Impact of vesicovaginal fistula repair on urinary and sexual function: patient-reported outcomes over long-term follow-up

A systematic review and meta-analysis of urinary incontinence following successful obstetric fistula repair: findings from five countries in sub-Saharan Africa

BACKGROUND

Obstetric vesico-vaginal fistula is a known complication that can occur following damage to the bladder wall during prolonged obstructed labor and operative delivery. Urinary incontinence following the repair of obstetric fistula remains a significant health problem and can greatly damage a women's ability to function confidently. There are approximately two million women suffering from urinary incontinence following obstetric fistula repair, most of whom are primarily in Africa.

OBJECTIVE

We aimed to systematically review and conduct meta-analysis on the magnitude of urinary incontinence among women following successful obstetric fistula repair in sub-Saharan African countries.

METHODS

We thoroughly searched online database including Medline, Scopus, Science Direct, Excerpta Medica Database, African Journals Online and Google Scholar for eligible articles from their inception to November 10, 2024. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) 2020 checklist. To generate pooled prevalence of urinary incontinence, we used random-effects model. The presence of publication bias was determined using a funnel plot and Egger's regression test.

RESULTS

Out of 1044 articles found following our initial search and after titles and abstracts review, we considered 277 full text articles for inclusion. Lastly, a total of 12 articles from five sub-Saharan African countries comprising 6,104 participants met the inclusion criteria for quantitative meta-analysis. The pooled prevalence of urinary incontinence following obstetric fistula repair was 16.32% (95%CI: 11.80, 20.84; I2 = 96.5%, P < 0.001).

CONCLUSION AND IMPLICATIONS

Overall, our findings show post-fistula repair incontinence remains an important clinical problem. Therefore, we believe that policy planners and researchers of sub-Saharan African nations may use the findings of the current study for evidence based care planning and patient counseling strategy.

REGISTRATION

Registered in PROSPERO under protocol number CRD42023416541.

Female non-obstetric urogenital fistula repair: long-term patient-reported outcomes and a scoping literature review

OBJECTIVE

To investigate long-term and patient-reported outcomes, including sexual function, in women undergoing urogenital fistula (UGF) repair, addressing the lack of such data in Western countries, where fistulas often result from iatrogenic causes.

PATIENTS AND METHODS

We conducted a retrospective analysis at a tertiary referral centre (2010-2023), classifying fistulas based on World Health Organisation criteria and evaluating surgical approaches, aetiology, and characteristics. Both objective (fistula closure, reintervention rates) and subjective outcomes (validated questionnaires) were assessed. A scoping review of patient-reported outcome measures in UGF repair was also performed.

RESULTS

The study included 50 patients: 17 (34%) underwent transvaginal and 33 (66%) transabdominal surgery. History of hysterectomy was present in 36 patients (72%). The median (interquartile range [IQR]) operating time was 130 (88-148) min. Fistula closure was achieved in 94% of cases at a median (IQR) follow-up of 50 (16-91) months and reached 100% after three redo fistula repairs. Seven patients (14%) underwent reinterventions for stress urinary incontinence after transvaginal repair (autologous fascial slings). Patient-reported outcomes showed median (IQR) scores on the International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms Modules (ICIQ-FLUTS) of 5 (3-7) for filling symptoms, 1 (0-2) for voiding symptoms and 4.5 (1-9) for incontinence symptoms. The median (IQR) score on the ICIQ Female Sexual Matters Associated with Lower Urinary Tract Symptoms Module (ICIQ-FLUTSsex) was 3 (1-5). The median (IQR) ICIQ Satisfaction (ICIQ-S) outcome score and overall satisfaction with surgery item score was 22 (18.5-23.5) and 10 (8.5-10), respectively. Higher scores indicate higher symptom burden and treatment satisfaction, respectively. Our scoping review included 1784 women, revealing mixed aetiology and methodological and aetiological heterogeneity, thus complicating cross-study comparisons.

CONCLUSIONS

Urogenital fistula repair at a specialised centre leads to excellent outcomes and high satisfaction. Patients with urethrovaginal fistulas are at increased risk of stress urinary incontinence, possibly due to the original trauma site of the fistula.

Robotic management of urinary fistula

Objectives

To highlight critical preoperative and intraoperative considerations in approaching fistula repair robotically.

Methods

A search of the literature was conducted to identify relevant articles pertaining to robotic management of urinary fistulae.

Results

Fistulae of the genitourinary tract can be a challenging dilemma for urologists, as definitive management may require surgical intervention. Pathogenesis of both enteric and non-enteric fistulae are multifactorial, and successful repair hinges on the meticulous perioperative evaluation, planning, and execution. Traditional open techniques can subject patients to increased morbidity and prolonged hospitalizations. Since its introduction, the robotic surgical platform has continued to expand its indications. Its three-dimensional visualization and tremor free wristed instrument movements have made the robotic platform an attractive option for genitourinary fistula reconstruction.

Conclusion

Robotic management of complex urinary fistulae is feasible in expert hands; more studies are needed to define its role in the treatment algorithm of this devastating conditions.

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.

Repair of Vesicovaginal Fistulae: A Systematic Review

OBJECTIVE

To assess and compile the current level of evidence regarding successful surgical treatment of vesicovaginal fistulae and how these perioperative interventions affect anatomic, patient-centered, and adverse outcomes.

DATA SOURCES

PubMed and EMBASE were searched from inception through September 9, 2022.

METHODS OF STUDY SELECTION

This review included comparative studies (of any sample size) and single-group studies (1,000 or more participants) of primary or recurrent vesicovaginal fistula (ie, vesicovaginal fistula, urethrovaginal fistula, and bladder neck-vaginal fistula). We evaluated preintervention assessment or management, various techniques for intraoperative management, and postoperative management. Outcomes of interest included anatomic and objective outcomes (such as successful repair, fistula closure, urinary incontinence, recurrent fistula, perioperative complications) and subjective outcomes (such as voiding symptoms and quality of life). Abstracts and full-text articles were screened in duplicate, and study descriptions and findings were extracted into standardized extraction forms. Risk of bias was assessed independently by two investigators and adjudicated by a third. Study quality was summarized with standardized tools. We conducted random-effects model and restricted maximum-likelihood meta-analyses of relative risks when at least three studies compared similar interventions and reported similar outcome measures.

TABULATION, INTEGRATION, AND RESULTS

Forty-six studies met the inclusion criteria. Studies were categorized into 11 domains: 1) preoperative assessment, 2) preoperative and postoperative physical therapy, 3) route of surgery, 4) incorporation of a flap, 5) trimming, 6) layered closure, 7) intraoperative antibiotics, 8) fibrin glue, 9) fascial sling, 10) postoperative Foley catheter duration, and 11) quality of life. Although the strength of the data is insufficient, preoperative phenazopyridine, physical therapy, layered closure, and intraoperative antibiotics seemed to improve the rate of successful fistula repair. Route of surgery (vaginal vs abdominal laparotomy) was determined primarily by surgeon preference and showed no difference in successful fistula repair. In addition, use of interpositional flaps, trimming fistula edges, fibrin glue, and fascial sling did not show significant improvement in rates of fistula cure. Overall, quality-of-life scores improved postoperatively regardless of route of repair and use of interpositional flaps.

CONCLUSION

Our findings highlight the limited information available to guide evidence-based treatment of vesicovaginal fistula repair. Overall, high-quality evidence is lacking to provide guidelines; therefore, expert opinion remains the primary influence for fistula repair recommendations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021214948.

Quality of life, voiding & sexual dysfunction following robot-assisted vesicovaginal fistula repair: a tertiary care centre experience

Robot-assisted VVF (RA-VVF) repair has the advantage of small cystotomy, precise dissection and minimal surrounding tissue trauma. Translation of this to better functional outcomes is not studied so far. This study aims to evaluate the quality of life, voiding, and sexual dysfunction following robot-assisted VVF repair. Women with successful RA-VVF repair were screened using UDI-6, IIQ-7, FSFI, and WHOQOL-BREF questionnaires. The preoperative assessment was done in the prospective cohort only. Of the 75 women who underwent RA-VVF repair, 47 were enrolled, 33 in retrospective, and 14 in a prospective cohort. Overall, 28 (60%) women had urinary complaints with a median UDI-6 total score of 4 (0-100) and  IIQ-7 score (0-23) in 5 (10%) women. However, UDS (15 women) showed no DO with cystometric capacity (352 ± 98.12) ml and normal compliance in 14 (93%) women. Mean BOOI and DCI were 11.90 ± 7.01 and 44.25 ± 8.60 respectively, with PdetQmax ranging from 17 to 44. None had difficulty in voiding (Qmax 13.85 ± 4.90). Twenty (43%) women were sexually active, and 2 had sexual dysfunction (FSFI score < 26.55). Quality of life was "good" to "very good" in all domains (score > 90) except for the social domain. The prospective cohort showed significant improvement in UDI-6 score (p < 0.05), IIQ-7 score (p < 0.05), and quality of life (p < 0.05) postoperatively. RA-VVF repair results in minimal voiding dysfunction and significant improvement in overall quality of life. For sexual dysfunction assessment, a longer follow-up is required.