Pelvic Fistula - General
Transanal endoscopic microsurgical repair of iatrogenic recto-urethral fistula.
Quinlan M, Cahill R, Keane F, Grainger R, Butler M
Surgeon. 2005 Dec;3(6):416-7.
BACKGROUND: Recto-urethral fistula formation following radical prostatectomy is an uncommon but potentially devastating event. Traditional surgery for such fistulae is technically demanding, jeopardizes continence and usually necessitates a diverting colostomy. We present the case of an iatrogenic fistula treated by a transanal endoscopic microsurgical approach, without recourse to a stoma. METHOD: A 71-year-old man had recently undergone a radical prostatectomy, complicated by significant intra-operative haemorrhage. He subsequently developed a recto-urethral fistula, confirmed clinically and endoscopically. Due to his bleeding diathesis, he was considered for, and underwent, a transanal endoscopic microsurgical (TEMS) repair. CONCLUSION: TEMS is a safe and reliable minimally-invasive surgical technique for the treatment of this difficult condition.
Successful Repair of Iatrogenic Rectourinary Fistulas Using the Posterior Sagittal Transrectal Approach (York-Mason): 15-Year Experience.
Moro FD, Mancini M, Pinto F, Zanovello N, Bassi PF, Pagano F
World J Surg. 2005 Dec 12;.
INTRODUCTION: Rectourinary fistulas (RUFs) represent a challenging clinical problem. Most RUFs are secondary to lower urinary or intestinal tract surgery. Several surgical approaches have been proposed. The aim of this study was to review a 15-year experience using the York-Mason posterior sagittal transrectal approach to iatrogenic RUFs. METHODS: Seven patients with RUFs secondary to urologic surgery were operated on with the York-Mason technique at the Department of Urology, University of Padova, Italy between 1988 and 2003. The patients' data have been collected and analyzed retrospectively. RESULTS: All the patients were treated successfully (100%). In one patient with Crohn's disease the fistula recurred 11 years after the first surgery. One patient died for metastasis of prostate cancer 1 year after surgical repair of the RUF. A temporary colostomy was performed in five patients; the colostomies were subsequently closed, and the patients regained complete fecal continence with no postoperative anal strictures. The colostomy remained in place in one patient with Crohn's disease and in another with ulcerative rectocolitis. CONCLUSIONS: The posterior sagittal transrectal approach provided easy access and identification of RUFs and good surgical exposure, with no subsequent strictures or fecal incontinence. Our data show that the York-Mason technique alone is a highly effective option for treating an iatrogenic postoperative RUF.
Humanitarian ventures or 'fistula tourism?': the ethical perils of pelvic surgery in the developing world.
Wall LL, Arrowsmith SD, Lassey AT, Danso K
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan 4;:1-4.
The vesico-vaginal fistula from prolonged obstructed labor has become a rarity in the industrialized West but still continues to afflict millions of women in impoverished Third World countries. As awareness of this problem has grown more widespread, increasing numbers of American and European surgeons are volunteering to go on short-term medical mission trips to perform fistula repair operations in African and Asian countries. Although motivated by genuine humanitarian concerns, such projects may serve to promote 'fistula tourism' rather than significant improvements in the medical infrastructure of the countries where these problems exist. This article raises practical and ethical questions that ought to be asked about 'fistula trips' of this kind, and suggests strategies to help insure that unintended harm does not result from such projects. The importance of accurate data collection, thoughtful study design, critical ethical oversight, logistical and financial support systems, and the importance of nurturing local capacity are stressed. The most critical elements in the development of successful programs for treating obstetric vesico-vaginal fistulas are a commitment to developing holistic approaches that meet the multifaceted needs of the fistula victim and identifying and supporting a 'fistula champion' who can provide passionate advocacy for these women at the local level to sustain the momentum necessary to make long-term success a reality for such programs.
Colouterine fistulas in elderly women: a report of 2 cases.
Hoekstra AV, Doan T, Kosinski A, Dini M
J Reprod Med 2005 Oct;50(10):796-800.
BACKGROUND: Colouterine fistula is a rare complication of diverticulitis. We report 2 cases of colouterine fistula in elderly women presenting with fever and pyuria and managed with an aggressive workup and surgical treatment. CASES: Two elderly women presented with persistent pyuria, abdominal pain and fever without a vaginal discharge. Imaging revealed diverticulitis and a fistula. One patient, 92 years of age, underwent hysterectomy, sigmoid resection and primary colorectal anastomosis. The second patient, aged 87, was treated with hysterectomy, sigmoid resection and diverting colostomy with delayed colostomy closure. CONCLUSION: Colouterine fistula may present with pyuria, fever and abdominal pain even in the absence of vaginal discharge. Patients who are elderly and fragile are more likely to be treated conservatively and inappropriately. We advocate surgical management, including resection of all involved tissue, early in the course of the disease. In elderly women, aggressive 1- or 2-stage procedures are highly successful and could save the patients' lives.
Martius repair in urethrovaginal defects.
Baskin D, Tatlidede S, Karsidag SH
J Pediatr Surg 2005 Sep;40(9):1489-91.
AIM: To repair a urethrovaginal defect in childhood is a challenge for a pediatric surgeon. Martius fat-pad flap repair is being used in women successfully. Here, we report 2 girls who had Martius repair for their urethrovaginal defects. METHOD: Topical estriol and asiaticoside perineally were administered for preoperative 3 weeks to reinforce the tissues. Martius repair was done using 1-sided labial fat-pad flap. Urethral and bladder catheters were inserted. Urethral catheter was removed on postoperative day 14 and bladder catheter on day 21 after controlling residual urine. PATIENTS: Patient 1, a 6-year-old girl, had lipomeningocele repair at the age of 18 months and had an iatrogenic urethrovaginal fistula that is caused by catheter insertion. She developed urinary incontinence, and 3 primary repair attempts were unsuccessful. Patient 2 is a 5-year-old girl who had pouch colon with persistent cloacal malformation and had posterior anorectovaginourethroplasty. The urethrovaginal septum did not heal, and she was incontinent. One attempt of primary repair was unsuccessful. The urethrovaginal wall was completely open at the time of Martius repair in both patients. RESULTS: Urethral wall was completely healed after Martius repair in both patients. CONCLUSION: Martius fat-pad flap repair can be used to repair urethrovaginal fistulas in girls. It has both functionally and cosmetically good results, and neourethra is easily catheterizable.
Low anorectal malformation associated with 'ano-urethro-cutaneous' fistula.
Kumar V, Rao PL, Vepakomma D
Pediatr Surg Int 2005 Sep 22;:1-2.
Anorectal malformations are one of the common congenital anomalies encountered in the newborn period. The plethora of anomalies described makes it a complex subject for embryological explanations. Fistulous communications between the blind rectum and the urinary tract are common in boys with high/intermediate anomalies, but it is uncommon in children with low anorectal malformations, more so a double fistula. We are reporting a case of 'ano-uerthro-cutaneous fistula' associated with a low ano rectal malformation.
Neobladder-vaginal fistula after cystectomy and orthotopic neobladder construction.
Smith JA Jr
J Urol 2005 Sep;174(3):970-1.
Rectovaginal fistula after Posterior Intravaginal Slingplasty and Polypropylene mesh augmented rectocele repair.
Hilger WS, Cornella JL
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 29;.
Posterior Intravaginal Slingplasty and mesh augmented rectocele repairs are procedures promoted for correction of vaginal relaxation. There is little data on the complications of these procedures alone or in combination. The first report of rectovaginal fistula after Posterior Intravaginal Slingplasty with graft augmented rectocele repair is presented. A 60-year-old female developed a rectovaginal fistula 3 months after undergoing a Posterior Intravaginal Slingplasty and mesh augmented rectocele repair for prolapse. Two attempts at correcting the fistula failed and there was a recurrence of her vault prolapse. She may now require diverting colostomy and repeat repair of her vault prolapse. The case report highlights the difficulties in treating a rectovaginal fistula that developed after Posterior Intravaginal Slingplasty and mesh augmented rectocele repair for vaginal vault prolapse. More data regarding complications associated with use of these procedures is needed prior to widespread use.
Ileal Pouch-Anal Anastomosis-Vaginal Fistula: A Review.
Lolohea S, Lynch AC, Robertson GB, Frizelle FA
Dis Colon Rectum 2005 Jun 24;.
BACKGROUND: Fistula between an ileal pouch and the vagina is an uncommon complication of ileal pouch-anal anastomosis. Its optimal management has not been determined because of its low incidence. METHODS: The literature describing such fistulas was reviewed to determine the incidence, cause, and appropriate investigation and repair of these lesions. A literature search was performed with the PubMed, MEDLINE, and EMBASE databases. Through this search we located English-language articles from 1970 to 2003 on pouch-vaginal fistulas following ileal pouch-anal anastomosis. References from these articles were searched manually for further references. RESULTS AND CONCLUSION: Pouch-vaginal fistula occurs in 6.3 (range, 3.3-15.8) percent of female patients with an ileal pouch-anal anastomosis. Sepsis and technical factors are the most common contributors. It is the cause of considerable morbidity. Management depends on the level of the fistula, the amount of pelvic scar tissue, and previous treatments. An algorithm for surgical treatment is suggested.
Vesicouterine fistula following Cesarean delivery-ultrasound diagnosis and surgical management.
Alkatib M, Franco AV, Fynes MM
Ultrasound Obstet Gynecol 2005 Jul 5;.
Vesicouterine fistulae are uncommon, with most units reporting 1-5 cases over 5-15-year periods. To date there has been a paucity of case reports regarding this problem and only a few case series. In this report we outline the presentation and management of a vesicouterine fistula complicating a repeat Cesarean delivery, specifically describing the role of transvaginal ultrasound. Copyright (c) 2005 ISUOG. Published by John Wiley & Sons, Ltd.
Retropubic repair of genitourinary fistula using a free supporting graft.
J Urol 2005 Jul;174(1):183.
Treatment of perineal suppurative processes. (SSAT).
J Gastrointest Surg 2005 Mar;9(3):457-9.
Anovestibular fistula in adults: a rare presentation.
Kumar V, Chattopdhay A, Vepakomma D, Shenoy D, Bhat P.
Int Surg 2005;90:27-9.
Adult presentation of anorectal malformations (ARM) is rare. Most of these anomalies are diagnosed and corrected at birth or shortly thereafter. We will present two cases of anovestibular fistula presenting in adulthood. One case is a woman with a history of passing stools through the vagina after marriage and the other case is a woman with a history of chronic constipation since childhood. Case 1 was treated with limited anterior sagittal anorectoplasty, and case 2 was treated with limited posterior sagittal anorectoplasty. Total correction was achieved both anatomically and physiologically after surgery. The reporting of this information should increase the awareness of this disease among surgeons treating adults.
Idiopathic necrotizing fasciitis: risk factors and strategies for management.
Taviloglu K, Cabioglu N, Cagatay A, Yanar H, Ertekin C, Baspinar I, Ozsut H, Guloglu R.
Am Surg 2005 Apr;71(4):315-20.
The prognosis of necrotizing fasciitis (NF) depends on early diagnosis and management. Idiopathic NF may be more challenging, because it occurs in the absence of a known causative factor. Therefore, our purpose in this study was to identify the distinct features of idiopathic NF that may be important in early recognition of this disease and determine the factors associated with mortality. A retrospective chart review was performed in patients with a diagnosis of NF between 1988 and 2003. Patients were classified as idiopathic and secondary NF, and data were analyzed in terms of etiological and predisposing factors, causative microbiological organisms, and clinical outcome. The study included 98 patients, 63 men and 35 women, with a diagnosis of NF. The median age was 55.5 years (range, 13 - 80). Idiopathic NF occurred in 60 of 98 patients (61%). The principal anatomic sites of infection for NF were perineal localisation in 55 patients (66%) and extremities in 31 patients (32%). Characteristics that distinguish patients with idiopathic NF from secondary NF were as follows: age older than 55 years (P = 0.0001), presence of comorbid illnesses like DM (P = 0.007) or chronic renal failure (P = 0.041), and perineal localization (P = 0.008). By logistic regression analysis, independent risk factors for idiopathic NF remained age > 55 years and perineal localization as statistically significant factors, when all the significant variables found in univariate analysis were included in the model. The majority of patients (82%) had polymicrobial infections. The mortality rate was 35 per cent. All patients were treated with radical surgical debridement and a combination of antibiotics. Female gender, presence of malignant disease, and diabetes mellitus (DM) were found to be associated with increased mortality as independent factors in logistic regression analysis, when all of these three factors were included in the model. Understanding the distinct clinical characteristics and the factors associated with mortality in patients with NF may lead to rapid diagnosis and improve the survival rates. Therefore, idiopathic NF is a crucial entity that requires serious suspicion for its diagnosis.
Hyperbaric oxygen for the treatment of Fournier's gangrene.
Mindrup SR, Kealey GP, Fallon B.
J Urol 2005 Jun;173(6):1975-7.
Fournier's gangrene is a necrotizing fasciitis of the genitalia that is associated with high morbidity and mortality. Groups at many institutions have initiated routine adjuvant hyperbaric oxygen (HBO) therapy. We examined whether HBO has made a difference in the morbidity, mortality and costs associated with treating this disease. We also analyzed predictors of extended hospital stay and mortality. MATERIALS AND METHODS: The records of patients with the hospital discharge diagnoses of Fournier's gangrene, necrotizing fasciitis, gangrene of the genitalia and scrotal gangrene from 1993 to 2002 were reviewed. Data concerning clinical presentation characteristics, hospital stay, complications, hospital charges and outcomes, including graft failure and death, were analyzed. RESULTS: A total of 42 patients were identified and followed a median 4.2 years. Of the patients 16 underwent surgical debridement and antibiotic therapy alone, and 26 were treated with HBO plus surgery and antibiotics. Overall disease specific mortality was 21.4%, that is 12.5% in the nonHBO group and 26.9% in the HBO group. Three or more complications occurred in 13% of nonHBO and in 19% of HBO cases, of which the most common was myocardial infarction. The skin graft failure rate was 6% (nonHBO) and 8% (HBO). Physical disability was a statistically significant predictor of extended hospital stay (p <0.01). There was a trend toward a correlation between known coronary artery disease and death (p = 0.2). A statistically significant difference was noted in average daily hospital charges in nonHBO vs HBO cases ($2,552 vs $3,384 daily, p <0.01). CONCLUSIONS: These data do not support routine HBO in the treatment of Fournier's gangrene. There was a trend toward higher morbidity and mortality in the HBO group, suggesting that treatment may have been given to patients who were more ill.
Laparoscopic repair of vesicovaginal fistula.
Sotelo R, Mariano MB, Garcia-Segui A, Dubois R, Spaliviero M, Keklikian W, Novoa J, Yaime H, Finelli A
J Urol 2005 May;173(5):1615-8.
PURPOSE: Vesicovaginal fistula may be a complication of urogynecologic surgery. We describe the technique of laparoscopic repair of vesicovaginal fistula as performed at our 2 institutions. MATERIALS AND METHODS: Since August 1998 laparoscopic repair of vesicovaginal fistula was performed in 15 select patients who had clear indications to undergo surgical treatment through an abdominal approach. Hysterectomy had previously been performed in 14 patients (93%). Conservative treatment was initially attempted for more than 2 months in all cases. Four patients had undergone a previous surgical fistula closure attempt with unsuccessful results. Our technique involved cystoscopy, catheterization of the vesicovaginal fistula, laparoscopic cystotomy, opening and excision of the fistulous tract, dissection of the bladder from the vagina, cystotomy closure and colpotomy with interposition of a flap of healthy tissue. Demographic as well as perioperative and outcome data were recorded. RESULTS: Average patient age was 38 years. None of the cases required open conversion. Mean operative time was 170 minutes (range 140 to 240). Mean hospital stay was 3 days (range 2 to 5). The mean duration of bladder catheterization was 10.4 days (range 9 to 15) At a mean followup of 26.2 months (range 3 to 60) 14 patients (93%) were cured. CONCLUSIONS: We believe that laparoscopic repair of vesicovaginal fistula is a feasible and efficacious minimally
Pouch-Vaginal Fistula After Ileal Pouch-Anal Anastomosis: Treatment and Outcomes.
Johnson PM, O'connor BI, Cohen Z, McLeod RS
Dis Colon Rectum 2005 Apr 14;.
PURPOSE: Pouch-vaginal fistula is an uncommon but serious complication after ileal pouch anal anastomosis. The management of pouch-vaginal fistulas is challenging and a number of treatment options exist. The purpose of this study was to examine the outcomes after various procedures for pouch-vaginal fistula performed at our institution. METHODS: Patients who were treated for pouch-vaginal fistula at Mount Sinai Hospital were identified from a prospectively maintained database. Demographic, disease history, treatment, and outcomes data were obtained. Treatment success was defined as no recurrence of the fistula with a functioning pouch and no ileostomy. RESULTS: Since November 1982, 24 of 619 (3.9 percent) women who had primary ileal pouch-anal anastomosis performed at Mount Sinai Hospital developed a pouch-vaginal fistula. Five women had ileal pouch-anal anastomosis performed at another institution and were referred for management of their pouch-vaginal fistula. Local and/or combined abdominoperineal repairs were performed in 22 of 29 patients. Combined abdominoperineal repairs were associated with a higher success rate than that of local perineal repairs (52.9 vs. 7.9 percent, respectively, at 10 years after repair; p = 0.035). Overall, 50 percent (11/22) of patients who underwent surgical repair of a pouch-vaginal fistula had a successful result with a functioning pouch and no recurrence of the fistula, and 21 percent (6/29) of patients required pouch excision. CONCLUSIONS: The management of pouch-vaginal fistula after ileal pouch-anal anastomosis is associated with a high recurrence rate. Combined abdominoperineal repair appears to offer better results than those of local procedures.
Vesicocervical fistula--a rare complication secondary to caesarean section.
Mahomoud S, Arunkalaivanan AS, Devarajan R, Kaur H
Int Urogynecol J Pelvic Floor Dysfunct 2004 Nov-Dec;15(6):439-41. Epub 2004 Aug 12.
We report a case of vesicocervical fistula secondary to caesarean section. This is a rare complication of caesarean section, which was not recognised intraoperatively. Diagnosis was made clinically, radiologically and endoscopically during the post-operative period. Conservative management with indwelling catheterisation for 3 weeks failed. Hence the fistula was repaired surgically by an abdominal approach.
Functional outcomes of primary and secondary repairs of vesicovaginal fistulae via vaginal cuff scar excision.
Flynn MK, Peterson AC, Amundsen CL, Webster GD
Int Urogynecol J Pelvic Floor Dysfunct 2004 Nov-Dec;15(6):394-8; discussion 398. Epub 2004 Jun 2.
Hospital and office charts of patients who underwent vaginal cuff scar excision for vesicovaginal fistula (VVF) repair from February 1998 to December 2002 at our institution were reviewed. Preoperative demographics and fistula characteristics were gathered. Intraoperative data included use of tissue flaps, blood loss, OR time and anesthetic type. Postoperative review included time to discharge, successful repair and postoperative urinary or sexual dysfunction. Forty fistula repairs were identified. Ninety-three percent occurred after a hysterectomy and no subjects had a history of radiation. Forty-two percent had failed at least one surgical repair of their fistula and 12% had failed two or more attempted repairs. Twenty percent of the fistulae measured 1 cm or more in diameter and the remaining 80% were 5 mm or less. Peritoneal flaps and martius flaps were performed in 32% and 5%, respectively. Postoperatively, 100% of subjects were evaluated at 3 weeks when the suprapubic catheter was removed and 93% were evaluated at 3 months or later. All subjects were cured of their fistulae at last contact. At 3 months postoperatively, 94% percent denied any urinary dysfunction and 85% had resumed sexual intercourse. Two sexually active subjects reported mild deep dyspareunia. Transvaginal cuff scar excision is an effective method for the primary and secondary repair of vesicovaginal fistulae and does not appear to cause postoperative irritative voiding symptoms or dyspareunia.
Conservative management of vesicouterine fistula after uterine rupture.
Novi JM, Rose M, Shaunik A, Ramchandani P, Morgan MA
Int Urogynecol J Pelvic Floor Dysfunct 2004 Nov-Dec;15(6):434-5. Epub 2004 Jun 12.
We report the closure of a vesicouterine fistula with conservative management utilizing an indwelling transurethral Foley catheter. Uterine rupture occurred during a trial of vaginal birth after cesarean section, necessitating an emergency cesarean section. Upon entry into the abdomen, the base of the bladder was noted to be involved in the uterine rupture. The bladder trigone and ureteral orifices appeared normal. A primary, two-layer bladder repair was performed. A cystogram on postoperative day 14 demonstrated a vesicouterine fistula. Conservative management involving bladder drainage for 21 days with a transurethral Foley catheter was successful in closure of the fistula.Vesicouterine fistula, a documented complication of uterine rupture due to attempted vaginal birth after previous cesarean section, can spontaneously resolve with conservative management alone.
Vesicouterine fistula as a complication of forceps delivery: a case report.
Nouira Y, Feki W, Rhouma SB, Salah IB, Horchani A
Int Urogynecol J Pelvic Floor Dysfunct 2005 Apr 5;.
We report a case of vesicouterine fistula as a complication of forceps delivery revealed by urinary incontinence in a 68-year-old woman. Diagnosis was confirmed by examination and cystography. The treatment was a transperitoneal excision of the fistula. The literature is briefly reviewed and the treatment options are discussed.
[Recto-seminal fistula and cancer of the rectum]
Roupret M, Varkarakis J, Valverde A, Sebe P
Prog Urol 2004 Dec;14(6):1219-20.
The authors present a case of left epididymo-orchitis associated with rectal adenocarcinoma and suspected fistula between the left seminal vesicle and the rectum. This fistula was confirmed by pelvic computed tomography and surgical exploration. Treatment consisted of parenteral antibiotics and surgical drainage of the abscess associated with colorectal resection. This is an original case, as, retrospectively, the cancer of the rectum, diagnosed 4 days previously, was found to be responsible for the recto-seminal fistula and the seminal vesicle abscess.
Transvaginal repair of the posthysterectomy vesicovaginal fistula using a peritoneal flap: the gold standard.
J Reprod Med 2005 Jan;50(1):41-4.
OBJECTIVE: To evaluate the transvaginal approach to management of vesicouterine fistulas. STUDY DESIGN: Over a 10-year period, 7 cases of simple posthysterectomy vesicovaginal fistulas were identified. The surgical technique involved resection of the fistulous tract completely, performance of layered closure and placement of a peritoneal flap between the bladder and vaginal suture lines. RESULTS: One fistula closed spontaneously, and the remaining 6 were repaired transvaginally. Primary repair was successful in all cases, with no complications. CONCLUSION: The transvaginal repair described is the preferred method of repair, associated with an extremely high success rate, low morbidity and cost savings. Its approach should be considered the gold standard.
Laparoscopic vesicovaginal fistula repair with robotic reconstruction.
Melamud O, Eichel L, Turbow B, Shanberg A
Urology 2005 Jan;65(1):163-6.
INTRODUCTION: To describe, to our knowledge, the first case report of robotic-assisted laparoscopic repair of a vesicovaginal fistula. A 44-year-old woman presented with a vesicovaginal fistula after vaginal hysterectomy. She had been noted to have a bladder injury that was repaired at that time. A vesicovaginal fistula developed several weeks later, and she was referred for repair. The location of the fistula was deemed amenable to repair using a robot-assisted laparoscopic approach. TECHNICAL CONSIDERATIONS: The total operative time was 280 minutes, including placement of ureteral catheters and repositioning. The estimated blood loss was 50 mL. The fistula was repaired using robot-assisted laparoscopic techniques without complications, and the patient went home on the second postoperative day. The Foley catheter was removed 2 weeks postoperatively. The patient continued to void normally without recurrence at 16 weeks of follow-up. CONCLUSIONS: Laparoscopic repair of vesicovaginal fistulas has not gained widespread acceptance owing to its technical difficulty. We describe a minimally invasive laparoscopic approach using the DaVinci robotic system to repair a vesicovaginal fistula.
[Rectovaginal fistulas in adults]
Manaouil D, Dumont F, Regimbeau JM, Duval H, Brazier F, Dupas JL, Verhaeghe P
Gastroenterol Clin Biol 2004 Dec;28(12):1267-79.
Vesicocervical fistula: an unusual complication of vesicovaginal [corrected] fistula repair.
Kesarwani PK, Misra R, Goel A, Hemal AK, Goel R
Int Urogynecol J Pelvic Floor Dysfunct 2004 Sep-Oct;15(5):358-9. Epub 2004 May 19.
A rare case of vesicocervical fistula following repair of a vesicovaginal fistula is presented. The patient complained of cyclical menouria since the first repair done 15 years ago and gradually worsening urinary incontinence. A laparoscopic assisted repair of the fistula was performed and the patient is fully continent at 12-months follow up.