title: Complex obstetric fistulas.
abstract: Obstetric fistulas are rarely simple. Most patients in sub-Saharan Africa and parts of Asia are carriers of complex fistulas or complicated fistulas requiring expert skills for evaluation and management. A fistula is predictably complex when it is greater than 4 cm and involves the continence mechanism (the urethra is partially absent, the bladder capacity is reduced, or both); is associated with moderately severe scarring of the trigone and urethrovesical junction; and/or has multiple openings. A fistula is even more complicated when it is more than 6 cm in its largest dimension, particularly when it is associated with severe scarring and the absence of the urethra, and/or when it is combined with a recto-vaginal fistula. The present article reviews the evaluation methods and main surgical techniques used in the management of complex fistulas. The severity of the neurovascular alterations associated with these lesions, as well as inescapable limitations in staff, health facilities, and supplies, make their optimal management very challenging.
authors.affiliation: Department of Gynecology and Obstetrics, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA. rgenadr@jhmi.edu
authors.forename: R R
authors.initials: RR
authors.lastname: Genadry
authors.forename: A A
authors.initials: AA
authors.lastname: Creanga
authors.forename: M L
authors.initials: ML
authors.lastname: Roenneburg
authors.forename: C R
authors.initials: CR
authors.lastname: Wheeless
mesh_terms: D003906:Developing Countries; D005260:Female; D013509:Gynecologic Surgical Procedures / Q000379:methods; D006801:Humans; D008427:Maternal Health Services / Q000191:economics / Q000458:organization & administration*; D007744:Obstetric Labor Complications / Q000145:classification* / Q000175:diagnosis* / Q000601:surgery*; D017063:Outcome Assessment, Health Care; D011247:Pregnancy; D012006:Rectovaginal Fistula / Q000145:classification / Q000175:diagnosis / Q000601:surgery; D013519:Urogenital Surgical Procedures / Q000379:methods; D014624:Vaginal Fistula / Q000145:classification / Q000175:diagnosis / Q000601:surgery; D014719:Vesicovaginal Fistula / Q000145:classification* / Q000175:diagnosis* / Q000601:surgery*