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A fistula is predictably complex when it is greater than 4\u00a0cm 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\u00a0cm 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\u2010vaginal 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.<\/jats:p><\/jats:sec>","DOI":"10.1016\/j.ijgo.2007.06.026","type":"journal-article","created":{"date-parts":[[2007,9,4]],"date-time":"2007-09-04T12:42:51Z","timestamp":1188909771000},"source":"Crossref","is-referenced-by-count":23,"title":["Complex obstetric fistulas"],"prefix":"10.1002","volume":"99","author":[{"given":"R.R.","family":"Genadry","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"A.A.","family":"Creanga","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"M.L.","family":"Roenneburg","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"C.R.","family":"Wheeless","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2007,8,31]]},"reference":[{"key":"e_1_2_9_2_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2004.02.007"},{"issue":"2","key":"e_1_2_9_3_2","first-page":"123","article-title":"Genitourinary and rectovaginal fistulae in Adigrat Zonal Hospital, Tigray, North Ethiopia","volume":"41","author":"Gassessew A.","year":"2003","journal-title":"Ethiop Med J"},{"key":"e_1_2_9_4_2","doi-asserted-by":"publisher","DOI":"10.1007\/BF01894198"},{"key":"e_1_2_9_5_2","doi-asserted-by":"publisher","DOI":"10.1007\/BF00372737"},{"key":"e_1_2_9_6_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2005.08.053"},{"key":"e_1_2_9_7_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0022-5347(01)67522-0"},{"key":"e_1_2_9_8_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0090-4295(96)00079-9"},{"key":"e_1_2_9_9_2","doi-asserted-by":"publisher","DOI":"10.1016\/S1040-8428(03)00123-9"},{"issue":"5","key":"e_1_2_9_10_2","doi-asserted-by":"crossref","first-page":"564","DOI":"10.1046\/j.1464-410x.1999.00006.x","article-title":"Vesicovaginal fistula","volume":"83","author":"Smith G.L.","year":"1999","journal-title":"BJU Int"},{"issue":"4","key":"e_1_2_9_11_2","first-page":"727","article-title":"The use of modified Martius graft as an adjunctive technique in vesicovaginal and rectovaginal fistula repair","volume":"75","author":"Elkins T.E.","year":"1990","journal-title":"Obstet Gynecol"},{"key":"e_1_2_9_12_2","doi-asserted-by":"publisher","DOI":"10.1016\/S1072-7515(00)00351-3"},{"key":"e_1_2_9_13_2","doi-asserted-by":"publisher","DOI":"10.1007\/s00192-003-1102-z"},{"key":"e_1_2_9_14_2","doi-asserted-by":"publisher","DOI":"10.1097\/01.ju.0000049723.57485.e7"},{"key":"e_1_2_9_15_2","doi-asserted-by":"publisher","DOI":"10.1097\/00006250-199203000-00026"},{"issue":"3","key":"e_1_2_9_16_2","first-page":"273","article-title":"Pediculated labial ureteroplasty: an original treatment procedure for ureteral lesions of obstetric origin","volume":"57","author":"Falandry L.","year":"1997","journal-title":"Med Trop"},{"key":"e_1_2_9_17_2","doi-asserted-by":"publisher","DOI":"10.1023\/B:UROL.0000032682.84973.e9"},{"key":"e_1_2_9_18_2","doi-asserted-by":"publisher","DOI":"10.1007\/BF01901602"},{"issue":"5","key":"e_1_2_9_19_2","first-page":"S45","article-title":"Urinary tract reconstruction augmentation cystoplasty","volume":"24","author":"Ahmed S.","year":"2003","journal-title":"Saudi Med J"},{"key":"e_1_2_9_20_2","doi-asserted-by":"publisher","DOI":"10.1007\/BF02236220"},{"key":"e_1_2_9_21_2","doi-asserted-by":"publisher","DOI":"10.1089\/jwh.2005.14.839"},{"issue":"1","key":"e_1_2_9_22_2","first-page":"15","article-title":"Ethiopia: an epidemiological study of vesico\u2010vaginal fistula in Addis Ababa","volume":"48","author":"Kelly J.","year":"1995","journal-title":"World Health Stat Q"},{"key":"e_1_2_9_23_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0090-4295(96)00078-7"},{"key":"e_1_2_9_24_2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1464-410X.2005.04531.x"},{"key":"e_1_2_9_25_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0266-6138(05)80230-X"}],"container-title":["International Journal of Gynecology &amp; 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