A Hundred And Fourteen Cases Of Iatrogenic Genital Fistula:A Retrospective Analysis

BackgroudFemale genital fistula is one of the common complications of gynecological and obstetric surgeries,resulting in decreasing of quality of life.With the development of social economy and medical services,obstetric genital fistulas has declined,nonetheless,fistulas still occur after severe perineal lacerations,cesarean deliveries,gynecological surgeries and procedures.Despite improved management,genital fistulas remain a scourge.ObjectiveRetrospective analysis of genital fistula cases related to gynecological and obstetric surgeries was conducted to explore the etiology,clinical manifestations,diagnosis,management and prognosis.MethodsThe medical records of patients with genital fistula related to gynecological and obstetric surgeries admitted in Qilu Hospital of Shandong University were retrospectively reviewed from January 2004 to December 2018.General information,history of present illness,preoperative examination,characteristics of genital fistula,treatment strategy and perioperative preparation were recorded.Patients were followed up by telephone and out-patient consultation system to August 2019.The etiology,clinical manifestations,diagnostic measures and prognosis of female genital fistula were descriptively analyzed.STATA version 13,0 was used to draw histograms and line charts to describe the etiology and growth trend of genital fistula.IBM SPSS version 23.0 was used to analyze the factors affecting the outcome of genital fistula repair.Continuous data were analyzed by Mann-Whitney U test,and two-category data were analyzed by Fisher's exact test All calculated P values were 2 sided,and P values less than 0.05 were considered statistically significant.ResultsA hundred and fourteen patients were included,with a median age of 46(range,21-76 years),including 43 cases of vesicovaginal fistula(VVF),40 of ureterovaginal fistula(UVF),23 of rectovaginal fistula(RVF),and other 8 of uncommon types.Eighty(70.18%)cases of genital fistulas were related to gynecological factors,of which 46(40.35%)were secondary to benign surgery,30(26.32%)secondary to malignant surgery,and only two respectively secondary to forceps curettage and ectopic intrauterine device(IUD).The rest were related to obstetric factors that 18(15.79%)were secondary to laceration of birth canal,10(8.77%)secondary to cesarean section,4(3.51%)secondary to obstructed delivery,and 2(1.75%)secondary lateral episiotomy.The etiologies of genital fistulas varied to the types.VVF was mostly caused by benign gynecological surgery of 26 cases,followed by gynecological malignant surgery of 10.UVF was caused by gynecological benign and malignant surgery equally of 18.RVF was mostly caused by laceration of the birth canal of 18 cases.The number of genital fistula except for those resulted from vaginal deliveries were increasing every year from 2009 to 2016 as the cases associated with laparoscopy increased gradually,subsequently decreasing.And The number of cases related to vaginal delivery seemed to be stable every year with more than 50%occurred before 2000.All of patients with genitourinary fistula presented vaginal urine leakage with varying degrees,parts of whom were also accompanied by urinary tract infections and perineal itching.Besides,most of UVF patients were accompanied by fever,back pain and abdominal pain,and parts of them with nausea,vomiting.All patients underwent one or more the following examination for further diagnosis,including methylene blue test,ultrasound,cystoscope,intravenous pyelograpgy(IVP),or pelvic and abdominal CT,of which cystoscope and IVP were used more frequently.All of RVF patients presented vaginal defecation and exhaustion with varying degrees,parts of whom underwent colonoscopy and pelvic MRI for further diagnosis.Thirty-five(81.40%)patients with VVF underwent surgical repair,of which 31 underwent transabdominal repair as 4 via transvaginal approach.Twenty-nine patients(82.86%)were successfully repaired while 6 patients(17.14%)failed.Thirty-three(82.50%)patients with UVF underwent ureteral reconstruction,of which 31(93.94%)underwent laparoscopic ureteroneocystostomy and 2(6.06%)performing transabdominal simple ureteral repair.The median time of postoperative ureteral stent placement was 9 weeks(range,6-1 8),and all patients successfully repaired.Seventeen(73.91%)patients with RVF underwent transvaginal repair successfully,with 7 undergoing perineal angioplasty simultaneously.And rare types of genital fistula also underwent repair surgeries and all of them were successfully repaired.Conclusion1.VVF,UVF and RVF are the most common types of genital fistula related to gynecological and obstetric surgeries.Most of them are secondary to benign gynecological surgery,followed by gynecology malignant surgery,birth canal laceration,cesarean section,obstructive delivery,lateral episiotomy,forceps curettage and ectopic IUD.The etiologies of genital fistulas vary to the types.VVF is mostly secondary to hysterectomy,and the primary diseases are usually uterine fibroids.UVF is often secondary to laparoscopic surgery and the primary diseases are usually uterine fibroids and cervical cancer.RVF is mostly secondary to laceration of the birth canal.2.Genital fistulas related to gynecological surgeries and cesarean section have increased in recent years,which may be associated with the introduction of laparoscopic techniques.The cases related to vaginal delivery is relatively stable every year.3.Urogenital fistulas are mostly diagnosed by cystoscopy,IVP.VVF is mostly diagnosed by colonoscopy,and the lower fistulas can be diagnosed by physical examination alone.4.Genital fistulas can be treated conservatively,but most people preferred surgical repair.VVF patients in our hospital were usually treated by urologists;therefore transabdominal route occupied a large proportion with success rate higher than 80%.UVF is usually treated by transabdominal ureteroneocystostomy with success rate of 100%.RVF is usually treated by transvaginal repair with success rate of 100%.