urethrovaginal fistula repair

Urinary fistula is one of the problems in vaginal surgery. If you don't have the ability to make a full estimate of the success or failure of the surgery and skilled repair techniques, don't take it lightly. Because the pupils seem small, the relationship is often complicated; the organizations around which they can be filled are very limited. If the estimation is insufficient, the pupils will become loose after the incision; or the inability to clean up in all directions; or the surrounding tissue is small, barely sewed, and the tension is too large, often causing surgery failure. Moreover, it has damaged a lot of valuable filling organizations, which made it difficult to repair it again. Some patients have changed their urinary tracts due to repeated patch failures, so they must not rush. Most of the urinary fistula is caused by birth injury, so the patient is often a young adult woman, and it still occurs in rural and mountainous areas of China. Disease-causing people have cancer erosion, radiation damage, tuberculosis ulceration, stone embedding, etc., can occur at all ages. Followed by surgical accidental injuries: such as radical cancer surgery, difficult hysterectomy, vaginoplasty, etc. Others have congenital malformations: such as the ureter or urethra opening in the vagina or vestibule. In addition, there are trauma, uterine tube compression and necrosis, drug corrosion and so on. The cause is different, the location and size of the pupil, the extent of the involvement, and the degree of scar formation are different. Therefore, the diagnosis must be carefully diagnosed before surgery to avoid passive operation. It is difficult to repair urinary fistula, and it is necessary to carefully analyze and estimate before surgery. Special examinations such as methylene blue test, cystoscopy, and urography should be used when necessary. The most difficult to repair are the following factors: pupil > 3cm, scar thick and hard, vaginal stenosis, high pupil position and less active cervix, urethral split, fracture, obstruction, defect, pupil from the ureteral orifice <0.5cm, The pupil is close to the back of the pubis, multiple repair failures, radiation damage, tuberculous fistula, combined with fecal fistula, stones, multiple hernias. There are many types of urinary fistula, and only those who can be repaired from the vagina are described here. In addition to careful selection of indications and conditions from vaginal repair of urinary fistula, surgical operations must pay attention to: 1. Cherish the normal tissue, the operation is gentle, accurate and fine. 2. Strictly sew the corners of both ends of the pupil to ensure no bleeding or leakage. 3. The suture can not be pulled by force. The assistant should push the two cutting edges together and gently knot them to avoid cutting the cutting edge tissue during the pulling, which makes the suturing difficult. 4. The blood stain of the wound surface is gently sucked up with a small suction head. It can not be pressed with gauze or cotton ball, rubbing it, so as not to damage the tissue and remove the knot. 5. After the first layer of the pupil is sewn, the rubber catheter must be inserted into the urethral opening, and the methylene blue solution or sterile milk should be injected to test whether the suture is leaked. If there is a leak, it must be filled until it is leak-free. Treatment of diseases: urinary fistula Indication Simple urethral vaginal hernia repair is suitable for urethral hernia <2cm, located in the middle and lower urethra, soft tissue around the vaginal pupil, no urethral obstruction or rupture, cervical activity, local inflammation or other lesions. Contraindications Systemic or local acute and chronic inflammation, diabetic patients must be treated after or after treatment. Preoperative preparation In addition to the repair of the urinary fistula at the time, the old urinary genital majority of the vulva and the inner thigh, diaper dermatitis in front of the breech, cystitis and vaginitis, etc., must be cured before surgery, the method is as follows: 1. Urine dermatitis with 1:1000 benzalkonium or potassium permanganate bath 2 times a day, external anti-inflammatory ointment. Change the shade pad until the inflammation disappears. 2. Cystitis and vaginitis should be supplemented with sensitive antibiotics. Partially washed once a day with nitrofurazone or boric acid solution until the inflammation and redness completely disappeared, and the urine culture was negative. 3. Each enema is given 1 time before and on the morning of the operation. Shave the pubic hair and wash the vulva with soapy water. 4. Administration before anesthesia is carried out in accordance with the anesthetic regulations used. Several days before surgery, estrogen such as Premarin can be used as appropriate to promote the healing of vaginal mucosa. However, there are many people who do not advocate the addition of sex hormones. 5. In addition to the commonly used vulvovaginal surgical instruments, surgical instruments must be prepared for urinary fistula repair with long handle thin, straight, curved small scissors, small pointed blades, small scorpion-shaped pointed blades, sickle catheters, female metal catheters, Ureteral catheter, small suction tube (front curved tube), well-lit spotlights, etc. The needles and stitches are complete. Surgical procedure 1. Disinfection and exposure The vulva and vagina were once again rubbed once with 75% ethanol or 0.05% chlorhexidine solution or 0.5% strong iodine. Disinfecting towels with vaginal surgery. Open the labia minora to the sides and fix it on the outside of the labia majora or on the towel (sewing a needle thread). The upper edge of the perineal disinfection towel is fixed with a towel clamp to cover the anus. Use a heavy hammer to expand the vaginal device or vaginal pull hook to open the vagina, use the cervical clamp to clamp the upper lip of the cervix and pull the cervix up and out of the vaginal opening to expose the anterior wall of the vagina. The metal catheter is introduced into the bladder from the external urethra and ejected from the urethral pupil to check the urethra, pupil and surrounding tissue. 2. Incision Use a small sharp knife to make a circular incision around the pupil opening, tightly outside the scar tissue, and cut the entire vaginal mucosa. With a small scimitar, the blade is outward, separated from the vaginal mucosa and the urethral wall, and separated to a circumference of about 1.5 cm. The visceral mucosa cutting edge was clamped with tissue clamps, and the scar tissue at the edge of the pupil was finely cut with a small curved shear to make the muscle layer and connective tissue of the urethral wall completely free, and the pupil edge was neat and smooth. Intraoperative oozing and shredded tissue residue, gently sucked with a small suction head, the wound surface is clean, avoid rubbing, so as not to damage the tissue. If the tissue around the pupil is thick and soft, suture can begin. 3. Stitching Use a fine round needle, 3-0 or 4-0 gut, or a needle 4-0 to absorb the suture, and traverse, interrupt, and invert the suture. The corners of both ends of the slit are sealed with a half purse or a suture. When the tissue is abundant, it generally does not pass through the urethral mucosa. If the tissue is thin, it can also pass through the urethra mucosa without affecting healing. Each needle is about 0.3cm apart, and the stitches are neat and uniform in tension is the key to successful surgery. After the suture is completed, the test is leaked. As described above, the rubber catheter is inserted into the rubber urethra into the methylene blue, and no leakage is leaked. If the tissue is rich, the second layer of the urethral muscle wall tissue can be used in the same method. The suture is slightly sparse, and the first The layer stitches are staggered into the needle point and do not have to be closed. Stitch the vaginal mucosa to align the incisions and trim them neatly. Use round needle 0 or 2-0 gut or 2-0 absorbable suture for wales (cross at right angles to the urethral sinus suture for better fit) intermittent valgus suture. Some pupils are very small. After separating the connective tissue around the pupil, use the 3-0 gut or 4-0 absorbable suture to suture the pupil 8 times (can not wear through the urethra mucosa) ), then the vaginal mucosal incision is covered with a 2-0 gut line or a 2-0 absorbable suture interrupted valgus suture to cover the pupil, do not forget to test the first layer after the suture. complication If strictly implemented in accordance with the principles of surgery, success is still the main outcome. In case of infection or bleeding, the treatment is the same as vaginal surgery. If the wound is split, the operation fails, and the infection is treated, and only after the inflammatory bleeding stops, consider the subsequent operation. In the near future, heavy sewing will not help.