properly identifying the urinary tract and vaginal tissues, and planning for the right incision lines, and developing the normal planes of dissection. And most surgeons also do hydro-dissection to help them with tissue identification and developing normal tissue planes using adrenaline saline solution. And there are different techniques, but almost all fistula surgeons now implement what is a flap-splitting technique, and this is basically dissecting the bladder with an investing fascia separate from the vagina and repairing each flap separately. And you also have to develop adequate margins of the flaps with enough width of tissue from the edge to put your sutures. And of course, always also make sure that all corners have been identified. And the second one, and the most, one of the most, you know, the most important principles is always make sure that the ureters are kept safe, and this can be assured by a visualization of the ureters draining well inside the bladder. And sometimes you might require also to catheterize the ureteric stains, particularly if they are close to your surgical site. And these are all better done before you start your dissection. But in some situations, you might be required to mobilize the ureters and actually uncover them out from scars because they could even sometimes be draining outside the bladder margin. And the third principle is always you have to make optimal closure. And what we mean by optimal is usually surgeons prefer to do single layer closure, but it should be watertight. And you have to make sure that your closure should also be tension free. And then always you have to maintain normal anatomy of the repair of your tissues. And usually this can be well visualized after you mobilize your tissue. And then particularly when it comes to the ureters, then you have to make sure that you maintain ureter length. Additional principles of surgical repair of vesicovaginal fistulas include the following. So the first is exposure. And this is also very important because you have to get adequate visibility and access to your surgical site to have optimal closure. So this can be achieved by different means, some of which are adequately, properly positioning your patient, performing episiotomies, vaginal retraction, I mean labial retraction, labial skin retraction, and sometimes performing lateral vaginal voluntations. The other principle is that if there is excess scar, because we all know that scar heals very poorly, then removal of excess scar is also recommended. And mainly this should be done if your margins, edges of repair are covered with a scar. And most surgeons also agree that you have to maintain a normal urethral and bladder vaginal tissue and avoid any unnecessary excision and include any normal tissue of the lower urinary tract and the vagina within the mobilization and reconstruction of your repair. And flaps and grafts are also part of surgical, the surgical repair of, can be parts of surgical repair of VVFs and they are taught to improve healing and give better vaginal patency after closure and also were taught to reduce the risk of urinary incontinence after repair. So, fat flaps, perineal, partial and full thickness skin flaps, muscle flaps and peritoneal flaps all have been and are still being used by different fistula surgeons for different reasons. And this depends on the preference and choice of the surgeon, the skill of the surgeon and as well as the need for specific patients when it comes to, as I said, these indications, these flaps and grafts are done for. So, now we continue with the demonstration of implementation of these basic principles and we have a short video on a case who is a 30-year-old parodist lady who presented with leakage of urine through the vagina immediately after a total abdominal hysterectomy done for someone specified cervical pathology after she had a BIA examination at the health center, which was positive and her medical officer decided to do the procedure. And she has been on antiretroviral therapy for eight years and she had one attained after closure one week after the total abdominal hysterectomy, which had failed and on examination she had a seven blackhead transverse laparotomy scar and there was no mass, no tenderness through the abdomen and on speculum examination, on vaginal examination, she had palpable defects on the vault and during the speculum examination, the tissue was clean, there was no suspicious lesions for any malignancy, there was no signs of infection and routine lab examinations were normal and her viral load was undetectable and renal ultrasound was done in the short normal kidneys. She was diagnosed with a vault, the zicovaginal fistula, with one previous repair failure and so after she was taken to the theater and put on lithotomy, extremely lithotomy positioned and the procedure was conducted and as you can see, it is all started with the surgeon examining the tissue and the vault VVF was clearly visible and there was no scarring, the urethra was not involved, the bladder neck was not involved and as you can see the metal catheter when pushed through came out through the VVF. So this was clearly a vault VVF and the procedure was started by dividing the two bands of tissue that have given the picture of multiple VVFs, but once divided, it is clearly seen that she has one big defect in the vault of the vagina and the bladder opening into the vault of the vagina. So the ureters now are visibly being explored and it was confirmed that there was no ureters within the margin of the fistula and so dissection is now started from the proximal margin of the bladder defect and once the tissue lines have been clearly identified then the incision is made on the proximal edge of the fistula and as you can see when the first incisions are done then the peritoneal cavity is opened, so the bladder edge is grasped with Alice's forceps and the incision is extended on either side of the fistula till the edges of the margins of the fistula. But at the same time, you can see that loops of bowels are gently released from their attachments on the bolts to make sure that the proximal edge of the bladder can be immobilized. And because this is a high fistula, as we call them high fistulas, then it is very important to use your assistant with good traction and counter traction to keep having proper visualization and access to your surgical site. So now the distal edge of the bladder is also accessed and a line of incision is made on the clear line between the vagina and the bladder. And the line of incision is extended to the right edge of the fistula, but at the same time some margin between the vaginal wall and the anterior edge of the bladder is also developed to make sure that the dissection is continued in the proper plane. So it is clearly demonstrated here that the vagina is one of the flaps of the vagina and the rest, the other flap is the bladder with the investing fascia as I described earlier on, and that plane is now being extended. So once the right plane has been developed on the right side, it is extended to the left side following the same line of dissection. It can be clearly seen here that the fine connective tissue between the investing fascia of the bladder and the vagina is kept on, exposed, and a sharp fine dissection is done to access the left corner of the fistula. So once the corner cells have been reached out, then further dissection, distal is done to mobilize adequate tissue from the bladder flap across the distal edge of the fistula. So on getting to the left corner, then a tissue, a granulomatous tissue is found and it was excised. And now as can be seen, the endoperivic fascial attachment of the bladder with the vagina is easily accessed and to properly get on that corner of the fistula before repair, further reflection of the fascia is done off from the vagina. So the same thing is done on the right side of the bladder. But here again, you can see some scar tissue is now identified and excised off from the right edge of the fistula. So further dissection to access the AGC is done, the same thing done on the left side. So, and then some expected bleeding is now being arrested. And you can see that there is now adequate margins of the bladder tissue that is mobilized. So afterwards, the margins, the edges of the fistula are observed and any unexpected excess of tissue is excised. So again, time is taken to make sure that the ureters are not close to the margins of the fistula repair, and that there is no bleeding through from any side of the mobilization in dissection, including the peritoneal cavity. So because this patient also had a previous failure repair, and for such fistulas, like fistulas that are caused by radiation, fistula surgeons prefer to do some tissue flap to give it a better chance of healing. So a peritoneal flap was decided to be performed with this patient. Actually, this was planned even before the procedure was done. So some peritoneum is now being reflected off from the dome of the bladder. We all know that there is a bit of excess peritoneum on the dome of the bladder, which can be commonly used for this purpose. So some peritoneal flap is now being reflected off from the bladder dome. And this is made easy because the peritoneum has been opened during the initial phases of the fistula dissection. So it can be seen that an adequate amount of peritoneum has been reflected. So the first step in the enclosure is securing the edges, the corners, the corners of the fistula. So the right corner has been secured. And now the left corner of the fistula is being repaired and secured. So once the corners of the fistula have been visually confirmed and secured by the first sutures, then the repair is continued from one end of the fistula to the other. So commonly, a Vicryl 2.0 suture is preferred. And I prefer to use a UR6 suture. This is a five eighths of a circle of a needle, and it's rounded. And I also prefer to use the Henning needle holder, which has a little bit of a curve at the tip and helps to pass my needles very easily in deeper cavities, like as you see here in a repair of a high VVF. So the repair is continued from the left corner to the right corner of the VVF. And usually take about four to six millimeters distance between each suture. And most surgeons prefer to do standard interrupted closure. And as much as possible, the urethelium is spared and the sutures are passed through the investing fascia and the detrusor muscle of the blood. So as you can see, the closure is also done in a way that has no tension. The tissue can easily be seen moving very easily with no significant need for tension during closure and even after closure. So closure has been optimally completed. And the next step is putting in a foley catheter into the bladder and doing a diatase. So it is not shown here when the diatase was done, but as you can see, the foley catheter was placed in the bladder and a blue dye with about 200 milliliters of saline was instilled into the bladder. And there was no leakage from any point of the repair. And the dye usually, I prefer to usually keep on the dye till the end of the procedure. So the dye after being instilled is still being kept inside the bladder. And once the closure has been confirmed to be watertight, then the peritoneal patching is continued. So with the peritoneal flap, you can see that the whole of the single layer repair of the bladder has been completely covered by the peritoneum. So none of the sutures are now visible and the whole repair has been covered with the peritoneum flap. And afterwards, the peritoneum is inspected and the bolt edges are inspected and the procedure is completed by closing the bolt. And as you can see here, because this is a bolt fistula, the anatomical normal natural line of repair would be doing a transverse repair, just as it was with the bladder defect. So figure of eight and matra sutures are interchanged to close the vaginal bolt. And because there was adequate mobilization of the attached bowel loops have been done during the dissection. And so there's not much fear of injuring the bowel, of course, as long as we stay to put our sutures through the edges of the vaginal bolt. And you can see also still the dye within the draining tube from the foley catheter. And we would just stop it there. He's just closing vagina now. So as any of you know that have done a fistula, the key to fistula repair is mobilization. And he had been he planned a priori to do a peritoneal flap, which is why he got in. But you really don't have to get in all the time. And you could tell the tissue after getting rid of some of the scar tissue was actually quite well vascularized. He closed with bites that inverted the urethelium in and did a imbricating layer over that, and then put the peritoneal flap up and then enclosed vagina. He will keep the catheter in probably for two weeks, like we do here. That's 10 days to two weeks, probably two weeks is a pretty good size, size one. So I think he can. So is he going to do chat? So, what the doctor here is asking Fikada is, sometimes he has seen that when they're right at the apex that they can be tough, and so that's why he's asking the question. Okay, is he typing or whatever? I would just say my impression is, I've never, knock on wood, I mean, I've, a cuff fistula, I've always been able to repair it in the vagina. I can usually mobilize it enough. How do you check in the office? Pardon me? How do you, do you check in the office? Do you do it either way? He has response. Okay, what does he say? Dr. Fikada says, not visible proximal edge of fistula, either the vault or in the presence of the uterus in vascu-uterine fistula is attached to abdominal scar, stuck edges to the pubis. So I, what's that? Scarring and immobility. Any follow-ups? Any thoughts? It's nice, yes. It was well-received, Fikada. Any other questions? Okay, thank you so much, Dr. Fikada. We really appreciate you doing this for us. Yes, thank you very much. Take care. Bye-bye. That was great.

vesico-vaginal fistula

urogynecologist

surgical repair

capacity building

peritoneal flaps

atherogenic fistulas

Ethiopia