ISSUES IN CLINICAL MANAGEMENT Complex obstetric fistulas R.R. Genadry a, ⁎ , A.A. Creanga b , M.L. Roenneburg c , C.R. Wheeless a a Department of Gynecology and Obstetrics, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA b Population, Family and Reproductive Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA c Weinburg Center for Women's Health and Medicine, Mercy Medical Center, Baltimore, Maryland, USA 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. © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. KEYWORDS Abdominal repair; Complex obstetric fistulas; Fistula repair; Urinary augmentation; Urinary diversion; Urinary reconstruction 1. Introduction Obstetric fistulas are rarely simple. Vesico-vaginal fistulas (VVFs) are caused by a broad injury resulting in extensive scarring and the breakdown of the more severely affected areas, and involve the urogenital barrier [1]. The recto-genital barrier can also be involved, causing the formation of a recto- vaginal fistula (RVF) or a combined VVF and RVF. The combination is reported in 5% to 10% of surgically treated patients [1,2]. Lucky is the patient who presents with a small communication, less than 2 cm in diameter, above the vesical trigone and far from the urinary continence mechanism, because her fistula is easily accessible and has minimal scarring. Most likely, in both the developed and developing world, such a fistula is iatrogenic and follows a cesarean section or hysterectomy. In sub-Saharan Africa and parts of Asia, most patients who present with obstetric fistulas are not so fortunate. Theirs are the consequence of obstructed labor away from a medical facility where a cesarean section could have been performed in time [2,3]. These patients are often carriers of complex and/or complicated (N 6 cm) fistulas requiring expert skills for evaluation and management. Although the data on the true distribution of simple and complex VVFs are inadequate, more than 70% of obstetric VVFs are reported as complicated [4]. This high percentage may reflect a significant reporting bias by ⁎ Corresponding author. Department of Gyn/Ob, JHU School of Medicine, 10755 Falls Road, Suite 330, Lutherville, MD 21093, USA. Tel.: +1 410 583 2991. E-mail address: rgenadr@jhmi.edu (R.R. Genadry). 0020-7292/$ - see front matter © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2007.06.026 available at www.sciencedirect.com www.elsevier.com/locate/ijgo International Journal of Gynecology and Obstetrics (2007) 99, S51–S56