Commentary
Comment to: “Treatment of urogenital fistula in women”
Comentario editorial a: «Tratamiento de la fístula urogenital en la mujer»
J. González
Servicio de Urología, Hospital Universitario de Getafe, Madrid, Spain
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González" "autores" => array:1 [ 0 => array:3 [ "nombre" => "J." "apellidos" => "González" "email" => array:1 [ 0 => "fjgg1975@yahoo.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Urología, Hospital Universitario de Getafe, Madrid, Spain" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comentario editorial a: «Tratamiento de la fístula urogenital en la mujer»" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Fistulous communication between the ureter, bladder or urethra and adjacent anatomical structures is a cause of great suffering and discomfort for the patient. There are few entities in which this shows greater anxiety about the disabling condition, or greater the gratitude directed toward the surgeon once resolved, because, regardless of its origin, whether traumatic, surgical, inflammatory, neoplastic, or radio-induced, it is almost invariably susceptible to surgical repair.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The scientific evidence on the prevalence of this entity and its treatment is limited by unusual historical circumstances. Before the second half of the 19th century, the vesicovaginal fistula was generally considered a hopeless and incurable process. Until the appearance of the works by the North American surgeon J. Marion Sims in 1852<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and some of his contemporaries, the treatment of this entity could not be performed with security and safety for the patient. Once obstetrics was developed as an independent specialty in the first half of the 20th century, puerperal maternal and child mortality plummeted in most developed countries. This made the obstetric fistula disappear from the clinical and social Western experience at the time when the basis of scientific rigor started to be established. As a result of such a particular historical circumstance, the scientific literature on obstetric and gynecologic fistulas is old and uncritical under the current scientific standards and criteria. The evidence at our disposal at present is made practically of collections of anecdotes,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> case series (some with a high number of patients), and isolated personal experiences of specialized surgeons that provide the results of their casuistry from the farthest points of the globe, often facing circumstances of absolute deficiency and in a completely adverse scenario.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On the other hand, the subdivision between ‘simple’ and ‘complex’ fistulas at first sight may be considered an unnecessary way to turn what is difficult into something still more complex. However, for practical purposes, it is a useful tool when properly defining the type of surgical repair that a particular patient will require. While the so-called simple fistulas can be solved mainly by excision of the fistulous tract and appropriate reapproximation and correct apposition of the tissue layers involved, the most complex cases, in which there is great devascularization associated, history of previous attempts at repair, major loss of tissue or persistence of an infectious or tumor focus may require auxiliary procedures for their final solution.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The lack of appropriate definitions and categorization, as well as consensus on which procedure or procedures (both diagnostic and therapeutic) to use and in which sequence, often makes it difficult to make decisions in a particular case. Very few articles currently reach a substantial level of evidence to answer this and other questions. The availability of a single prospective clinical trial on vesicovaginal fistulas in the developed world<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> further strengthens the idea of the lack of scientific awareness in this regard in the Western world. The lack of well-designed studies now makes it impossible to generate a sophisticated meta-analysis or to obtain a core of knowledge about this entity. It is, therefore, important that the centers of greater experience and volume not only communicate their experience,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> but they must also try to establish the basis for future prospective studies, properly designed, in order to reverse this situation, as yet some important aspects require a larger study.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: González J. Comentario a: “Tratamiento de la fístula urogenital en la mujer”. Actas Urol Esp. 2012;36:196–7.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fístulas urinarias: puesta al día" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Allona" 1 => "J.L. Sanz" 2 => "P. Pérez" 3 => "B. Pozo" 4 => "S. Navío" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Actas Urol Esp" "fecha" => "2002" "volumen" => "26" "paginaInicial" => "776" "paginaFinal" => "795" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12645375" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "On the treatment of vesico-vaginal fistula" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.M. 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Thornton" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Obstet Gynaecol" "fecha" => "1998" "volumen" => "105" "paginaInicial" => "397" "paginaFinal" => "399" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9609264" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tratamiento de la fistula urogenital en la mujer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C. Göktaş" 1 => "G. Horuz" 2 => "G. Faydaci" 3 => "A. Cihangir-Çetinel" 4 => "O. Akça" 5 => "S. 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