Hypothesis / aims of study
The surgical treatment of urogenital fistula requires specialist skills, and as a result these procedures are usually concentrated in a relatively small number of hospitals. The establishment of a fistula service can therefore be challenging especially in units without prior experience of treating fistulas. The aim of this study was to report initial results for a newly-established surgical team from an existing fistula centre who had limited prior experience of this type of surgery. As in-house training was unavailable, a novel programme of remote mentorship from another existing high-volume fistula centre was developed. The establishment of a new fistula service using this training technique is reported.
Study design, materials and methods
The surgical team consisted of a urologist and a urogynaecologist operating jointly (both of whom had limited previous experience of urogenital fistula surgery). A training programme was designed involving mentorship from another high-volume urogenital fistula service comprising multiple observations of fistula surgery and familiarisation of surgical technique, direct hands on training sessions and ongoing remote support including case review and outcome recording.
A retrospective study was conducted to examine preliminary outcomes. This included the initial 23 urogenital fistula patients comprising 15 vesico-vaginal fistulas (VVF), 5 urethro-vaginal fistulas (UVF) and 3 colo-vaginal fistulas (CVF). The surgical history, diagnostic investigations, procedure notes and post-operative follow-up were reviewed. Outcome was based on anatomical closure and patient reported symptom resolution.
In total, there were 20 surgical repairs (16 VVF, 3 UVF, 1 CVF) on 17 patients.
Table 1: Characteristics n=17 (Figure 1 - Attached below)
Of the 20 procedures, 15 were repaired using a vaginal approach (75%) and 5 were repaired using an abdominal approach (25%). 80% had Martius graft interposition.
Post-operative follow-up was via cystourethrogram or CT urogram and face-to-face symptom review. Anatomical closure was achieved in 88% of patients. 2 patients had a persistent fistula, 1 of these was a neobladder-vaginal fistula.
A vaginal approach achieved closure in 8 out of 10 VVFs (80%), and 2 patients with UVF. 3 VVFs were a re-do procedure. Anatomical closure was successfully achieved in 2 of these 3 patients following a second procedure. Abdominal approach achieved anatomical closure in all 5 (100%) patients; 3 VVF, 1 UVF, 1 CVF.
On clinical follow-up, symptom resolution was reported in 94%. 1 patient with a persistent fistula on cystourethrogram declined further surgery in view of minimal vaginal urinary leakage following the repair.
Interpretation of results
Despite the varied aetiology of the fistulas, anatomical closure was successful in 88% of the patients. This is comparable to published results from other high-volume fistula centres. Despite not achieving anatomical closure, 1 patient reported acceptable symptom resolution. Therefore 94% of the patients had successful symptom resolution following surgery.