Welcome to today's webinar. I'm Fumi Yusuf, the moderator for today's webinar. Before we begin, I'd like to share that we will take questions at the end of the webinar, but you can submit them at any time by typing them into the question box on the left-hand side of the event window. Today's webinar is titled Vaginal Repair of Lower Urinary Tract Fistula and is being presented by Dr. Grace Chen. Dr. Chen is currently an associate professor at the John Hopkins University School of Medicine in Baltimore, Maryland, in the Department of Gynecology and Obstetrics, specializing in female pelvic medicine and reconstructive surgery. She also developed and now leads the John Hopkins Global Health Leadership Program, which is an interprofessional global health learning experience for medical, nursing, and public health students. Dr. Chen is also active in scientific research, specifically in obstetric, fistula, and global health, and in surgical skills assessment and surgical education. She received training specifically in the care of obstetric fistula patients and fistula surgery in Ethiopia and has now worked with local health ministries and international agencies, such as the United Nations Population Fund, on clinical and research initiatives aimed at caring for fistula patients and patients with other pelvic floor disorders in sub-Saharan Africa and South Asia. More recently, she is a part of the ACOG Global Operations Advisory Board and is developing a simulation course designed to better prepare senior OB-GYN residents and faculty with limited global health experience for work in lower resource settings. I'd now like to welcome Dr. Chen to begin her presentation. Thank you for the introduction. I'm excited to give you guys this talk on vaginal repair of lower urinary tract fistula. I have no disclosures. However, I will apologize in advance. I do have a cough. The cough is not infectious. It is, unfortunately, irritative, which can be also quite irritating to the members of this audience. So apologies in advance. In terms of the outline, we're going to spend just a brief amount of time on etiology and epidemiology. We're going to spend the bulk of the time speaking on evidence-guiding perioperative management and surgical principles and techniques involved specifically in vaginal repair of vesicovaginal fistula. The Ebers papyrus from Egypt, circa 1550 B.C., actually contains the earliest reference to pelvic fistula. The oldest fistula was actually found from the mummified remains of Queen Henehet in 2050 B.C. As you can see here, there's a large VVF, vesicovaginal fistula, within a contracted pelvis. Most lower urinary tract fistulas in higher resource settings are due to hysterectomies, which account for over 80% of these fistulas in the U.S. It's estimated to occur in up to 3 out of 1,000 hysts performed. So if we estimate that 200,000 hysterectomies are performed annually, the incidence of lower urinary tract fistulas range between 160 to 600 per year. And as we all know, these fistulas are more commonly associated with laparoscopic hysterectomies. Typically, the etiology is thought to be due to vascular compromise or unrecognized injury. Now, in higher resource settings, we also have fistulas that result from obstetric procedures, C-sections, forceps deliveries, and, of course, fistulas that may also result from other pelvic surgery, urethroidevertecolectomy, incontinence procedures, and also from radiation. Now, in lower resource settings, most lower urinary tract fistulas are resulting from obstructive labor. So the pathophysiology is that the bony fetal head gets entrapped within the bony maternal pelvis, leading to ischemia, eventual necrosis, and fistula formation, of course, of the soft tissue. So the WHO estimates that there are 2 million obstetric fistulas with 50,000 to 100,000 new cases per year. The incidence is estimated at 120 cases per 100,000 births. However, the accuracy of this is unknown, as these are mostly based either on expert opinions or extrapolation from hospital-based data. And as this is an important statistic, some of my work has been focused on developing and validating a symptom-based screening questionnaire for obstetric fistula. So in lower resource settings, obstetric fistulas or pelvic fistulas can also result from, of course, obstructive procedures such as C-sections and forceps delivery. And in fact, as access to care improves in these settings, more and more of these fistulas are being associated with C-sections. There are other causes as well, as you would expect, including hysterectomies, other pelvic surgery, and radiation. So what do some of these fistulas look like? So just for orientation, this is a patient in lithotomy. So this is a weighted speculum. And here you see the urethral meatus. And as you can see here, this is the anterior vaginal wall. And here there are two fistulas. So in a large series of over 1,000 patients done from my work in Ethiopia, we actually found that almost 10% of the patients in our series had multiple fistulas, so more than one. And this underscores the importance when examining these patients to be aware that, of course, you can have more than just one fistula. This is a large fistula which involves the urethra. And I will present later large fistulas or rather small residual bladder size. And those that involve most of the urethra are independent risk factors for repair failure. And in our large series, about 10% of the patients had urethral involvement. In our series, greater than 20% of the fistulas involved or adjacent to the ureters. So again, when planning surgical repair, it is, of course, important to know the location of the ureters. And then finally, 6% of the fistulas in our series were circumferential fistulas. So first, let me direct your attention to this schematic. So this is a sagittal schematic. Here is the pubic bone. Here is the uterus. And this is the bladder and the urethra. So circumferential fistulas, basically the entire proximal bladder has been detached from the urethra. And in this case, again, here is the urethra. Here is the rest of the bladder. So during our question and answer session, I will be showing in the background a surgical video on repair of circumferential fistulas. For this talk specifically, I will actually focus mostly on repair of simple fistulas. But in the video, for those of you guys that are interested in the Q&A portion of the talk, you'll be able to see a surgical video on repair of circumferential fistulas. So before we delve into surgical technique, what are some preoperative evaluations specific to lower urinary tract fistula? Well, this is a tampon's head or bladder type dye test. So very simply, a catheter is placed in the bladder. You retrograde fill the bladder with a dye fluid. You can usually use food dye with saline or water. And you place a gauze or a tampon in the vagina. You can also do a double dye test by retrograde filling the bladder with, again, some sort of a dyed fluid and also giving PO peridium to determine if there may be involvement of the ureters. A retrograde voiding systoleurethrogram can also be performed. And as you can see here, there's contrast in the bladder and contrast in the vagina, and you see a fistula track. This can also be done not just preoperatively but postoperatively after a fistula repair and before catheter removal to check for the integrity of the repair. Obviously, a CT urogram can be performed. So here you can see contrast in the bladder. And although you can't see the fistula track well, you can see contrast in the vagina. So usually this is not needed to diagnose fistula even in higher resource settings unless you're also worried about concomitant ureteral involvement. So this is a CT urogram demonstrating a ureteral vaginal fistula. You can see the dilated ureter, and there's contrast in the vagina. So in most series, the prevalence of isolated ureteral vaginal or ureteral uterine fistula is estimated to be 10% to 15%. Concomitant vesicle vaginal and ureteral vaginal fistula is estimated at 4%. So typically in higher resource settings, it is reasonable to make sure that there is no ureteral involvement. So other perioperative considerations include when should the surgery be performed? So there was a large retrospective analysis basically aimed at challenging the traditional practice of waiting for at least three months before performing surgery. And all the women basically received exams serially. They also received catheter placement and debridement in this series. And surgery was delayed until, quote, necrosis and tissue sloughing has resolved. And in this series, the duration between delivery and repair ranged from three to 75 days, with most of these repairs occurring 60 days or less. Successful closure resulted in greater than 90% of patients, regardless of the timing of repair. So basically, the key here is that there's not necessarily an exact duration of time that one should wait for before fistula repair, that it really depends on the tissue quality. And also importantly, these authors found that the catheter drainage itself resulted in about 15% cure. And usually, these are fistulas that present soon after the delivery, so soon after the onset of injury. And typically, these fistulas are small. And there's been other case series that have also found cure rates in this range for cure associated with just catheter placement. So what do I do? Well, if the fistula presents early or if it's diagnosed early, then I do perform immediate repair, provided that there's no significant inflammation or edema. Having a trial catheter is reasonable if the fistula is small. Obviously, if it's not due to radiation or malignancy. Most theories show that any fistula associated with radiation will require surgical treatment. And even if this does not result in cure or repair or resolution of the fistula, having a trial catheter allows for inflammation and edema to subside so that these patients can then undergo surgical management. So another issue in terms of perioperative planning is then, well, should these fistulas be repaired abdominally or vaginally? So most repairs reported in the literature are done vaginally, greater than 80%, in both higher and lower resource settings. So for both obstetric fistulas and for iatrogenic fistulas. The vaginal approach obviously has minimally invasive surgery benefits, such as faster recovery, decreased hospital time. It's also been shown to be associated with decreased operative time and decreased cost. However, ultimately, it's not clear which route is better. And so the message here is that you should use whatever route you have the most experience. Vaginal approach in general, because of the minimally invasive surgical benefits, is preferred unless there's a need for other abdominal procedures. So, for example, if the patient requires a hysterectomy, if you cannot access the fistula vaginally, obviously if there's ureteral involvement, or if there's a requirement for bladder augmentation or conduit. There's been small series, no randomized controlled trials, but small series comparing vaginal versus abdominal. And they do show that both success rates were comparable. And as would be expected, the hospital stay was, of course, shorter in the vaginal group. However, about 25% of the patients in the vaginal group did experience dyspareunia. So what do I do? I typically do the vaginal approach with the above exceptions. So, obviously, unless there is a need for concomitant abdominal surgery, or if I can't access the fistula vaginally. Now, oftentimes, it may be difficult to access the fistula vaginally. And so a vaginal perineal incision, such as the Schuchardt incision, can be made. And essentially, this is an incision, the perineum extending into the forenecks. And it was actually originally described, this technique originally was described, that included cutting the levator ani muscle. However, oftentimes, you don't need to do that. And it still allows you access to the fistula. So another consideration is whether or not the fistula edges should be trimmed. So there is a randomized control trial of 64 women with obstetric fistula. And they were randomized to trimming or no trimming of the bladder edges. And the women that underwent trimming, generally about half a centimeter of tissue was trimmed. All of the women underwent vaginal VVF repair with a Martius graft. And the primary outcome was absence of fistula on exam at three months. And as would be expected from a randomized control trial, both groups were similar in regards to demographics and fistula characteristics. The authors found that both groups resulted in similar success rates. There was no differences in success rates, irrespective of the location of the fistula, the number of the fistula, whether or not the fistula was a recurrent fistula. However, the authors did find that in the group that underwent trimming, for those women that had failed repairs, obviously their fistulas were larger. However, the limitation with the study was that there was lack of information regarding the amount of fibrosis or scarring. So what do I typically do? I typically do not trim unless there is extensive fibrotic tissue. The other question is, well, should the fistula be repaired in one or two layers? And this can oftentimes be an important consideration, especially dealing with larger fistulas. So in a retrospective series that I did during my time in Ethiopia, which involved over 800 women, and this wasn't a randomized control trial, it was a retrospective series. But it just so happened that approximately 45% of the women underwent a one-layer closure, 55% underwent a two-layer closure, and the success rates were comparable. So what do I do? I typically do a two-layer closure, because again, this was not an RCT, this was just a retrospective series, unless the bladder size will be significantly compromised, or unless I risk damaging the ureters by doing a two-layer closure. So let's review some of the principles of fistula repair. So the first one is, of course, to locate and protect the ureter. And again, just for orientation, this is a way to speculum. So this is the actual photograph, and this is a schematic. And as you can see, the fistula is here and here. This is external urethral meatus, there's a foley in the urethra there, and here are the ureters right here. The fistula should be mobilized from the vaginal epithelium, and again, trimming of the fistula edges is only needed if there is significant fibrosis. Enough of the tissue should be mobilized to allow for tension-free closure. Typically after the first layer, I will do a bladder dye test to check for integrity of my repair. And if minimal, I will add a second layer to imbricate over the first layer. And then finally, of course, close the vaginal epithelium and drain the bladder. So as I mentioned before, the principles are exactly the same for any type of fistula repair, be it what I just described or the Lasko partial cobalt clysis that many of you may be more familiar with. Now the difference here is that there are stay sutures that are placed at the four corners, typically one to two centimeters from the fistula track. Now by placing these stay sutures, this can be used to help both retract the surrounding tissue, and the sutures can be hooked up to a, for example, a Lone Star retractor, as well as a Lasko partial cobalt clysis. And the sutures can be hooked up to a, for example, Lone Star retractor, as well as be used to bring the fistula closer to the vaginal introitus so that it's more accessible. To further increase accessibility to the fistula track, oftentimes a pediatric Foley can be placed within the fistula track with a balloon inflated, and traction then can be placed on the Foley, again, to bring the fistula track closer. So how successful are these fistula repairs? Well, in the obstetric fistula-specific literature, success is estimated at 83% or greater, primarily with the highest rate of success repair after the first attempt, and the success rates decrease after two or more attempts. In the iatrogenic fistula literature, there was actually a 2017 systematic review that included 124 studies, which involved over 1,400 women, with follow-up periods of almost 20 months. In this review, the authors found that less than 4% of the women underwent conservative treatment, be it catheter drainage or some sort of a glue or electrocautery or laser, with a pretty wide range of success rates, specifically with catheter drainage with a duration of anywhere from 2 to 12 weeks. The success rate was about 8%. So most of these women still required surgery. And in terms of the surgical group, about 39% underwent vaginal repair, 36% abdominal, and 15% laparoscopic, with high success rates. And as you can tell, the confidence intervals overlapped, so it's very difficult to say which one is more successful, but they do appear to be all relatively successful. So what are some of the risk factors for failure? So again, in a large retrospective series that I did when I was in Ethiopia of over 1,000 women, we had 11% failure rate. And within that, we found that independent risk factors for failure included complete urethral destruction, severe vaginal scarring. And vaginal scarring is really, in my opinion, a proxy of the extent of ischemic damage that happened when the initial fistula developed. So obviously, if there's more ischemia, more vaginal scarring, this would be a risk factor for failure. The small bladder size, or in other words, a large fistula, and then finally, if the fistula was circumferential. Similar risk factors have been confirmed by other authors and other studies with the addition of prior surgery as a risk factor for repair of failure. And remember, earlier I alluded to that the success is highest after the first attempt. So some of the instruments that may especially facilitate repair includes a lacrimal duct probe. So oftentimes, this is helpful to delineate the fistula track, especially if it's torturous. And oftentimes, you can bend these so that it kind of stays in the fistula track. Obviously, self-retaining retractors. Foleys, I mentioned this earlier, including pediatric foleys. So foleys range quite widely in size, from 6-French to 30-French. And if your fistula is very small, too small for a 6-French foley, then oftentimes, I've used a Fogarty arterial embolectomy catheter, which range even smaller sizes. So this can oftentimes be helpful, especially for iatrogenic fistulas that we see here. Other instruments that I've found helpful in terms of surgical repair of these fistulas include the Gerald tissue forceps with and without teeth. And these are basically forceps with very fine teeth. You may need to utilize scissors from other specialties, such as plastics or ENT. So, for example, in this case, tenotomy scissors with very small, sharp blades, a slightly curved tip can help with the dissection. If you're doing this vaginally, these fistulas can be a little bit more difficult to use. So, for example, if you're doing this vaginally, these fistulas can be a little bit more difficult to use. So, for example, in this case, tenotomy scissors with very small, sharp blades, a slightly curved tip can help with the dissection. If you're doing this vaginally, these fistulas are oftentimes located at the roof or the anterior plane of your operative seal. So having scissors with a curved tip with or without a curved handle can facilitate this dissection, such as these thorax scissors with an angled tip, and then these tonsil scissors. In addition, sharply curved GU or UR needles can also be especially helpful, as oftentimes you are having to suture under the pubic bone or on the underside of the pubic arch. So in order to fully mobilize these fistulas, especially the larger type of fistulas, such as ones that you see in lower resource settings, oftentimes you will need to enter the retropubic space vaginally in order, again, to have sufficient mobilization to allow for this dissection. So, for example, in this case, you may be entering the retropubic space vaginally in order to have sufficient mobilization to allow for tension-free closure. Now, entering this retropubic space may be especially challenging, and it may be difficult to do it bluntly. In addition to, of course, you risk injuring the bladder further. So oftentimes you may have to do this sharply with scissors. And even though most of us don't typically enter the retropubic space vaginally, for those of you that actually perform sacrospinous fixation through an anterior approach, this is actually something you do already. So it may not be as unfamiliar to you. And certainly if you're doing a diaparticulectomy, you know, that involves kind of an anterior portion, you would have to do this as well. So another surgical consideration may be placement of a martius graft, so whether or not one should be placed. So the next series of slides will involve the technique of placing a martius graft. So again, just for orientation, this is a Foley catheter through the external urethromyatis. Here's the labia. And then here you see a schematic of the same thing with the weight of speculum. The fistula has already been closed and this just is mobilization of a Martius graft. So here you see an incision over the labia majora. And in this case, we have preserved the inferior blood supply to the Martius, but it's important to remember that both the inferior or inferior posterior and the anterior blood supply should be secured. So if you're planning to preserve the inferior blood supply, you need to typically secure the anterior blood supply with a clamp and suture, so you need to tie it off. In this case, again, the inferior blood supply has been secured and the Martius has been harvested from an anterior approach. So then the Martius graft, once it's mobilized, it can be mobilized and placed over the previous fistula repair. And you see here that it's been brought over your fistula repair. So what does the evidence demonstrate regarding whether or not a Martius graft is needed? So in oral studies, the success rates did seem to increase from about 70 to 90 percent. The disadvantages with performing a Martius graft routinely, of course, is that it is longer operative time. There is possible increased rates of post-operative infection. Of course, this can be disfiguring. In a retrospective series of more than 400 women with obstetric fistulas who underwent vaginal repair, 50 percent of these women underwent repair with a Martius and 50 percent without a Martius. The failure rates were the same, so the success rates were comparable, even in cases of recurrent fistula. There's been similar findings in other series. So again, the evidence does not show that performing a Martius definitively improves success rates. What about any adverse long-term outcomes? So in a series of over 100 women with mean follow-ups of 85 months, most of these women still had normal sensation. However, 14 percent of women did experience numbness, 7 percent distortion of the labia majora, 5 percent pain. And it's important to know that there were no significant changes in sexual outcomes. However, this question was only answered by a minority of the women. So what do I do? I do not routinely perform a Martius flap. However, in cases of recurrent fistula in which there is tissue compromise, I would of course consider it. And then finally, the duration of bladder drainage with the Foley catheter. How long should we leave the Foley in? So there's been a couple of non-inferiority trials. One that was published in the Lancet that involved different countries and different centers. So the two RCTs, one compared 10 days of continuous drainage versus 14 days. And one that compared 7 days versus 14 days. And again, as would be expected, both groups were similar with regards to demographics and fistula characteristics. And in both studies, the authors found similar rates of success at the time of discharge. Importantly, there was also no differences in length of possible stay, proportion of women with fevers, post-operative infections, incontinence. So what do I do? I typically do 10 days of continuous bladder drainage for simple fistulas. The WHO in 2018 came out with a recommendation of 7 to 10 days. What about post-operative antibiotics while the Foley catheter is in place? So while ACOG does not recommend antibiotic use with intramensin catheterization, there is evidence to support continued antibiotic use with short-term indwelling catheter. In a large RCT, specifically women with obstetric fistulas, who were randomized to either one interoperative dose of antibiotics versus extended antibiotic use while they had the catheters in place. The outcome was successive closure, incontinence, fevers, and infections. The authors found that both groups resulted in similar success rates and there was no difference in length of possible stay, proportion of women with fevers, post-repaired infections, or incontinence. So what do I do? I typically use one dose of intraoperative antibiotics. So in summary, some tips and tricks on vaginal lower urinary tract fistula repairs. So it's important to evaluate for concomitant ureteral involvement. The timing of repair depends on tissue quality. Typically I would recommend vaginal repair if the fistula is accessible and there's no need for abdominal surgery, but really you should pick the route of repair that you're most comfortable with. And again, for accessibility of these fistulas, a vaginal perineal incision can be made if needed. I do not recommend routine trimming of the fistula track unless there is a lot of fibrosis. The fistula should be closed in a tension-free manner, so you should mobilize at least one to two centimeters around the fistula to allow for tension-free closure. When performing a LASCO, place stay sutures at least one to two centimeters from the fistula track. And again, a lone star can be used for retraction. A Foley or artery embolectomy catheter placed in the fistula track can be used for traction on the fistula so that it's more accessible. You may need to use some scissors that are found usually in the plastics tray or the ENT tray, forceps I mentioned such as the Gerald's, and GU needles. In order to mobilize enough of the bladder surrounding the fistula, you may have to enter the retropubic space vaginally. This is usually performed sharply with scissors with tips directed towards the ischiopubic rami so that you do not inadvertently cause more damage. Typically, I recommend checking for a watertight closure after the first layer of repair. Perform an imbricating second layer if possible. Martius graft is not routinely needed, but again, should be considered in cases of recurrent fistula and or if there is tissue vascularity is an issue. For cases of simple fistulas, bladder drainage should be performed for anywhere from seven to ten days. One dose of intraoperative antibiotics is recommended, but prolonged antibiotic use while catheter is in place is not routinely needed. Avoiding cystourethrogram may be performed, especially in high resource settings, after or prior to the catheter removal as this actually may identify any repair failures, which may ultimately heal with longer durations of catheter or bladder drainage. And finally, anyone can become proficient in the skills of fistula surgery. Case in point, this was a monkey that used to visit us doing fistula surgery in Ethiopia at around two o'clock in the afternoon. Thank you very much. Thank you very much, Dr. Chen, for your presentation. It was an excellent, excellent overview, and we really appreciate the take-home points and your perspective on what you do in the OR. We have a few minutes for questions, and you can submit your question for Dr. Chen in the questions box on the left-hand side of the window. So while we're doing that, I'm just going to play the surgical video on repair of a circumferential fistula. And towards the end of that video, there's also a demonstration of a pupal coccygeus sling that can be used for incontinence after successful fistula repair. And I purposely turned the sound off just so I can address any questions. But if you guys would like me to turn the sound on, please respond in the portal, and I'm happy to turn the sound on. Maybe we'll wait for the video to finish and then address a couple of the questions. Yeah, we're actually a bit early, so maybe I'll just turn the sound on and address the questions at the end, because the video itself is only another, I think, five, six minutes. What do you guys think about that? Is that reasonable? Yeah, that sounds like a great plan. Okay. So this is a distal anterior vaginal fistula with the anterior bladder mucosa prolapsing through. The labia minora have already been sutured to the labia majora and a weighted speculum placed for retraction. Hydrodissection is performed with injectable normal saline. SIMS retractor is used to retract the prolapsed bladder interior. Middle catheter is placed in the urethra, and incision has been made around the fistula. The distal anterior vaginal epithelium overlying the proximal urethra is dissected free and sutured to the labia majora for retraction. As there is no vacuum section, sterile cotton gauze is used to maintain a clean operative field. As there is also no electrocautery, bleeders must be sutured to maintain hemostasis. The posterior bladder and fistula edge is dissected free from the proximal anterior vaginal epithelium. The left ureteral orifice is visualized and confirmed with a metal catheter and ureteral stent is placed. If the ureteral orifice is difficult to visualize, intravenous Lasix can be given to facilitate this localization. The right ureteral orifice is visualized and seen to spill urine. Ureteral stent is placed. The bladder and ureter are dissected off the underlying vaginal epithelium. The right anterior side of the bladder is dissected off its paravesical attachments. Often a headlight is helpful to improve visualization. The anterior side of the bladder is further dissected away from the underside of the pubic symphysis. The bladder is completely mobilized. A vicro suture is placed to reconnect the anterior proximal urethra to the anterior distal bladder at 12 o'clock. Another suture is placed at 3 o'clock to reconnect the left proximal urethra to the left distal bladder. A third suture is placed at 9 o'clock to reconnect the right proximal urethra to the right distal bladder. The bladder and urethra are now reconnected anteriorly and laterally with ureteral stents exiting the urethra. What remains is to reconnect the posterior bladder to the posterior urethra and repair any residual defects. A Foley catheter is first placed. A purse string suture is placed at the posterior urethra to the left posterior bladder. Then to the right posterior bladder with care taken to make sure that the Foley is not sutured. This will reconnect the posterior urethra to the posterior bladder. The remainder of the bladder defect is re-approximated in a vertical fashion with care taken not to compromise the ureters. As most obstetric fistulas are large, it is often possible to only perform the closure in one layer without tension. Dye test is performed to check the integrity of the repair. The vaginal epithelium is re-approximated. Vaginal packing is placed for 24 hours. Foley catheter is left to drainage for 10 to 14 days. In a published series addressing the short-term outcomes of circumferential vesicle vaginal fistula repairs in 72 cases, 97% of patients had successful repairs with two patients experiencing wound breakdowns requiring re-operations. The urinary retention rate was 8% with an incontinence rate of 47%, mostly secondary to stress provocations. Therefore, although most of these fistulas were successfully repaired, these patients still leaked urine to some degree. Some experts advocate that a sling be placed at the time of the fistula repair. An autologous fibromuscular sling, such as the pupal coccygeus sling, which can be created and placed vaginally, may be ideal in these patients. This sling is created by detaching the pupal coccygeus muscle and perineal membrane complex proximally from under the pubic rami and sutured in the midline under the urethra. An Alice clamp is used to grasp the distal end of the confluence of the pupal coccygeus muscular tissue and perineal membrane under the pubic ramus. This muscle is detached as it heads proximately. The muscle is detached in a similar manner on the opposite side. Care is taken to ensure that the muscle and perineal membrane remains attached to the pubic bone fistulae. The muscle is re-approximated in the midline with interrupted vicral sutures at approximately the level of the midurethra. In a published series addressing the short-term outcomes after pupal coccygeus slings, in 27 cases, the continence rate was 81% with a retention rate of 15%. In summary, the key surgical principles involved in vaginal repair of obstetric vesicle vaginal fistulas are mobilization of the fistula adequately from the surrounding tissue to allow for tension-free repair of the bladder. Visualization of the ureteral orifice with administration of Lasix to facilitate in dislocalization if necessary. If the ureters may be compromised during the repair, ureteral stents can be placed. The fistula is closed in one layer as there is often not enough tissue to allow for two or more layer closure. Perform a dye test after the bladder closure to ensure that the repair is watertight. A concomitant sling procedure may be necessary in circumferential fistulas to restore the continence mechanism. Foley catheters should be placed to facilitate prolonged continuous bladder drainage to prevent tension on the repair. By adhering to these surgical principles, obstetric vesicle vaginal fistulas can be successfully repaired with simple operating room setups and basic surgical instruments, thereby restoring urinary continence to these patients and restoring their status within their communities. Dr. Chen, that was an excellent video and thank you for sharing that with us. We have a couple of questions. One is given the majority of the data is from obstetrical patients, are your tips and tricks generalizable to the post-hysterectomy or pelvic reconstructive case, the post-surgical case of a vesicle vaginal fistula? Yeah, that's a great question and the audience is absolutely correct that if you look at any pelvic fistula, especially on the management side, so repair literature, most of it is coming from obstetric fistula. And although the type of fistula, the pathophysiology is a little bit different, right? The amount of ischemic damage is usually a lot wider, whereas the type of kind of vascular compromise or ischemic damage we see here are much smaller and more pinpoint. I do, in my experience, most of these type of principles and most of the tips and tricks are absolutely applicable. Now, the instrumentation may be a little bit different, right? Because with iatrogenic fistulas, typically they're going to be high and so you may need the things I talked about such as the pediatric Foley or a Fogarty embolectomy catheter in order to bring the fistula closer to the vaginal introitus or in order to access it vaginally. But the principles in terms of making sure you know where the ureters are, making sure there's tension-free closure, checking for integrity of repair, all of this is really quite applicable. Typically, for iatrogenic fistulas, we do have the luxury of performing more than just a one-layer closure. So that part may not be as applicable. But again, even for obstetric fistulas, if I'm able to perform a two-layer closure, that is and that would be my preference. Great. Our next question is, how do you secure a Martius flap and what does your aftercare look like? So, it depends on where your fistula is. So, you can secure a Martius flap by either preserving the anterior blood supply or the posterior blood supply. And regardless of which blood supply you're planning on preserving, you have to secure the other one, meaning that you can't typically just, let's say you're preserving the inferior blood supply, you can't typically just, you know, dissect the Martius flap and cut the anterior. You typically have to clamp it and suture it. And where or which way you go, it depends on where your fistula is. So, for example, if I'm dealing with a rectal vaginal fistula, which obviously was not the topic of today's talk, typically I do preserve the inferior blood supply of the Martius and sacrifice the anterior in order to be able to swing that flap over. For an anterior or for a vesicle vaginal fistula, it really just depends on the anatomy and it could go either way. But, you know, oftentimes I may secure the posterior and preserve the anterior. It depends after I develop the Martius flap and after I secure it, it depends on how bloody that area looks, whether or not I place a drain. So, oftentimes I have placed a drain in that space in order, again, for hematoma not to form. But if that area looks fairly dry after I have developed my Martius and secured the blood supply, I may just close the labial skin and maybe place some deeper sutures. Got it. Thank you for that advice. You mentioned that with your circumferential fistulas, you often do a pubococcygeus sling. When do you choose to do a rectus fascial sling instead of the pubococcygeus sling? Yeah, so this was a video that I developed when I was in fellowship in Cleveland. And at that time, I had the opportunity to work in Ethiopia for a month. And a pubococcygeus sling was something that my mentor there, Andrew Browning, developed and did. And I have to admit, I have done the sling a couple of times. But I think in general, because I am obviously quite familiar with the rectus autologous fascial sling, and because I know the data behind it, my preference, if the patient is appropriate, my preference is actually to do a rectus fascial sling. Now, the only difference is that I do not typically do a sling concomitant to the fistula repair, meaning that I will typically do a staged procedure. And typically, what Dr. Browning has done is that he will do the fistula repair and then go ahead and add in his pubococcygeus sling. And his rationale is that it's almost like another layer of support. So even if it may not work well for an incontinence procedure, it's another layer of support supporting your repair. And so he will do that concomitantly. And so that's the difference. And so if I'm going to do a pubococcygeus sling, I will also do it concomitantly. But if I'm going to do a rectus sling, then I will stage those patients. Our next question is regarding suture choice. Was that vicryl in the video? And can you comment on the types of sutures that you prefer? That was vicryl in the video. And I do typically use vicryl for my fistula repair. And I also use vicryl when I have or when I'm called in for a bladder injury. So I do typically use vicryl. Got it. And then our last question is regarding radiation and any tips or tricks you have for patients that have been radiated and now have a fistula. Yeah, so those patients obviously are quite challenging. So there are some case theories out there. The largest one is by Dr. Pashkar. And I'm happy to send a reference for this. And in his case theories, these were all radiation-induced vesicle-vaginal fistulas. And they were all repaired vaginally with a Martius flap. So for these fistulas, I do think, you know, if at all possible, I would add some sort of a vascular graft. Because, as you know, with radiation injury, these are microvascular injuries, right? And I don't typically, I mean, depending on the tissue quality, obviously if things are still evolving, then you could rest them or you could place them on a trial catheter and bladder rest and see if they will heal. But I typically don't hear of radiation-induced VVF healing spontaneously with just catheter drainage. The other thing is that these fistulas do not typically occur right after radiation treatment. They typically occur, you know, months, maybe even years after the initial radiation. So typically the tissue has already evolved however it's going to evolve. So, you know, again, when I see these patients, I typically, unless their tissue quality looks like it's still evolving, I will typically take them for surgical repair. And I do typically add in some sort of a vascular graft like the Martius. That makes sense. On behalf of the Oggs Education Committee, I'd like to thank Dr. Chen and everyone for joining us today. Our next webinar is entitled CY2020, Medicare Physician Fee Schedule, Final Rule Changes in Coding and Billing for Office Visits, Biofeedback Procedures, Now Practice RVUs, and the Future of Global Surgical Packages and Payments. And this will be presented by Dr. Stephen Metz, Cedric Oliveira, and Jill Rathbun on December 11th. Thank you again, Dr. Chen, for your excellent presentation. Thank you. Have a good night.

Vaginal Repair

Lower Urinary Tract Fistula

Surgical Management

Urinary Tract Fistulas

Vaginal Repair Techniques

Etiology

Epidemiology

Surgical Principles

Martius Grafts