We have noticed that when we do repair of complex and difficult VVF, there is sometimes a leakage of urine after or even before the traditional 14 days’ catheterisation. Does prolonging the duration of catheter for few more weeks help in healing? Although there is now enough evidence that for simple fistula 7 days’ catheterisation is enough ( Dr Arrowsmith et al Multi-centric study), we are still not confident enough to remove the catheter early. We want to have your insights and and experience.
Hi Ganesh,
Thank you for your question. I co -authored and was a site investigator for a randomized control trial done by Engender Health and WHO, that showed 7 days bladder catheterization was not inferior to the traditional 14 days for simple OF repair (Barone MA, et al. Lancet. 2015). Therefore, for simple fistulas I can confidently recommend you drain the bladder for 7 days as this will help to minimize post operative bladder infection as well as cut down on patients in hospital stay. However, when it comes to complex cases, from my experience I would suggest they a treated on a case by case bases. Complex cases might leak for several reasons other than a repair break down. It could be a urethral sphincter incompetence, small bladder , patients nutritional status ect . My advice would be to do a dye test on post OP day 10 and that will dictate your further treatment. I hope this helps.
In that case I would drain the bladder for a longer period of time but not more than 21 days.
RCT should not be followed in fistula case. Solely depends upon the experience of the surgeon. In complex fistula, Incontinence is a routine (in my experience) while involving urethra along with bladder or multiple attempts. If Incontinence, second sitting surgery (don't like or prefer primary) often requires if it persists by sling or graft. Catheterisation for two weeks is sufficient. You could put upto three weeks. If leakage, then it fails.
I would like to add that Evidence Based Medicine is scanty in the area of Obstetric Fistula and extremely important to help standardize patients treatment..
Hi Ganesh!
Regarding our previous conversation. I just wanted to let you know that the WHO guidelines on duration of catheterization after fistula repair have been released http://www.who.int/reproductivehealth/repair-simple-urinary-fistula/en/ . These guidelines are based on our RCT and it is an excellent example of moving evidence based medicine to policy and hopefully having a positive impact on clinical practice in the near future. I hope you find this helpful.
Kind Regards
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