Pathophysiology and Management of Long-term Complications After Transvaginal Urethral Diverticulectomy

Female urethral diverticulum (UD) is a rare and benign condition that presents as an epithelium-lined outpouching of the urethra. It has various symptoms, of which incontinence in the form of postmicturition dribble is the most common. The gold standard for the diagnosis of UD is magnetic resonance imaging, and the treatment of choice is transvaginal diverticulectomy. Despite the high success rate of transvaginal diverticulectomy, postoperative complications such as de novo stress urinary incontinence (SUI), recurrence, urethrovaginal fistula, recurrent urinary tract infections, newly-onset urgency, and urethral stricture can occur. De novo SUI is thought to result from weakening of the anatomical support of the urethra and bladder neck or damage to the urethral sphincter mechanism during diverticulectomy. It can be managed conservatively or may require surgical treatment such as a pubovaginal sling, Burch colposuspension, or urethral bulking agent injection. Concomitant SUI can be managed by concurrent or staged anti-incontinence surgery. Recurrent UD may be a newly formed diverticulum or the result of a remnant diverticulum from the previous diverticulectomy. In cases of recurrent UD requiring surgical repair, placing a rectus fascia pubovaginal sling may be an effective method to improve the surgical outcome. Urethrovaginal fistula is a rare, but devastating complication after urethral diverticulectomy; applying a Martius flap during fistula repair may improve the likelihood of a successful result. Malignancies in UD are rarely reported, and anterior pelvic exenteration is the recommended management in such cases.

Living with obstetric fistula for ten years: a delayed diagnosis and review of pertinent surgical technique

Obstructed labour is a common cause of vesicovaginal fistula in the developing world. Those fistulae occurring after labour and its complications is called obstetric fistula. We report a case of complex obstetric fistula in a 32 y woman who was having continuous leakage of urine since last 10 y following caesarean section for obstructed labour. A successful fistula repair was done with transvaginal approach with Latzko technique and interposition with Martius flap.

Rare case of rectovaginal fistula in adults

Rectovaginal fistula is an abnormal epithelial lined connection between the rectum and the vagina. The term anovaginal fistula may also be used when the internal fistula opening is found below the anorectal angle. Bowel contents leak through the fistula, allowing gas or stool to pass through the vagina. It may be congenital or acquired. Congenitally these are the anorectal malformations which affect the females when present since birth. Here, we have discussed the cases of adult rectovaginal fistula which the women had developed after vaginal delivery, the obstetric fistula. Patient presented with passage of stool from the vagina after the delivery. They were examined, assessed was successfully treated in our institution. Depending on the site of fistula formation, decision is taken for surgical approach and various techniques. Here the well-known Martius flap, which is based on bulbocavernosa muscle and pudendal artery has been used in both the cases. This flap is best used to repair fistula in the perineal region when there is no underlying sphincter defect.

Comparison of Transvaginal Repair of Vesicovaginal Fistula with and without Martius Flap

Background: Different approaches and techniques have been adopted to repair Vesicovaginal Fistula (VVF) successfully. However, role of tissue interposition in success of VVF repair is still controversial. Objective: To compare the outcomes of transvaginal repair of Vesicovaginal fistula (VVF) with and without martius flap in terms of success rate and recurrence. Study Design: Randomized control study. Settings: Department of Urology Lahore General Hospital, Lahore Pakistan. Duration: One year and six months from January 01, 2019 to June 30, 2020. Methodology: Total 40 patients with VVF were included in the research, malignant, radiation induced and complex fistula are excluded. 40 patients of transvaginal repair of VVF, split into two groups, randomized by serial number technique each consisting of 20, group A repaired with martius flap and group B with simple repair without martius flap. After 2, 4 and 8 weeks all the patients were assessed for recurrence or any other complication. The data was collected in a specially designed proforma. Results: 40 patients fulfilling the inclusion criteria were included, 20 patients in each group. Mean age of group A patients was 36.70±5.16 and of that group B was 37.10±4.58. 33 (85.5%) patients have supra-trigonal fistula, while 7(14.5%) had trigonal fistula and mean fistula size was 1.96cm ±1.0. The success rate was 100% (20/20) in group A, while in group B, 95 % (19/20) with recurrence in one case. Chi square analysis was employed for comparison of adequacy of both the techniques. p-value was found to be 0.311 which suggests that the difference between the efficacies of two techniques was not statistically significant. Conclusion: Both the techniques of transvaginal repair of simple benign Vesicovaginal fistula are successful with equal success rate in martius inter positional flap repair and simple bilayer repair without flap.