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.

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.

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.

This study suggests that an alternative to the traditional in-house training, remote mentorship can be utilized with good effect. The establishment of a new fistula service can be safely and effectively delivered using this approach. Surgical outcome was comparable to published results from established high volume units. A key factor to ensure success is a close working relationship with the mentoring unit including the ongoing facility for case discussion and maintenance of a collaborative relationship between mentor and mentees.

Ockrim, J., Greenwell, T., Foley, C., Wood, D. and Shah, P. (2009). A tertiary experience of vesico-vaginal and urethro-vaginal fistula repair: factors predicting success. BJU International, 103(8), pp.1122-1126
Hilton, P. (2011). Urogenital fistula in the UK: a personal case series managed over 25 years. BJU International, 110(1), pp.102-110