Kadın Genital Yol Fistülleri ve Cerrahi Tedavisi
Özet
Kadın genital yol fistülleri, epitel veya mezotel yüzeyler arasındaki anormal bağlantılardır. Gelişmiş ülkelerde genellikle histerektomi gibi jinekolojik cerrahilere veya radyoterapiye ikincil gelişirken, gelişmekte olan ülkelerde obstetrik travma kaynaklıdır. En sık vesikovajinal fistüller görülmekle birlikte; üretrovajinal, üreterovajinal, vesikouterin ve rektovajinal tipleri de mevcuttur. Hastalar sürekli ağrısız idrar kaçırma, gaz veya kötü kokulu gaita gelmesi şikayetleriyle başvururlar. Tanıda fizik muayene, boya testleri, sistoskopi ve tomografi gibi görüntüleme yöntemlerinden yararlanılır. Tedavi yönetiminde drenaj sağlanması küçük fistüllerde spontan iyileşme sağlayabilir ancak kalıcı olgularda cerrahi müdahale şarttır. Cerrahi onarım zamanlaması tartışmalı olup, doku ödeminin dağılması için genellikle 6-12 hafta beklenmesi ve enfeksiyonun önlenmesi önerilir. Cerrahi yaklaşım vajinal veya abdominal yolla yapılabilir. İlk cerrahi girişimin başarı şansı en yüksek olduğundan operasyonun deneyimli merkezlerde yapılması kritiktir. Geniş veya tekrarlayan vakalarda doku desteği ve kanlanmayı artırmak amacıyla Martius, Gracilis, Pudental veya Omental flep yöntemleri uygulanır. Rektovajinal onarımlardan sonra ise düşük rezidü diyet takibi önemlidir.
Female genital tract fistulas are abnormal communications between epithelial or mesothelial surfaces. While they usually develop secondary to gynecological surgeries like hysterectomy or radiotherapy in developed countries, they result from obstetric trauma in developing countries. Although vesicovaginal fistulas are most commonly encountered, urethrovaginal, ureterovaginal, vesicouterine, and rectovaginal types also occur. Patients present with complaints of continuous painless urinary leakage, gas, or foul-smelling stool. Physical examination, dye tests, cystoscopy, and imaging methods such as tomography are utilized for diagnosis. In management, providing drainage can lead to spontaneous healing in small fistulas, but surgical intervention is required for persistent cases. The timing of surgical repair remains controversial; however, waiting 6-12 weeks for tissue edema to subside and preventing infection are recommended. The surgical approach can be performed via vaginal or abdominal routes. Since the first surgical attempt has the highest success rate, it is critical that the operation is performed in experienced centers. In large or recurrent cases, Martius, Gracilis, Pudental, or Omental flap methods are applied to provide tissue support and increase vascularity. Following rectovaginal repairs, low-residue diet management is important.
Referanslar
Hilton P, Cromwell DA. The risk of vesicovaginal and urethrovaginal fistula after hysterectomy performed in the English National Health Service--a retrospective cohortstudy examining patterns of care between 2000 and 2008. BJOG 2012;119(12):1447-54.
Walters MD, Karram MM. Urogynecology and reconstructive pelvic surgery. 3rd ed. Philadelphia (PA): Mosby; 2007.
Rock JA, Jones HW III. Te Linde’s operative gynecology. 9th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2003.
Härkki-Sirén P, Sjöberg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol 1998;92(1):113–8.
Rovner ES. Urinary tract fistulae. In: Wein A, Kavoussi L, Novick A, Partin A, Peters C, editors. Campbell-Walsh urology. 10th ed. Philadelphia (PA): Elsevier Saunders; 2012. p. 2223–61
Blandy JP, Badenoch DF, Fowler CG, Jenkins BJ, Thomas NW. Early repair of iatrogenic injury to the ureter or bladder after gynecological surgery. J Urol 1991;146(3):761–5
Symmonds RE. Ureteral injuries associated with gynecologic surgery: prevention and management. Clin Obstet Gynecol 1976;19(3):623–44.
Raassen TJ, Verdaasdonk EG, Vierhout ME. Prospective results after first-time surgery for obstetric fistulas in East African women. Int Urogynecol J Pelvic Floor Dysfunct 2008;19(1):73-9.
Hoch WH, Kursh ED, Persky L. Early, aggressive management of intraoperative ureteralinjuries. J Urol 1975;114(4):530-2.
Boateng AA, Eltahawy EA, Mahdy A. Vaginal repair of ureterovaginal fistula may be suitable for selected cases. Int Urogynecol J 2013;24(6):921-4.
Tomlinson AJ, Thornton JG. A randomised controlled trial of antibiotic prophylaxis for vesico-vaginal fistula repair. Br J Obstet Gynaecol 1998;105(4):397-9.
Latzko W. Postoperative vesicovaginal fistulas: genesis and therapy. Am J Surg 1992;48(1):211.
Mackenrodt, A. Die operative Heilung grosser Blasenscheiden-fistein. Zentralbl Gynakol.1894; 8:180.
Browning A, Williams G, Petros P. Skin flap vaginal augmentation helps prevent and cure post obstetric fistula repair urine leakage: a critical anatomical analysis. BJOG 2018;125(6):745-749.
Sanderson DJ, Rutkowski J, Attuwaybi B, Eddib A. Robotic Repair of SupratrigonalVesicovaginal Fistula with Sigmoid Epiploica Interposition. JSLS 2018;22(4): e2018.00055.
Kliment J, Beráts T. Urovaginal fistulas: experience with the management of 41 cases. IntUrol Nephrol 1992;24(2):119-24.
Tancer ML. Vesicouterine fistula—a review. Obstet Gynecol Surv 1986;41(12):743–53.
Roman H, Bridoux V, Merlot B, et al. Risk of Rectovaginal Fistula in Women with Excision of Deep Endometriosis Requiring Concomitant Vaginal and Rectal Sutures, with or without Preventive Stoma: A Before-and-after Comparative Study. J Minim Invasive Gynecol. 2022;29(1):56-64.e1.
Rogers RG, Jeppson PC. Current Diagnosis and Management of Pelvic Fistulae in Women. Obstet Gynecol. 2016;128(3):635-650.
Martius H. Uber die Behandlung von Blasenscheidenfisteln, insbesondere met Hilfe einer Lappenplastik. Geburtshilfe Gynakol 1932;103:22–34.
Zinman LN, Libertino JA, Smith JJ. Vesico-vaginal fistula. In: Libertino JA, editor. Reconstructive urologic surgery. 3rd edition. St. Louis (MO): Mosby; 1998. p. 259–
