Predicting the risk of failure of closure of obstetric fistula and residual urinary incontinence using a classification system

Proportions and determinants of successful surgical repair of obstetric fistula in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Obstetric fistula is a serious and debilitating problem resulting from tissue necrosis on the reproductive and urinary and/or lower gastrointestinal tract organs due to prolonged labor. Primary studies of the treatment of obstetric fistulae report significantly variable treatment outcomes following surgical repair. However, no systematic review and meta-analysis has yet estimated the pooled proportion and identified the determinants of successful obstetric fistula surgical repair.

OBJECTIVE

To estimate the proportion and identify the determinants of successful surgical repair of obstetric fistulae in low- and middle-income countries.

METHODS

The protocol was developed and registered at the International Prospective Register of Systematic Reviews (ID CRD42022323630). Searches of PubMed, Embase, CINAHL, Scopus databases, and gray literature sources were performed. All the accessed studies were selected with Covidence, and the quality of the studies was examined. Finally, the data were extracted using Excel and analyzed with R software.

RESULTS

This review included 79 studies out of 9337 following the screening process. The analysis reveals that 77.85% (95%CI: 75.14%; 80.56%) of surgical repairs in low and middle-income countries are successful. Women who attain primary education and above, are married, and have alive neonatal outcomes are more likely to have successful repair outcomes. In contrast, women with female genital mutilation, primiparity, a large fistula size, a fistula classification of II and above, urethral damage, vaginal scarring, a circumferential defect, multiple fistulae, prior repair and postoperative complications are less likely to have successful repair outcomes.

CONCLUSION

The proportion of successful surgical repairs of obstetric fistula in low and middle-income countries remains suboptimal. Hence, stakeholders and policymakers must design and implement policies promoting women's education. In addition, fistula care providers need to reach and manage obstetric fistula cases early before complications, like vaginal fibrosis, occur.

Urinary incontinence following successful closure of obstetric vesicovaginal fistula repair in Southern Ethiopia

BACKGROUND

Urinary incontinence (UI) after successful closure of obstetric vesicovaginal fistula (VVF) repair is a widely recognized public health problem. However, there is insufficient research evaluating the factors associated with UI after successful obstetric VVF repair in Ethiopia.

OBJECTIVES

The main aim of this study was to assess the magnitude and associated factors of UI following the successful closure of obstetric VVF repair at the Yirgalem Hamlin Fistula Center in the Sidama region of southern Ethiopia.

METHODS

A retrospective cross-sectional analytical study was performed on patients who underwent obstetric VVF repair at the Yirgalem Hamlin Fistula Center between 2016 and 2020. The data were collected from September to October 2021. EPI Data Version 3.1 and SPSS Version 25.0 were used for data entry and analysis. A multivariable binary logistic regression model was used for all variables significant in the bivariate binary logistic analysis to determine the association between the independent variables and outcome variables. The data are presented in tables and figures. Variables with a p-value < 0.05 were considered to be statistically associated with the study outcome.

RESULTS

In total, 499 study subjects were included. The magnitude of UI after successful closure of obstetric VVF repair was 23.25%. A Goh type 4 fistula (AOR = 4.289; 95% CI 1.431, 12.852), a fistula size > 3 cm (AOR = 8.855; 95% CI 4.786, 16.382), a partially damaged urethra (AOR = 2.810; 95% CI 1.441, 5.479), and a completely destroyed urethra (AOR = 5.829; 95% CI 2.094, 16.228) were found to be significantly associated factors with the outcome variable.

CONCLUSIONS

Nearly one in four patients who had successful closure of obstetric VVF repair at the Yirgalem Hamlin fistula center had UI, which is above the WHO recommendations. The presence of a Goh type 4 fistula, large fistula size, and damaged urethral status significantly affect the presence of UI. Therefore, interventions are necessary to prevent and manage UI among patients who underwent obstetric VVF repair and had a closed fistula.

Obstetric fistula repair failure and its associated factors among women who underwent repair in sub-Saharan Africa. A systematic review and meta-analysis

BACKGROUND

Obstetric fistula repair failure can result in increased depression, social isolation, financial burden for the woman, and fistula care programs. However, there is limited, comprehensive evidence on obstetric fistula repair failure in Sub-Saharan African countries. This systematic review and meta-analysis aimed to determine the pooled prevalence of obstetric fistula repair failure and associated factors among women who underwent surgical repair in Sub-Saharan African countries.

METHODS

To identify potential articles, a systematic search was done utilizing online databases (PubMed, Hinari, and Google Scholar). The Preferred Reporting Items for Systematic Review and Meta-Analysis Statement (PRISMA) guideline was used to report the review's findings. I2 test statistics were employed to examine study heterogeneity. A random-effects model was used to assess the pooled prevalence of obstetric fistula repair failure, and the association was determined using the log odds ratio. Publication bias was investigated using the funnel plot and Egger's statistical test at the 5% level of significance. Meta-regression and subgroup analysis were done to identify potential sources of heterogeneity. The data were analyzed using STATA version 17 statistical software.

RESULTS

A total of 24 articles with 9866 study participants from 13 Sub-Saharan African countries were included in this meta-analysis. The pooled prevalence of obstetric fistula repair failure in sub-Saharan Africa was 24.92% [95% CI: 20.34-29.50%]. The sub-group analysis by country revealed that the highest prevalence was in Angola (58%, 95% CI: 53.20-62.80%) and the lowest in Rwanda (13.9, 95% CI: 9.79-18.01%). Total urethral damage [OR  =  3.50, 95% CI: 2.09, 4.91], large fistula [OR = 3.09, 95% CI: (2.00, 4.10)], duration of labor [OR = 0.45, 95% CI: 0.27, 0.76], and previous fistula repair [OR = 2.70, 95% CI: 1.94, 3.45] were factors associated with obstetric fistula repair failure.

CONCLUSION

Women who received surgical treatment for obstetric fistulas in Sub-Saharan African countries experienced more repair failures than the WHO standards. Obstetric fistula repair failure was affected by urethral damage, fistula size, duration of labor, types of fistula, and history of previous repairs. Therefore, we suggest policy measures specific to each country to provide special attention to the prevention of all risk factors, including poor nutrition, multiparty, obstructed labor, and maternal age, which can result in conditions like large fistulas, urethral damage, and repeat repair, in order to reduce obstetric fistula repair failure.

Successful surgical closure and continence rate of obstetric fistula in Africa: systematic review and meta-analysis

Background

A female genital fistula is an abnormal connection between a woman's reproductive tract and her urinary tract or rectum. While numerous studies have aimed to determine the success rate of obstetric fistula closure in different health settings, there remains a significant scarcity of data on closure success rates and incontinence rates for various types of fistulas at the regional and sub-regional levels. The success rate reflects the continent's healthcare setup in regard to the World Health Organization standards. Thus, this study aims to determine the success of surgical closure and the continence rate of obstetric fistula in Africa.

Methods

This systematic review and meta-analysis review includes studies conducted up to February 2023. Search engines like EMBBASE, Medline, Google, PubMed, Google Scholar, African Journals Online, and ScienceDirect databases were utilized to find articles. The Joanna Briggs Institute critical evaluation checklist was used to evaluate the quality of our review, which was conducted in accordance with PRISMA criteria. Heterogeneity was indicated by a p-value for I2 statistics of less than 0.05. Publication bias was assessed using the Egger regression asymmetry test. Data were entered into Microsoft Excel and analyzed using STATA 16.

Result

This review includes 85 studies. A total of 24 countries from East, West, Central, North, and Southern African sub-regions were included. The overall pooled estimated rate of successful obstetric fistula closure is 86.15 (95% CI: 83.88-88.42). Moreover, the pooled estimated rate of successfully closed vesico-vaginal fistulas but with ongoing or residual incontinence (wet) was revealed as 13.41% (95% CI: 11.15-15.68). The pooled estimated rate of successfully closed rectovaginal fistulas and combined VVF and RVF are 91.06% (95% CI: 86.08-96.03) and 62.21% (95% CI: 48.94-75.49), respectively.

Conclusions

The rate of successful obstetric fistula closure in Africa is 86.15, which is higher than the WHO target. However, the surgical closure rate of a combined VVF and RVF is 62.2%, which is significantly lower than the WHO target.

Predictors and outcomes of surgical repair of obstetric fistula at Mekelle Hamlin Fistula Center, Northern Ethiopia

BACKGROUND

Obstetric fistula is a medical condition that involves an opening between vagina and bladder or vagina and rectum. From 2010 to 2013, on average, around 2000 women each year had surgery for obstetric fistula in Ethiopia. The success and failure rate of obstetric fistula repair varies from center to center and is determined by many factors. Thus, this study aimed to assess the predictors and outcomes of surgical repair of obstetric fistula at Mekelle Hamlin Fistula Center (MHFC).

METHODS

A retrospective reviewed medical records of 328 patients with obstetric fistula were carried out at MHFC. Multivariable logistics regression analysis was conducted, a significant association was declared when the p-value was less than 0.05, and the strength of the association was determined by computing the odds ratio at 95% CI. The analysis was done using SPSS version 24.

RESULTS

Obstetrics fistula patients who had formal education were 13% more likely to be successfully repaired than obstetrics fistula patients who had no formal education. Additionally, obstetrics fistula patients who had a live birth were 32.325 (exp (β) = 32.325) times more likely to have had a successful repair than those who had a stillbirth.

CONCLUSION

Fistula closure was achieved in 89.3% of cases. The success rate for VVF (vesico-vaginal fistula) and RVF (recto-vaginal fistula) surgical repair was 86.9% and 100% respectively, which is higher than the WHO target. Body mass index between 18.5-24.9 kg/m2, formal education, antibiotic use, live birth, large fistula size, and home and cesarean delivery were predictors of successful closure of obstetric fistula.

Prevalence and associated risk factors for failed obstetric fistula repair in East African countries: A systematic review and meta-analysis

Objective

Obstetric fistula repair failure is a combination of unsuccessful fistula closure and/or incontinence following a successful closure. There is an inconsistent finding on the failure of obstetric fistula repair in East Africa. Therefore, this systematic review and meta-analysis aimed to determine the pooled prevalence of failed obstetric fistula repair and its associated factors among women who have undergone fistula repair in East Africa.

Methods

This systematic review and meta-analysis were written following the PRISMA guideline protocol. A web-based electronic search of PubMed, Google Scholar, and HINARI was performed to find primary studies. Additional articles were searched by cross-referencing references. A random-effects model was used to estimate the pooled prevalence of failed obstetric fistula repair. The heterogeneity of studies was weighed using I2 test statistics. Publication bias was assessed by Eggers and funnel plot test.

Results

The 16 studies that met the inclusion criteria for this systematic review and meta-analysis of failed obstetric fistula repair were included. Nonetheless, one study was used for factor analysis but not in pooled prevalence analysis. The pooled prevalence of obstetric fistula repair failure in East Africa was 26.89% (95% confidence interval: 21.71, 32.07). Labor duration > 48 h (Pooled odds ratio = 2.46; 95% confidence interval 1.58, 3.82), fistula size >3 cm (Pooled odds ratio = 3.92; 95% confidence interval 2.19, 7.05), previous fistula repair (Pooled odds ratio = 3.20; 95% confidence interval 1.94, 5.29), Goh Type 4 fistulas (Pooled odds ratio = 6.07; 95% confidence interval 2.50, 14.75), completely destructed urethra (Pooled odds ratio = 3.35; 95% confidence interval 1.69, 6.65), and severe vaginal scaring (Pooled odds ratio = 3.89; 95% confidence interval 1.99, 7.62) were significantly associated with obstetric fistula repair failure.

Conclusions

One in four women with obstetric fistula repair experienced repair failure. To fight the problem The Ministry of Health in every part of the country, in collaboration with obstetric care providers, shall intervene on factors affecting obstetric fistula repair failure to reduce or prevent the failure of obstetric fistula repair.

Effect of vaginal scarring on the recovery of surgical repair of obstetric fistula in Northern Ethiopia

OBJECTIVE

To determine the effect of vaginal scarring on the recovery from surgical repair of obstetric fistula in Northern Ethiopia from 2015 to 2020.

METHODS

A hospital-based retrospective cohort study was conducted among 224 women who had obstetric fistula repair surgery in Northern Ethiopia from March 1 to March 31, 2020. Cox proportional hazards regression model was used to determine the adjusted predictors of recovery for each main baseline predictor variable, using 95% confidence interval (CI) and P < 0.05 to declare statistical significance.

RESULTS

The overall recovery rate was 57 of 1000 women (43 of 1000 and 73 of 1000 for women with and without vaginal scar, respectively), with an overall median time to recovery from obstetric fistula repair surgery of 15 days. Vaginal scarring (adjusted hazard ratio [aHR], 1.58 [95% CI, 1.13-2.21]), age of the patient (aHR, 4.05 [95% CI, 1.56-10.5]), mode of delivery (aHR, 2.14 [95% CI, 1.31-3.49]), place of delivery (aHR, 1.91 [95% CI, 1.17-3.12]), prior repair (aHR, 1.90 [95% CI, 1.08-3.35]), and duration of catheterization (aHR, 12.91 [95% CI, 7.21-23.13]) were independent predictors of recovery.

CONCLUSIONS

In the present study, we found that women who had no vaginal scar, age older than 30 years, facility and spontaneous vaginal delivery, first attempt repair, and shorter duration of catheterization had a shorter recover time.

FIGO recommendations: Use of midurethral slings for the treatment of stress urinary incontinence

BACKGROUND

Stress urinary incontinence (SUI) is a global problem. It can significantly adversely impact a woman's quality of life. The use of synthetic mesh in vaginal surgery is controversial, especially when used for pelvic organ prolapse surgery. Although negative effects have been reported, the synthetic mesh midurethral sling (MUS) is considered to be safe and effective in the surgical treatment of SUI.

OBJECTIVES

To provide evidence-based data and recommendations for the obstetrician/gynecologist who treats women with SUI and performs or plans to perform MUS procedures.

METHODS

Academic searches of MEDLINE, the Cochrane Library, Embase, and Google Scholar articles published between 1987 and March 2020 were performed by a subgroup of the Urogynecology and Pelvic Floor Committee, International Federation of Gynecology and Obstetrics (FIGO).

SELECTION CRITERIA

The obtained scientific data were associated with a level of evidence according to the Oxford University Centre for Evidence-Based Medicine and GRADE Working Group system. In the absence of concrete scientific evidence, the recommendations were made via professional consensus.

RESULTS

The FIGO Urogynecology and Pelvic Floor Committee reviewed the literature and prepared this evidence-based recommendations document for the use of MUS for women with SUI.

CONCLUSIONS

Despite the extensive literature, there is a lack of consensus in the optimal surgical treatment of SUI. These recommendations provide a direction for surgeons to make appropriate decisions regarding management of SUI. The MUS is considered safe and effective in the treatment of SUI, based on many high-quality scientific publications and professional society recommendations. Comprehensive long-term data and systemic reviews are still needed, and these data will become increasingly important as women live longer. These recommendations will be continuously updated through future literature reviews.

Obstetric fistula repair failure and its associated factors among women underwent repair in Yirgalem Hamlin fistula center, Sidama Regional State, Southern Ethiopia, 2021: a retrospective cross sectional study

Background

Obstetric fistula repair failure is a combination of unsuccessful fistula closure and/or incontinence following a successful closure. It causes a burden on both the patients and the fistula centers. The aim of this study was to assess the magnitude and associated factors of obstetric fistula repair failure among women who underwent fistula repair at Yirgalem Hamlin fistula center in Southern Ethiopia.

Methods

A facility-based retrospective cross-sectional study was conducted among women who underwent fistula repair at Yirgalem Hamlin fistula center, Southern Ethiopia, during the period from January 2016 to December 2020. All 562 women who underwent fistula repair in the last 5 years were included in the study. The data were collected using a pre-tested checklist from September 22 to October 22, 2021. The data were then imported into EPI info-data version 3.1, exported to SPSS version 25, and analyzed. Descriptive and logistic regression analyses were performed, and the significant statistical test was assessed at a 95% confidence interval. Variables with a p value of < 0.05 in multivariable logistic regression were regarded to have a statistically significant relationship.

Results

The magnitude of obstetric fistula repair failure in this study was 28.8%. Obstetric fistula repair failure was found to be associated with labor duration > 48 h (AOR = 2.037; 95% CI 1.268, 3.272), Goh Type 4 fistulas (AOR = 3.939; 95% CI 1.623, 9.560), fistula size > 3 cm (AOR = 6.627; 95% CI 3.802, 11.554), completely destructed urethra (AOR = 3.192; 95% CI 1.234, 8.256), and bladder catheterization > 14 days (AOR = 2.944; 95% CI 1.380, 6.281).

Conclusions

The magnitude of obstetric fistula repair failure was significantly higher than the World Health Organization standard. Obstetric fistula repair failure had a positive association with a longer duration of labor, Goh Type 4 fistulas, large fistula size, total urethral injury, and a longer period of bladder catheterization. Therefore, the concerned bodies need to implement interventions on factors affecting obstetric fistula repair failure to reduce or prevent the failure of obstetric fistula repair.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01866-z.

Survival Modeling on the Determinants of Time to Recovery from Obstetric Fistula: The Case of Mekelle Hamlin Fistula Center, Ethiopia

BACKGROUND

An obstetric fistula is an abnormal opening between the vagina, rectum, and/or bladder. Obstetric fistula has a devastating impact on women's physical, social, and psychological health. Despite the numerous health consequences in developing countries, including Ethiopia, there have been few studies on the determinants of time to recovery from obstetric fistula. Therefore, this study is aimed at addressing the gap.

METHODS

A retrospective cohort study was employed to include 328 randomly selected records of women admitted for obstetric fistula treatment at Mekelle Hamlin Fistula Center from January 2015 to 2020. Data collected from the medical records was coded and entered into SPSS software version 20 and exported to STATA 10 and R statistical software for data cleaning and data analysis. The Kaplan-Meier and log-rank tests were computed to explore the data. The log-logistic inverse Gaussian shared frailty model was employed using a 95% CI, and variables with a p value < 0.05 were declared as determinants of recovery time.

RESULTS

Of 328 fistula patients, 293 (89.33%) were physically cured. The Kaplan-Meier result showed that the overall mean and median survival time of time to recovery from obstetric fistula patients at Mekelle Hamlin Fistula Center is 42 and 33 days, respectively. In a log-logistic inverse Gaussian shared frailty model analysis, extensive fistula size (AHR : 1.282; 95% CI = 1.175-1.388), secondary and above education level (AHR : 0.830; 95% CI = 0.693-0.967), rural residence (AHR : 1.357; 95% CI = 1.236-1.479), and physiotherapy use (AHR : 0.801, 95% CI = 0662-0.940, 95% CI = 1.175-1.388) were statistically significant predictors of recovery from obstetrics fistula.

CONCLUSION

Rural place of residence, home delivery, and large and extensive size of the fistula prolong the timing of healing from the obstetric fistula. However, having tall height, physiotherapy treatment, secondary and above-educated women, and RVF type of fistula has a short time of healing for obstetric fistula in Mekelle Hamlin Fistula Center. Therefore, we recommend that health professionals promote institutional delivery and physiotherapy, shorten the duration of catheterization, and manage urine incontinence. In addition, we recommend that the regional health bureau promotes female education and pregnancy after 18 years. The survival probability of patients with obstetric fistulas is better predicted by the log-logistic inverse Gaussian shared frailty model. Therefore, it would be good for future researchers to take this model into account.

Factors Associated With Persistent Urinary Incontinence Among Women Undergoing Female Genital Fistula Surgery in the Democratic Republic of Congo From 2017 to 2019

Background

Despite high closure rates, residual urinary incontinence remains a common problem after successful closure of a vesico-vaginal fistula. The objective of this study was to identify factors associated with residual urinary incontinence in women with successful fistula closure in sites supported by the Fistula Care Plus project in the Democratic Republic of Congo (DRC).

Material and Methods

This was a retrospective cohort study using routine data extracted from the medical records of women undergoing fistula surgery in three hospitals supported by the Fistula Care Plus project in DRC between 2017 and 2019. We analyzed factors associated with residual urinary incontinence among a subsample of women with closed fistula at discharge. We collected data on sociodemographic, clinical, gynecological-obstetrical characteristics, and case management. Univariate and multivariate analyses were performed to determine the factors associated with residual urinary incontinence.

Results

Overall, 31 of 718 women discharged with closed fistula after repair (4.3%; 95% CI: 3.1-6.1) had residual incontinence. The leading causes identified in these women with residual incontinence were urethral voiding (6 women), short urethra (6 women), severe fibrosis (3 women) and micro-bladder (2 women). The prevalence of residual incontinence was higher among women who received repair at the Heal Africa (6.6%) and St Joseph's (3.7%) sites compared with the Panzi site (1.7%). Factors associated with increased odds of persistent urinary incontinence were the Heal Africa repair site (aOR: 54.18; 95% CI: 5.33-550.89), any previous surgeries (aOR: 3.17; 95% CI: 1.10-9.14) and vaginal surgical route (aOR: 6.78; 95% CI: 1.02-45.21).

Conclusion

Prior surgery and repair sites were the main predictors of residual incontinence after fistula closure. Early detection and management of urinary incontinence and further research to understand site contribution to persistent incontinence are needed.

Benign Hepatic Tumors and Liver Transplantation: A Literature Review

Management of benign liver tumors represents still an open debate, with no clear guidelines for patient selection, treatment options, and indications to surgical intervention. Usually, most of these diseases are conservatively treated, in view of their low potential malignancy and incidental diagnosis. However, when the lesions are symptomatic, with a major hepatic parenchyma involvement or life-threatening complications, liver transplant represents the only curative option. The scope of this review is to present an up-to-date state of the art of transplantable benign hepatic neoplasms.

Vesico-vaginal fistula in Tunisia: Epidemiology and risk factors of treatment failure

INTRODUCTION

Vesico-vaginal fistula (VVF) is a global healthcare problem that has a high prevalence in developing countries. The aim of this work is to study the epidemiological, clinical and therapeutic characteristics of VVF post-obstetric and gynecologic procedures in order to identify the predictive factors of surgical treatment failure.

METHODS

Data were collected from 132 VVF patients in our institution between 1985 and 2017. VVF was classified according to Zmerli's classification. Patients underwent surgical treatment and were evaluated after a follow-up period of 6 months. Successful treatment was defined as the absence of urine leakage whereas recurrence was defined as the presence of urine leakage immediately after the surgery or after a period of dryness with a confirmed VVF. Risk factors of surgical treatment failure were identified.

RESULTS

The average age of patients was 44 years. The patients were multiparous in 62% of cases. VVF was consecutive to hysterectomy in 62.1% of cases, and after childbirth in 34%. VVF was retro-trigonal in 99 cases (75%) and trigonal in 33 cases (25%). The average size of the fistula was 1cm (0.3-2cm). VVF repair was performed by vaginal approach in 68% of cases and abdominal approach in 32% of cases. Treatment failure was noted in 36 patients (27%). Predictive factors of treatment failure were: vaginal fibrosis (P<0.001); trigonal location of the fistula (P<0.001); large diameter of the VVF>1cm (P<0.001); and complex and complicated fistulas (P=0.02).

CONCLUSION

Although Tunisia is a developing country, the main cause of VVF was not obstetrical. Treatment failure, noted in almost one third of cases, was, in our series, correlated with the quality of the vaginal tissue, the size and the location of the fistula, and its complexity.

LEVEL OF PROOF

4.

Contemporary Issues in Obstetric Fistula

We discuss a variety of contemporary issues relating to obstetric fistula. These include definitions of these injuries, the etiologic mechanisms by which fistulas occur, the role of specialist fistula centers in diagnosis and management, the classification of fistulas, and the assessment of surgical outcomes. We also review the growing need for complex reconstructive surgical procedures, follow-up challenges, and the transition to a fistula-free world in which other pathologies (such as pelvic organ prolapse) will be of increasing importance. Finally, we discuss the need to develop responsive systems of maternal health care that treat women with competence, compassion, respect, and fairness.

An International Continence Society (ICS) report on the terminology for female pelvic floor fistulas

INTRODUCTION

The terminology for female pelvic floor fistulas (PFF) needs to be defined and organized in a clinically based consensus Report.

METHODS

This Report combines the input of members of the International Continence Society (ICS) assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give a coding to definitions. An extensive process of 19 rounds of internal and external review was involved to examine each definition, with decision-making by collective opinion (consensus).

RESULTS

A terminology report for female PFF, encompassing 416 (188 NEW) separate definitions, has been developed. It is clinically based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in different specialty groups involved in female pelvic floor dysfunction and PFF. Female-specific imaging (ultrasound, radiology, and magnetic resonance imaging) and conservative and surgical PFF managements as well as appropriate figures have been included to supplement and clarify the text. Interval (5-10 years) review is anticipated to keep the document updated and as widely acceptable as possible.

CONCLUSION

A consensus-based terminology report for female PFF has been produced to aid clinical practice and research.

Prophylactic Autologous Slings at the Time of Obstetric Fistula Repair: A Randomized Clinical Trial

OBJECTIVE

To compare prophylactic slings for women with obstetric fistulas at high risk of residual incontinence.

METHODS

This was a multiple-site randomized controlled trial comparing autologous fascia slings to pubococcygeal (PC) slings at time of fistula repair. Women with a Goh type 3 or 4 vesicovaginal fistula (distal edge of the fistula is ≤2.5 cm from the external urethral orifice) with no prior repair were randomized to receive either a rectus fascia sling or a PC sling while undergoing fistula repair. Interviews were performed before surgery and at follow-up 1 to 6 months later including the Michigan Incontinence Symptom Index and the Incontinence Quality of Life Tool. Pad weights were also collected at this time. Safety analysis was performed after 10 participants were enrolled in each arm.

RESULTS

Eleven participants randomized to a PC sling and 10 to a rectus sling. There was 1 repair breakdown in the PC group and 3 in the rectus group. There was no significant difference noted in pad weights or quality of life scores between groups. Quality of life and Michigan Incontinence Symptom Index scores improved significantly for both groups after surgery. The study was terminated at safety analysis due to the number of breakdowns and difficulty of follow-up at 1 site.

CONCLUSIONS

There was no superiority between slings. Randomization proved problematic given the vast heterogeneity between fistula injuries. There is a need for an innovative anti-incontinence technique.ClinicalTrials.gov identifier: NCT03236922 https://www.clinicaltrials.gov/ct2/show/NCT03236922?cond=vesico-vaginal+fistula&rank=2.

Risk factors for early and late failures following repair of urogenital fistulas

INTRODUCTION AND HYPOTHESIS

In Sub-Saharan Africa, obstetric fistulas are a health crisis of extensive proportions. Although risk factors for failure are described, little data exist regarding differences in risk factors for early and late recurrences.

METHODS

A retrospective cohort study was conducted to evaluate risk factors for fistula recurrence. Inclusion criteria included women who underwent repair of urogenital fistula at a Fistula Hospital in Uganda between 2013 and 2019. Our primary objective was to determine the incidence of both early and late failures and to identify and compare risk factors for each. Logistic regression was used to calculate crude odds ratios (ORs) and 95% confidence intervals (CIs) representing the association between each risk factor for early and late failures. Covariates significantly associated with early or late failure in univariate analyses were included in multivariate logistic regression models.

RESULTS

A total of 541 patients were included. The incidence of early failure was 10.9%. Risk factors for early failure included stillbirth (aOR = 3.71, 95% CI: 1.38-9.96), fistula larger than 3 cm, (aOR = 3.12 95% CI: 1.40-6.93), presence of foot drop (aOR = 4.74, 95% CI:1.88-11.97), and perioperative blood transfusion (aOR = 3.10, 95% CI: 1.11-8.66). Risk factors for late failures included stillbirth (aOR = 4.63, 95% CI:1.04-20.51), and previous fistula repairs (aOR = 3.13, 95% CI:1.30-7.56).

CONCLUSION

Both early and late failures can occur and risk factors for each may be different. Identifying patients at risk for late failures is important for improved counseling and highlights the importance of developing risk-reducing strategies to improve patient outcomes after discharge.

A Comparison of Postoperative Surgical Outcomes among Women Undergoing Obstetric Fistula Repair with and without HIV

BACKGROUND AND OBJECTIVE

Obstetric fistula affects approximately 2 million women worldwide, predominantly in places with a high Human Immunodeficiency Virus (HIV) burden. In Malawi, where thousands of women live with fistulas, HIV prevalence is 11-13%. Although repair is usually successful, surgical outcomes among immunocompromised women are poorly understood. Inconsistent guidelines regarding the Cluster of Differentiation 4 (CD4) threshold necessary for repair make it difficult for surgeons to make informed decisions. This study compares the postoperative outcomes of women undergoing obstetric fistula repair with and without HIV, stratified by CD4 count.

METHODS

This is a retrospective case-control study using a database of women who underwent vesicovaginal fistula repair at the Fistula Care Center from 2010-2018. HIV-positive participants, stratified by CD4<350 and CD4>350, were matched to HIV-negative controls by age within 5 years and Goh classification. Controls were matched to cases in a 3:1 ratio. Bivariate analysis and logistic regression were conducted on indicators based on HIV status and CD4 count stratification. Outcomes included dye test results, pad weights, and continence status at 2 weeks post-repair.

RESULTS

54 seropositive women were matched to 135 seronegative women. Of the 54 HIV positive women, 22.2% (n=12) had a CD4 count < 350. We found no statistically significant difference in surgical outcomes between HIV-positive and negative patients. 93.5% of HIV positive and 90% of HIV negative women healed completely. In our sub-analysis of 12 seropositive women with CD4<350, we found a statically significant difference in successful closure, with 25% of women with CD4<350 having a positive dye test indicating incomplete closure, compared to 2.8% of women with CD4>350 (p=0.024).

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Our analysis confirms previous research indicating that seropositive women with a CD4>350 can safely undergo obstetric fistula repair. Further research is needed to evaluate postoperative outcomes among women with CD4<350.

Predictive value of classification systems and single fistula-related factors in surgical management of vesicovaginal fistula

AIMS

The aim of this study was to find the most clinically useful vesicovaginal fistula (VVF) classification system or single fistula-related factor, which would be helpful in determining the most proper management leading to successful treatment.

METHODS

Between 2018 and 2020, 30 patients were diagnosed with VVF and underwent the Latzko procedure. Nineteen patients, after previously failed surgery, were injected with platelet-rich-plasma (PRP) before a final attempt to close VVF. Patients with primary VVF were included into the surgery only group and patients with secondary VVF were included into PRP and surgery group. Each patient was classified according to 13 different classification systems.

RESULTS

Statistical evaluation revealed some significant differences between the patients who required PRP injection and repeated surgery, compared with patients who were successfully treated at first surgery but only with Lawson, Waaldijk, Arrowsmith, and Tafesse classifications. Patients who succeded with the fistula closure after the first surgical procedure had significantly higher body mass index (BMI) when compared with patients who required PRP injection prior surgical procedure (30.9 vs. 25.7, respectively; p < .05).

CONCLUSIONS

None of the classification systems allows to precisely predict VVF surgery outcome. There are several factors such as previous surgery, lack of urethral involvement, lack of circumferential defect which might suggest that PRP injection would help to preserve watertightness of the closure. The most important finding is that overweight is the most positive predicting demographic feature of surgical success. Thus we may conclude that Martius flap technique should be taken into consideration in patients with low BMI.

Autologous rectus fascia sling for post-vesicovaginal fistula repair stress incontinence: case series from a Nigerian experience

Background

Successful outcome of a urinary fistula repair involves a successful closure of the fistula without residual incontinence. However, a few women have post-repair stress urinary incontinence despite closure of the fistula, which requires special surgical technique to achieve total continence.

Case presentation

Four women with post-vesicovaginal fistula repair residual incontinence were selected for sling operation using autologous rectus fascia in a low resource setting. Their ages ranged between 20 and 30 years. None had a fistulous opening on vaginal examination and dye test. Two patients had one previous attempt at repair of post-repair stress incontinence, while the others had two and three attempts, respectively, without success. The patients had none to mild vaginal adhesion. Following the procedure, they were followed up for 6 months and they remained continent of urine.

Conclusion

All patients achieved total urinary continence following autologous rectus fascia slings with minimal complications. This demonstrates the possibility of achieving a successful outcome despite lack of modern equipment for diagnosis and follow-up, a typical problem of low-income country like Nigeria.

Clinical Profile, Surgical Approach and Outcome of Complicated Genital Fistulae in Urban Population of a Developing Nation

Objectives

To study aetiology and management of complicated genital fistulae and to evaluate the outcome of the treatment.

Methods

This observational study enrolled patients with complicated genital fistulae from September 2008 to August 2018 at Sant Parmanand Hospital, Delhi. Patients underwent a reparative surgery or ureteric stenting after a detailed preoperative workup. Patients were followed up for the assessment of outcomes.

Results

A total of 16 patients were recruited: Ten (62.5%) patients had fistulae secondary to gynaecological surgeries (seven laparoscopic and three abdominal hysterectomies) and six (37.5%) patients had obstetric fistulae. At a mean follow-up of 5.8 years among obstetric fistulae and 7.3 years among post-operative fistulae, 100% success rate was maintained with the first attempt of reparative surgery or ureteric stenting. There were no major complications. Two patients had recurrent urinary tract infections, and one patient had transient urinary incontinence for 4 weeks.

Conclusion

The study demonstrates that complicated genital fistulae occur more commonly secondary to gynaecological surgeries as compared to obstetric complications in a contemporary cohort from a metropolitan city. A 100% success rate of reparative surgery could be achieved with a transperitoneal approach. Good outcome in ureteric fistulae can be achieved with conservative approach, after proper case selection.

A review of surgical procedures to repair obstetric fistula

Although approximately 2 million women suffer from an obstetric fistula, the surgical literature is sparse. This review examines the evidence published to date. The most relevant surgical evidence is included, highlighting the need for further scientific investigations to contribute to our surgical practice. The most pressing needs relate to anti‐incontinence techniques and complex obstetric fistula repairs.

This summary of surgical techniques and procedures in obstetric fistula repair demonstrates the need for more evidence and innovation.

[Model predicting failure in surgical repair of obstetric vesicovaginal fistula]

Introduction

Il y a plus de 2 millions de cas de fistule génitale en Afrique subsaharienne et en Asie. Elles surviennent dans les zones où l'accès aux soins à l'accouchement est limité ou de qualité médiocre et où peu d'hôpitaux offrent les interventions chirurgicales correctives nécessaires. L'objectif de cette étude est de développer un score prédictif permettant d'identifier les facteurs influant sur l'échec de la réparation chirurgicale de la fistule obstétricale vésico-vaginale (ERCF) dans la partie Sud-Est de la province du Haut-Katanga.

Méthodes

Il s'agit d'une étude transversale analytique menée sur 384 femmes porteuses d'une fistule obstétricale vésico-vaginale ayant bénéficié d'une prise en charge chirurgicale. Nous avons procédé par une analyse univariée puis multivariée. La discrimination du score était évaluée à l'aide de la courbe Receiving Operating Characteristics (ROC) et du C-index et la calibration du score selon le test d'Hosmer-Lemeshow.

Résultats

La réparation chirurgicale de la fistule obstétricale vésico-vaginale s'était soldée par un échec dans 17,19% des cas (66/384). Après modélisation logistique, quatre critères ressortent comme facteurs prédictifs d'ERCF: la présence d'une fibrose cicatricielle (ORa=15,22; IC95%: 7,34-31,58), la présence de 2 fistules ou plus (ORa=7,41; IC95%: 3,05-17,97), l'abord trans-vésical comme voie d'abord (ORa=4,26; IC95%: 1,92-9,44) et l'atteinte urétrale (ORa=3,93; IC95%: 1,99-7,77). L'aire sous la courbe ROC du score est de 0,8759 avec une sensibilité de 57,58%, une spécificité de 91,82% et une valeur prédictive positive de 91,25%.

Research in Obstetric Fistula: Addressing Gaps and Unmet Needs

Although obstetric fistula has likely plagued women since the beginning of time, very little research proportionally exists. This article summarizes the most substantial research on the topic and delineates research gaps and future needs. Existing research demonstrates that access to care is the underlying cause of obstetric fistula and that the first attempt at closure holds the highest chance at success, ranging between 84% and 94%. For simple cases, 10 days of a catheter is sufficient, although what constitutes as simple is unclear. Circumferential fistulas are at high risk for ongoing urethral continence. Psychosocial programs are helpful for all women, but those who are "dry" tend to reintegrate into society, whereas those still leaking need additional support. Prenatal care and scheduled cesarean delivery are recommended to avoid another fistula. Gaps in research include accurate prevalence and incidence, interventions to improve access to care, surgical technique, especially for complex cases, and ways to prevent ongoing incontinence, among many others. In all areas, more rigorous research is needed.

Persistent depression after obstetric fistula repair

OBJECTIVE

To measure depression over time using the Patient Health Questionnaire 9 (PHQ-9) and identify characteristics associated with persistent depression.

METHODS

A database of women undergoing obstetric fistula repair was used to examine associations between depression and variables such as demographics, type of fistula, and postoperative continence status.

RESULTS

A total of 797 patients completed the PHQ-9 at the initial preoperative assessment; 365 (45.8%) had a PHQ-9 score of 5 or higher, indicating depression. Preoperatively, depression was associated with women aged 18-34 years, with no children, and with fistula for 5 years or less. Postoperatively, depression was associated with persistent incontinence. Over time, however, depression was rarely found among women returning for follow-up.

CONCLUSION

Postoperative depression decreased over time in women who returned for follow-up, either due to selection bias or due to improved adjustment to one's circumstances. This study underscores the need for ongoing follow-up, especially for those not presenting for care or with persistent incontinence.

Is there a relationship between female genital mutilation/cutting and fistula? A statistical analysis using cross-sectional data from Demographic and Health Surveys in 10 sub-Saharan Africa countries

OBJECTIVES

Literature on associations between female genital mutilation/cutting (FGM/C) and fistula points to a common belief that FGM/C predisposes women to developing fistula. This study explores this association using nationally representative survey data.

DESIGN

A secondary statistical analysis of cross-sectional data from Demographic and Health Surveys was conducted to explore the association between FGM/C and fistula.

SETTING

Sub-Saharan Africa.

PARTICIPANTS

Women aged 15-49 years in Burkina Faso (n=17 087), Chad (n=17 719), Côte d'Ivoire (n=10 060), Ethiopia (n=14 070), Guinea (n=9142), Kenya (n=31 079), Mali (n=10 424), Nigeria (n=33 385), Senegal (n=15 688) and Sierra Leone (n=16 658).

MAIN OUTCOME MEASURES

Fistula symptoms.

RESULTS

Multivariate logit modelling using pooled data from 10 countries showed that the odds of reporting fistula symptoms were 1.5 times (CI 1.06 to 2.21) higher for women whose genitals were cut and sewn closed than those who had undergone other types of FGM/C. Women who attended antenatal care (ANC) (adjusted odds ratio (AOR) 0.51, CI 0.36 to 0.71) and those who lived in urban areas (AOR 0.62, CI 0.44 to 0.89) were less likely to report fistula symptoms than those who did not attend ANC or lived in rural areas.

CONCLUSIONS

Severe forms of FGM/C (infibulation) may predispose women to fistula. Contextual and socioeconomic factors may increase the likelihood of fistula. Multisectoral interventions that concurrently address harmful traditional practices such as FGM/C and other contextual factors that drive the occurrence of fistula are warranted. Promotion of ANC utilisation could be a starting point in the prevention of fistulas.

Assessing quality of life in obstetric fistula patients: Validation of the urogenital distress inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7) in Lingala and Kikongo in DR Congo

AIMS

The Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7) are both well-known. In obstetric fistula (OF) repair outcome is usually assessed by the surgical team. The patient perspective is often neglected. Therefore we translated both questionnaires in Lingala and Kikongo, official languages in DR Congo. Secondly used the questionnaires in an OF population to assess the real life continence status and the impact of fistula repair surgery.

METHODS

UDI-6 and IIQ-7 were translated and underwent content validity checks using focus groups. The final versions were tested in a normal population and in an OF population (33 for Kikongo, 35 for Lingala) for internal consistency and test-retest reliability. The responsiveness was tested in an OF population and effect sizes were calculated.

RESULTS

Both questionnaires showed good internal consistency and reliability. The Cronbach's α for UDI-6 in both languages was 0.47 for the IIQ-7, 0.96 for Lingala and 0.94 for Kikongo in an OF population. The test-retest reliability was high in all cohorts. Both questionnaire scores improved significantly after fistula repair. The effect size for UDI-6 was -1.09 and -1.6 for IIQ-7.

CONCLUSION

Both IIQ-7 and UDI-6 questionnaires have been translated in Lingala and Kikongo, two languages of DR Congo. The questionnaires have been validated in an obstetrical fistula population, showing good content validity and test-retest reliability. The questionnaires show a highly significant effect size, demonstrating the dramatic positive effect of fistula surgery on urogenital symptoms and on the quality of live in an obstetric fistula population.

Predictors of Obstetric Fistula Repair Outcomes in Lubango, Angola

OBJECTIVE

Obstetric fistulas have a significant physical and social impact on many women in Angola. The majority of the population of this sub-Saharan African nation does not have access to high-quality obstetric care, and this is associated with a risk of prolonged labour and formation of obstetric fistulas. Fistulas are challenging to correct surgically and may require repeated operations. The objective of the study was to determine predictors of successful obstetric fistula repair.

METHODS

In this retrospective study, data from all recorded cases of fistula repair performed between July 2011 and December 2016 at the Centro Evangélico de Medicina do Lubango (CEML) hospital located in Lubango, Angola, were reviewed. Analysis of the data was carried out to determine factors affecting the success of fistula repair; parametric and non-parametric tests were used for group comparisons and logistic regression for outcome prediction (Canadian Task Force classification II-2).

RESULTS

A total of 407 operations were performed on 243 women. Of these, 224 women were diagnosed with a vesicovaginal fistula and 19 with a combined vesicovaginal and rectovaginal fistula. The success rate for the attempted repairs was 42%. On multivariate analysis, the success of first surgery was negatively affected by the difficulty of repair (odds ratio 0.28; P < 0.01). For patients requiring repeat surgery, the odds of success were increased with each subsequent operation (odds ratio 5.32; P < 0.01).

CONCLUSION

Although fistulas rated as difficult to repair had a higher likelihood of initial failure, successive attempts at repair increased the likelihood of a successful outcome.

Time to recovery from obstetric fistula and determinants in Gondar university teaching and referral hospital, northwest Ethiopia

BACKGROUND

Obstetric fistula is an abnormal connection between the vagina and rectum and/or bladder, which leads to continuous urinary or fecal incontinence. It is a serious problem in the world poorest countries, where most mothers give birth without any medical care. In most cases obstetric fistula is preventable and can be treated successfully, if it is carried out by a competent surgeon with a good follow-up of postoperative care. However, there remains to explore more on the duration of obstetric fistula recovery and determinant factors. The aim of this study was to estimate the average recovery time of obstetric fistula and to identify its determinants in Gondar University teaching and referral hospital, northwest Ethiopia.

METHOD

A retrospective follow up study was conducted at Gondar University teaching and referral hospital. A total of 612 fistula cases were included in the study and simple random sampling technique was applied to select the study subjects. Kaplan-Meier and log rank test were computed to explore the data. Weibull regression survival model with univariate frailty was done to identify the determinant factors of time to recovery.

RESULTS

Of 612 fistula patients, 539(88.07%) were recovered. The Average (median) recovery time was 5.14 (IQR = 3.14, 9.14) weeks. Using Antibiotic (AHR = 1.49, 95% CI = 1.11-2.01), having history of antenatal care (ANC) (AHR = 1.95, 95% CI = 1.39-2.73), being literate (AHR = 2.23, 95% CI = 1.62-3.06), duration of bladder catheterization (AHR = 0.93, CI = 0.90-0.95) and being multiparous (AHR = 1.51, 95% CI = 1.17-1.96) were a significant predictors of the rate of recovery. Also, underweight (AHR = 0.45, 95% CI = 0.30-0.68), overweight (AHR = 0.56, 95% CI = 0.41-0.76), being obese (AHR = 0.41, 95% CI = 0.21-0.80), having extensive fistula (AHR = 0.82, 95% CI = 0.73-0.91), large fistula (AHR = 0.42, 95% CI = 0.23-0.78), medium width (AHR = 0.62, 95% CI = 0.43-0.91) and large width (AHR = 0.42, 95% CI = 0.23-0.78) were statistically significant predictors of the rate of recovery from fistula patients.

CONCLUSION

The average recovery time from obstetric fistula patients was 5.14 weeks. Small Length and width of fistula, patients' educational status (literacy), antibiotic use, history of antenatal care visits, normal BMI, short period catheterization and being multiparous were the significant determinate variables which shorten the recovery time of obstetric fistula.

Systematic review of shorter versus longer duration of bladder catheterization after surgical repair of urinary obstetric fistula

BACKGROUND

Bladder catheterization duration after urinary obstetric fistula surgery varies widely.

OBJECTIVE

To assess the effect of bladder catheterization duration after urinary obstetric fistula surgery.

SEARCH STRATEGY

Medline, EMBASE, CINAHL, GIM, and POPLINE databases were searched, without language restrictions, using "obstetric urinary fistula" and "catheterization" from inception to September 30, 2017.

SELECTION CRITERIA

Randomized controlled trials comparing shorter versus longer (>10 days) bladder catheterization after urinary obstetric fistula repair were included.

DATA COLLECTION AND ANALYSIS

Data were extracted and meta-analyses were conducted. The GRADE system was used to assess evidence quality.

MAIN RESULTS

Two unblinded non-inferiority trials (684 patients combined) were included. There were no differences between shorter and longer bladder catheterization in the risk of fistula repair breakdown either before (relative risk [RR] 1.14; 95% confidence interval [CI] 0.49-2.64) or after (RR 1.64; 95% CI 0.81-3.31) hospital discharge. Similarly, urinary infection (RR 5.18; 95% CI 0.25-107.44); urinary incontinence before (RR 1.15; 95% CI 0.54-2.43) or after (RR 1.16; 95% CI 0.62-2.18) discharge; urinary retention (RR 1.34; 95% CI 0.79-2.27); or extended hospital stay (RR 9.33; 95% CI 0.51-172.41) were not associated with duration of catheterization. Evidence quality was low or moderate.

CONCLUSIONS

Shorter, compared to longer, bladder catheterization duration after urinary obstetric fistula surgery was not associated with significant outcome differences.

Pubovesical sling for residual incontinence after successful vesicovaginal fistula closure: a new approach to an old procedure

INTRODUCTION AND HYPOTHESIS

For decades, the pubovesical (PV) sling has been in the armamentarium of the fistula surgeon for treating persistent urinary incontinence after successful fistula closure. We report our early experience with slings, and then also introduce a new "tight" PV sling technique for management of post-fistula urethral leak. Our hypothesis is that performance of tight slings might result in improved continence for women with persistent urinary incontinence after obstetric fistula closure.

METHODS

Data from 120 patients in whom some type of sling procedure had been performed between 1996 and 2012 were extracted and labeled as "early slings." Beginning in October 2014, more complete data were recorded and a more uniform approach was undertaken in 40 patients. Data were extracted from their charts and recorded as "tight slings." This information was analyzed using Chi-squared analysis.

RESULTS

Tight slings were more successful in patients who had less severe fibrosis and who had a shorter time since initial injury. Thirty percent of women who underwent tight slings had improved continence at follow-up.

CONCLUSION

Persistent urinary incontinence despite successful surgical closure of obstetrical fistula remains a difficult problem. Tight slings may be warranted in an attempt to avoid urinary diversion.

Identifying Patients With Vesicovaginal Fistula at High Risk of Urinary Incontinence After Surgery

OBJECTIVE

To develop a risk score to identify women with vesicovaginal fistula at high risk of residual urinary incontinence after surgical repair.

METHODS

We conducted a prospective cohort study among 401 women undergoing their first vesicovaginal fistula repair at a referral fistula repair center in Lilongwe, Malawi, between September 2011 and December 2014, who returned for follow-up within 120 days of surgery. We used logistic regression to develop a risk score to identify women with a high likelihood of residual urinary incontinence, defined as incontinence grade 2-5 within 120 days of vesicovaginal fistula repair, based on preoperative clinical and demographic characteristics (age, number of years with fistula, human immunodeficiency virus status, body mass index, previous repair surgery at an outside facility, revised Goh classification, Goh vesicovaginal fistula size, circumferential fistula, vaginal scaring, bladder size, and urethral length). The sensitivity, specificity, and positive and negative predictive values of the risk score at each cut point were assessed.

RESULTS

Overall, 11 (3%) women had unsuccessful fistula closure. Of those with successful fistula closure (n=372), 85 (23%) experienced residual incontinence. A risk score cut point of 20 had sensitivity of 82% (95% confidence interval [CI] 72-89%) and specificity 63% (95% CI 57-69%) to potentially identify women with residual incontinence. In our population, the positive predictive value for a risk score cut point of 20 or higher was 43% (95% CI 36-51%) and the negative predictive value was 91% (95% CI 86-94%). Forty-eight percent of our study population had a risk score 20 or greater and, therefore, would have been identified for further intervention.

CONCLUSION

A risk score of 20 or higher was associated with an increased likelihood of residual incontinence with satisfactory sensitivity and specificity. If validated in alternative settings, the risk score could be used to refer women with a high likelihood of postoperative incontinence to more experienced surgeons.

Parity as a predictor of obstetric fistula classification

INTRODUCTION AND HYPOTHESIS

Obstetric fistulas are injuries to the genital tract in women without emergency obstetric services. Parity may predict the characteristics of fistulas that affect closure success and residual incontinence. Circumferential fistulas may predispose patients to postoperative incontinence. We hypothesized that primiparous women have more distal fistulas than multiparous women, leading to more scarring and circumferential fistulas.

METHODS

A retrospective observational study was conducted on 1,856 women with obstetric fistula evaluated at three sites by three providers. Fistulas were classified using the Goh classification system. Women aged 10 to 55 years were classified as primiparas or multiparas. Analysis by parity of fistula type and size, degree of scarring, and presence of circumferential defect used the Chi squared or Fisher's exact test, and binary logistic regression.

RESULTS

Of the 1,841 (99.2 %) women included, 878 (47.7 %) were primiparas and 963 (52.3 %) were multiparas. Primiparas were more likely to have distal fistulas, type 4 being most common (31.5 %), whereas multiparas were more likely to have proximal fistulas, most commonly type 1 (48.1 %). Primiparas were more likely to have moderate to severe scarring (11.7 % vs 5.6 %; p < 0.001), and category III (57.1 % vs 39.2 %; p < 0.001), but not to develop circumferential fistulas (5.6 % vs 4.0 %; p = 0.127), be present for repeat surgery (7.1 % vs 7.6 %; p = 0.721), or have ureteric involvement (1.5 % vs 2.2 %; p = 0.301). Multivariate analyses confirmed increased risk with primiparity for distal fistula and scarring.

CONCLUSIONS

As hypothesized, primiparas were more likely to have distal fistulas and more scarring, but were not more likely to have circumferential fistulas. Surgeons should plan accordingly.

Factors associated with the failure of obstetric fistula repair in Guinea: implications for practice

Background

The prevention and treatment of obstetric fistula still remains a concern and a challenge in low income countries.

The objective of this study was to estimate the overall proportions of failure of fistula closure and incontinence among women undergoing repair for obstetric fistula in Guinea and identify its associated factors.

Methods

This was a retrospective cohort study using data extracted from medical records of fistula repairs between 1 January 2012 and 30 September 2013. The outcome was the failure of fistula closure and incontinence at hospital discharge evaluated by a dye test. A sub-sample of women with vesicovaginal fistula was used to identify the factors associated with these outcomes.

Results

Overall, 109 women out of 754 (14.5 %; 95 % CI:11.9–17.0) unsuccessful repaired fistula at discharge and 132 (17.5 %; 95 % CI:14.8–20.2) were not continent.

Failure of fistula closure was associated with vaginal delivery (AOR: 1.9; 95 % CI: 1.0–3.6), partially (AOR: 2.0; 95 % CI: 1.1–5.6) or totally damaged urethra (AOR: 5.9; 95 % CI: 2.9–12.3) and surgical repair at Jean Paul II Hospital (AOR: 2.5; 95 % CI: 1.2–4.9).

Women who had a partially damaged urethra (AOR: 2.5; 95 % CI: 1.5–4.4) or a totally damaged urethra (AOR: 6.3; 95 % CI: 3.0–13.0) were more likely to experience post-repair urinary incontinence than women who had their urethra intact.

Conclusion

At programmatic level in Guinea, caution should be paid to the repair of women who present with a damaged urethra and those who delivered vaginally as they carry greater risks of experiencing a failure of fistula closure and incontinence.

Bladder stones in vesicovaginal fistula: is concurrent repair an option? Experience with 87 patients

INTRODUCTION AND HYPOTHESIS

The objective was to assess the outcomes of a one-stage approach to bladder stones in the setting of a vesicovaginal fistula, performing fistula repair concurrently with stone extraction.

METHODS

Retrospective review of urogenital fistula surgeries at Evangel VVF Center in Jos, Nigeria, between December 2003 and April 2014, identified 87 women with bladder stones accompanying their fistulas and 2,979 repaired without stones. Concurrent stone extraction and fistula repair were performed in 51 patients. Outcomes were compared with respect to fistula size, classification, and fibrosis.

RESULTS

Women presenting with bladder stones were older and had larger fistulas than those without stones (P < 0.001). Additionally, their fistulas were more often classifiable as large and less often as high (P = 0.02), and were more fibrotic (P = 0.003). Twenty-six (51 %) patients with concurrent repair successfully became dry. Comparing results by classification, concurrent repair of high fistulas with stones was very likely to be successful (OR 8.8, 95% CI 1.0-78.2), whereas low fistulas were not (OR 0.2, 95% CI 0.02-0.7). Outcomes were similar to those of patients without stones, except for low fistulas, which were 5 times more likely to fail (P = 0.04).

CONCLUSION

Concurrent closure of vesicovaginal fistula at the time of bladder stone extraction is possible and, in many respects, preferable to a staged approach, particularly among high or midvaginal fistulas.

[Obstetrical vesico-vaginal fistula in Guinea: Data analysis of three sites of treatment at Engender Health ONG]

OBJECTIVE

To analyze the management of obstetric vesico-vaginal fistula in the three sites of Engender Health in Guinea.

PATIENTS AND METHODS

It was a retrospective study of descriptive type having helped collect 450 cases of vesico-vaginal fistulas in three support sites engender health between January 2008 and December 2011. The variables studied were epidemiological, clinical and therapeutic reasons and treatment outcomes were evaluated after a decline of at least six months.

RESULTS

The mean age of onset of the fistula was 25years, ranging from 12 to 55years and 58.8% (n=265) of patients were aged between 18 and 30years. The mean duration of fistula was 11years, ranging from 1 to 38years. Eighty-two percent (n=416) of patients were housewives and 66.4% (n=299) off school. The complex fistula with 66% (n=297) was the most frequent. The treatment consisted of a fistulorraphie after splitting vesico-vaginal in 93.3% (n=420) of cases. Therapeutic results considered after a mean of 8months have resulted in a cure in 79.3% (n=357) of cases, improvement in 4.2% (n=19) of cases and failure in 16 4% (n=74) of cases.

CONCLUSION

Vesico-vaginal fistula is a major cause of maternal morbidity in Guinea. The establishment of a real health policy based on sound medical and social structures contributes to its eradication.

LEVEL OF EVIDENCE

5.

Trends in the aetiology of urogenital fistula: a case of 'retrogressive evolution'?

It has long been held as conventional wisdom that urogenital fistulae in low-income and middle-income countries are almost exclusively of obstetric aetiology, related to prolonged neglected obstructed labour, whereas those seen in high-income countries are largely iatrogenic in nature. There is, however, a growing perception amongst those working in the field that an increasing proportion of urogenital fistulae in low-income and middle-income countries may be iatrogenic, resulting from caesarean section. Recent studies suggest that adverse patterns of care may also be emerging in high-income countries; an increase in the risk of both vesicovaginal and ureterovaginal fistulae following hysterectomy has been reported, concurrently with the reduction in overall use of the procedure. These apparent secular trends are discussed in the context of evolution of practice, teaching and training in obstetrics and gynaecology.

[Vesicovaginal fistula. Incidence, etiology and phenomenology in Germany]

BACKGROUND

Vesicovaginal fistulae are much more common in developing countries along the equatorial fistula belt than in industrialized countries. However, although the classical obstetric fistula caused by lack of medical support through pregnancy and delivery in adolescent primiparae has almost vanished in Germany, we are now facing new and predominantly iatrogenic variants. Increasing frequency of gynecological surgery as well as pelvic radiation, forgotten vaginal foreign bodies, or uninhibited cancer growth are the modern causes for vesicovaginal fistula in elderly patients. Comorbidities and genital atrophy impair surgical therapy in view of a limited success rate of conservative transient transurethral catheterization.

METHODS

Diagnostics should start early and should be initially limited to vaginal inspection, cystourethroscopy, and the blue dye test. Radiological investigations including CT and MRI are only indicated in patients suspicious for ureterovaginal fistula or with inconclusive findings or malignant fistula. The surgical armamentarium comprises vaginal, abdominal, and combined approaches, which all underlie basic principles of fistula repair: protection of the ureteral orifices, complete excision of the fistula canal, accurate separation of the organs connected to the fistula, sufficient tissue mobilization for tension-free suturing, interposition of padding material for prevention of recurrency.

CONCLUSION

Depending on the degree of sphincter damage, stress urinary incontinence might persist despite successful fistula repair, requiring further incontinence surgery or ultimate urinary diversion in recurrent cases that are hopeless.

Management of genitourinary fistula

PURPOSE OF REVIEW

To review current literature on the management of genitourinary fistulae, specifically, the techniques for diagnosis, timing to repair, surgical approach and recent advancements in surgical technique.

RECENT FINDINGS

Recent advancement in minimally invasive surgery has prompted surgeons to perform fistula repairs with laparoscopic or robotic-assisted laparoscopic techniques. Whereas there is a role for transabdominal fistula closure, the majority of fistulae are still best approached via a transvaginal route.

SUMMARY

Genitourinary fistulae from obstetric trauma have received increased attention and funding to treat and prevent this devastating condition in developing countries. Despite multiple classification systems, a standardized classification that accurately identifies predictors of successful repair is lacking. In industrialized nations, genitourinary fistulae are rare and are most frequently associated with pelvic surgery, pelvic radiation, cancer or trauma. Surgical techniques to repair these fistulae have shifted from transabdominal laparotomy to minimally invasive laparoscopic procedures. Vascularized tissue flaps can play an important role in successful closure of complex fistulae. Despite advancements in surgical technology, overarching principles of fistula closure remain. The majority of fistulae can be closed through a transvaginal approach, with a tension-free, watertight, multilayer closure.

Minimally invasive treatment of traumatic high rectovaginal fistulas

BACKGROUND

We propose a new minimally invasive technique by laparoscopic approach which minimizes parietal damage and allows precise location of the fistula, hence reduces blind dissection.

METHODS

Ten consecutive patients suffering from a HRVF benefited from the described technique. Location and time frame were east of the Democratic Republic of Congo and September 2012 through January 2014. By laparoscopy, dissection of the mesorectum in the "holy plane" is taken posteriorly as distally on the sacrum as possible. Dissection subsequently continues laterally beyond the fistula in an effort to maximally circumvene the fistulous area where no plane of cleavage can be found. If the cleavage plane beyond the fistula addresses a healthy rectum, a suture of vaginal and rectal defect is performed. If the cleavage plane beyond the fistula involves significant laceration of the rectum, while leaving at least 2 cm of healthy rectum above the sphincter, rectal resection and colorectal anastomosis are performed. If the rectal laceration involves the distal 2 cm but halts short of the sphincter (large fistula), the pull-through technique is performed.

RESULTS

Of ten participants, four had large HRVF and two presented significant fibrosis. Three underwent simple suture of rectal and vaginal defect, one rectal resection and six a "pull-through" technique. The median procedure time was 1h50 (1h00-3h30). There was no morbidity. None of the patients required protective ileostomy or colostomy. Nine patients were declared clinically cured with a median follow-up of 14.3 months (11-36). The Cleveland Clinic Incontinence Score was 20 in all patients before the treatment and was significantly (p = 0.004) reduced to 2.6 [0-20] after the treatment.

CONCLUSIONS

This minimally invasive technique allowed us to treat HRVF, including complex ones in ten patients without significant morbidity. Clinical success with a median follow-up of 14.3 months was 90%.

Genitourinary Fistula: An Indian Perspective

BACKGROUND

In developing countries, obstetric trauma is the most common cause of genitourinary fistulae. But over the last two decades, health care facilities have been improved and the scenario has been changed.

PURPOSE

The aim of the present study is to share our experience with genitourinary fistula in terms of mode of presentation, diagnostic modality, and management with the emphasis on the surgical approach and a parallel review of the available literature.

MATERIALS AND METHOD

During a 6-year period from January 2007 to December 2013, 41 cases of genitourinary fistula, who admitted and treated in the urology department of a tertiary care center, were retrospectively analyzed for etiology, site, size and number of fistulae, clinical presentation, diagnostic modalities, and management. The literature search was done using the Medline database.

RESULT

Mean age of the patient was 27 years (range 16-51). Primary and simple fistulae were common. Obstetric trauma was the most common etiology (56.09 %) followed by iatrogenic (39.03 %). Vesicovaginal fistula was the most common type (78.37 %) and trigone was the most common site involved (51.72 %). 51.35 % of patients were approached successfully by the vaginal route. Ancillary procedures were required in patients for various other associated anomalies at the time of fistula repair. The success rate on follow up was 94.5 %. In the mean follow up of 3 years, 35 patients were sexually active.

CONCLUSION

Genitourinary fistula is a frustrating entity with potentially devastating psychosocial consequence. Its management poses a tricky challenge to the surgeon. Accurate and timely diagnosis, adhering on basic surgical principle, and repair by an experienced surgeon provide the optimum chance of cure.

Treatment-seeking behaviour and social status of women with pelvic organ prolapse, 4th-degree obstetric tears, and obstetric fistula in western Uganda

INTRODUCTION AND HYPOTHESIS

This study looks at a trilogy of women's health issues including severe pelvic organ prolapse, unrepaired 4th degree obstetric tears and obstetric fistula, all of which can cause significant suffering in the lives of women and their families.

METHODS

Women undergoing surgery for severe pelvic organ prolapse, unrepaired 4th degree obstetric tears and obstetric fistulae, were interviewed to assess their perceptions of what caused their condition, subsequent impact on their social situation and sexual activity, and whether they had sought treatment previously.

RESULTS

One hundred fifty women participated in the survey, including 69 undergoing surgery for genito-urinary fistula, 25 with faecal incontinence only (including 24 women with unrepaired 4th degree obstetric tears and 1 woman with an isolated rectovaginal fistula), and 56 women with severe pelvic organ prolapse. All groups of women were exposed to abandonment by their families with 42 % of women with genito-urinary fistula, 21 % with unrepaired 4th degree obstetric tear, and 25 % of women with severe pelvic organ prolapse rejected by their husbands. Most of the women had actively sought treatment for their condition with no success due to unavailability of treatment or misinformation.

CONCLUSIONS

This study confirms the social stigma associated with obstetric fistula, however also highlights the social stigma faced by women suffering with severe pelvic organ prolapse and unrepaired 4th degree obstetric tears in western Uganda. There is an urgent need for education and training in obstetric management and pelvic organ prolapse management in such areas of limited resources.

Use of periurethral injections of polyacrylamide hydrogel for treating post-vesicovaginal fistula closure urinary stress incontinence

AIMS

Following successful closure of obstetric genitourinary fistula, stress urinary incontinence (SUI) is a common and challenging problem. Despite many decades of various treatment options, the effective management of post-fistula SUI remains unresolved. This study aims to assess the feasibility of periurethral injections of polyacrylamide hydrogel, commonly used for urinary stress incontinence in non-fistula women, in women with post-fistula closure SUI.

MATERIAL AND METHODS

Women with urinary incontinence following successful fistula closure were assessed to exclude detrusor overactivity and urinary residual volumes of more than 100 mL. The urethrovesical junction was identified and polyacrylamide hydrogel was injected through the periurethral skin and vaginal epithelium at three sites.

RESULTS

Four women with post-fistula SUI were treated with polyacrylamide hydrogel injections. Three of the four women were dry post-operatively and remained continent at discharge.

CONCLUSION

In the short-term, periurethral injections of polyacrylamide hydrogel appears to be a promising method to treat post-obstetric fistula urinary stress incontinence.

Obstetric fistula in Burundi: a comprehensive approach to managing women with this neglected disease

BACKGROUND

In Burundi, the annual incidence of obstetric fistula is estimated to be 0.2-0.5% of all deliveries, with 1000-2000 new cases per year. Despite this relatively high incidence, national capacity for identifying and managing obstetric fistula is very limited. Thus, in July 2010, Medecins Sans Frontieres (MSF) set up a specialised Obstetric Fistula Centre in Gitega (Gitega Fistula Centre, GFC), the only permanent referral centre for obstetric fistula in Burundi. A comprehensive model of care is offered including psychosocial support, conservative and surgical management, post-operative care and follow-up. We describe this model of care, patient outcomes and the operational challenges.

METHODS

Descriptive study using routine programme data.

RESULTS

Between July 2010 and December 2011, 470 women with obstetric fistula presented for the first time at GFC, of whom 458 (98%) received treatment. Early urinary catheterization (conservative management) was successful in four out of 35 (11%) women. Of 454 (99%) women requiring surgical management, 394 (87%) were discharged with a closed fistula, of whom 301 (76%) were continent of urine and/or faeces, while 93 (24%) remained incontinent of urine and/or faeces. In 59 (13%) cases, the fistula was complex and could not be closed. Outcome status was unknown for one woman. Median duration of stay at GFC was 39 days (Interquartile range IQR, 31-51 days).

CONCLUSION

In a rural African setting, it is feasible to implement a comprehensive package of fistula care using a dedicated fistula facility, and satisfactory surgical repair outcomes can be achieved. Several operational challenges are discussed.