John J. Bauer, M.D.
www.flinturology.com Urology Services, Inc.
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Contents
General information
Pre-operative instructions
Risks and Complications
Detailed Surgery Description
Family waiting instructions
Post-operative instructions
Printing tip: If you want to print only one portion of this entire document, you should be able to do this depending on your software. To print a selection, highlight the section you want to print using your mouse, then click on print, and then in the print menu, choose "selection."
Terminology tip: If you come across words you don't understand, look them up in the On-Line Medical Dictionary.
An urethrovaginal fistula is a connection between the urethra and the vagina. The most common causes of this entity are: recent Gynecological surgery, use of forceps in delivery of a baby, trauma, and childbirth in third world countries. The symptom usually encountered is continuous urinary leakage. The definitive diagnosis is a CAT scan that shows air in the bladder and some dye leakage from the bladder into the vagina. The treatment of this condition is surgery to remove the connection and it usually entails removal of a section of vagina and a small bladder cuff. A separate tissue is then placed between the two structures to prevent re-fistulization. The surgery is done vaginally on the first attempt and can be completed through an abdominal incision, which is reserved for failures of the vaginal procedure.
Your pre-operative appointments
Before your surgery, you will be seen by the physician and the anesthesiologist, and when applicable, there is a pre-admission appointment with the hospital. Click here to read more details about these appointments, referred to as the Pre-Operative Work-Up.
Change In Health Status
Notify your surgeon if you experience any significant change in your health status: develop a cold, influenza, a bladder infection, diarrhea, or other infection, before your surgery.
Pre-Operative Medication Instructions
Unless specifically instructed otherwise by your surgeon or anesthesiologist, please observe the following guidelines for taking your medicines before surgery:
Your procedure involves the bowel and therefore needs the most thorough cleaning protocol. It will be ordered by your physician and it may require hospital admission the day before.
Pre-Operative Diet Instructions
Unless specifically instructed otherwise by your surgeon or anesthesiologist, patients of all ages must observe the following diet restrictions before surgery:
Patients undergoing operative or diagnostic procedures involving sedation are required to refrain from eating, drinking or taking anything by mouth for a stated period prior to their surgery or procedure. The reason for this is to prevent complications caused by nausea or vomiting while you are unconscious. Should you vomit while in the unconscious state, the risk exists that the vomit may enter into your lungs causing serious complications such as pneumonia. These complications may result in an extension of your hospitalization following your surgical procedure. It is for this reason patients are often instructed to have nothing by mouth after midnight the night prior to your operation unless otherwise instructed by an anesthetist.
Pre-Operative Cleaning Instructions (bathing and showering instructions)
Pre-operative showers are to be taken the night before and the morning of surgery just prior to your arrival. All adults are required to take a shower using either a Betadine or Hibiclens Surgical Scrub antibacterial soap. The reason is to remove as much bacteria from your skin as possible prior to your surgery. If you are allergic to these products please notify your physician or nurse. Perform your shower as follows:
On The Day Of Surgery
The anesthesiologist will discuss with you the anesthetic most appropriate for your medical condition and procedure prior to surgery.
After your surgery you must be escorted/driven home by a responsible adult. You may take a taxi car or shuttle if accompanied by a responsible adult who can stay with you after the driver departs.
Time To Arrive For Your Surgery
During your Pre-Admission Interview, our Registered Nurse will provide you with the correct time to arrive for check-in prior to your surgery.
ARRIVAL TIME:
WHERE TO ARRIVE:
The risks and complications for this surgery are described in the "Counseling and Pre-Op Note" that you will need to sign before the surgery. The main content of that note is listed below.
Indications:
Patient is a female with a symptomatic urethral or vesicovaginal fistula.
Alternatives:
Options include observation with prophylactic antibiotic usage, prolonged Foley catheterization, prolonged suprapubic catheterization or prolonged bilateral percutaneous renal drainage. Prolonged ureteral stent placement is an option for ureterovaginal fistula. Options for surgery are vaginal approach or abdominal approach.
Risks/Complications:
The risks and complications of the procedure where extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures, deep venous thrombosis, pulmonary embolus, myocardial infarction, heart failure, stroke, death or a long-term stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal head-ache, nerve damage, spinal canal bleeding and malignant hyperthermia. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary.
The specific risks of this procedure include, but are not limited to: prolonged urethral catheterization, urethral diverticulum, urethral abscess, stricture formation, future alternative procedures for failures, prolonged dysuria and injury to rectum/bladder/ureters. If vaginal approach is unsuccessful then it may be converted to an open abdominal surgery. If this procedure is a redo or a very large fistula an interposition with labial fat pad or omentum will be required. If there is a ureterovaginal fistula a distal ureterectomy and re-implant may be required. Ureteral stent placement will be needed with removal by cystoscopy at a later date.
You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.
To view the actual printable form for this surgery, click here: Counseling Note for Fistulectomy- GU Tract. To print the document, simply select print after you have opened the page. You can use that copy to sign before your surgery.
Terminology tip: If you come across words you don't understand, look them up in the On-Line Medical Dictionary.
Indications: Female with a vesicovaginal fistulaSample Procedure Dictation:
The patient was given general anesthesia / Spinal anesthesia, placed in the dorsal lithotomy position and then prepped and draped in the usual standard sterile manner. 2-0 silk sutures were used to retract the labia folds and a medium vaginal speculum was placed into the vaginal vault. A 17 French cystoscope was placed into the urethra and a cystourethoscopy was performed to rule out any further fistula tracts and to identify the proximity of the vesicovaginal fistula to the ureteral orifices. The ureteral orifices were noted to have clear efflux and were sufficiently far from the suspected fistula site that a distal ureteral re-implant was not required. No other bladder lesions were noted on the cystoscopic examination. A 16 Fr Foley catheter with 30cc of saline in the balloon was placed to empty the bladder. Methylene blue dye was instilled in the bladder to identify the fistula on the vaginal side. The Foley was then clamped with a Kelly. The vaginal mucosa half way between the meatus and the bladder neck was clamped with an Allice clamp for retraction. The vaginal mucosa down the midline of the fistula was injected with sterile injectable saline using a 19-gauge needle to help develop the plane between the mucosa and submucosal connective tissues. A midline incision was made through the mucosa. The connective tissues were dissected laterally with blunt and sharp dissection to the level of the inferior ramis laterally and to the vaginal cuff posteriorly. The entire vaginal fistula opening, fistula tract and a one-centimeter bladder cuff were excised without difficulty. The bladder was closed in a two-layered transverse manner using 2-0 vicryl sutures. Lateral perivesicle connective tissues and vaginal submucosal tissues were closed over this site for additional protection from recurrence. The vaginal mucosa was closed in a vertical manner with a running 2-0 vicryl suture. The bladder was again emptied and placed to gravity drainage. The vagina was packed with antibiotic cream and vaginal packing for hemostatis. Patient was then awaken from anesthesia without complications and transferred to the Recovery Room (RR. The patient arrived to the RR in stable condition and without complications.
To the family and friends of patients undergoing surgery.
SCHEDULED STARTING TIME OF SURGERY:ESTIMATED LENGTH OF SURGERY:
You should plan to check in at the waiting area information desk as soon as your family member or friend has left for the Operating Room. This is the only way we can talk to you afterwards, or on occasion; reach you to give you updates on the operation's progress. If the surgery is scheduled for many hours, you can leave to eat or do other things, but you should let the information desk know that you are going to leave the area, where you are going, and how long you might be gone so that we might reach you if need be. You should be in the area before the elected time of the end of the operation.
The information deck will overhead page you or the "family of" when they receive the recovery call to let you know that the surgery has been completed. The overhead page system works ONLY on the Surgical Waiting Area and not throughout the hospital or the cafeteria.
We will plan to see you in the surgical waiting area after we have safely completed the early phases of the post-anesthesia recovery in the "Recovery Room" or PAR (Post Anesthesia Recovery). This may take up to an hour after the initial call. Sometimes, especially if another case is ready to start, we will call and talk to you. If for some reason, we have not come or called within 30 minutes, please ask the information desk to page us.
Your family member will be in the Recovery Room for 1-2 hours. This is standard recovery time, although the times vary with each individual. For example, spinal anesthetics take longer to "wear off," local anesthetics are much shorter acting. Under no circumstances are family members or friends allowed in the recovery room. The information deck will inform you of the patient's return to the room as soon as they receive the information that the patient has left recovery. At that time, they will give you the room number and direct you to the correct wing and floor.
Activity
Diet
Medication
Catheter and Wound Care
Bowel Movements
When to Contact your Doctor
Contacting Your Physician
Dr. Bauer can be contacted by calling the number listed at the top of the page. You may also call the hospital to have them contact us. Please do not hesitate to call with any questions or concerns.
Frequently Asked Questions after surgery
This section is under construction.