Predictors of Recurrence and Successful Treatment Following Obstetric Fistula Surgery

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.

Epidemiological, anatomoclinical, and therapeutic profile of obstetric fistula in the Democratic Republic of the Congo: About 1267 patients

OBJECTIVE

Our aim is to describe the epidemiological, anatomoclinical and therapeutic profile of obstetric fistula (OF) in the Democratic Republic of the Congo (DRC).

METHODOLOGY

This was a descriptive retrospective study that collected 1416 obstetric fistulas in 1267 patients in seven provinces of the DRC, treated between January 2017 and December 2022. The variables studied were epidemiological, anatomoclinical and therapeutic.

RESULTS

The mean age of patients at the time of surgical repair was 33.2 years (range: 15 and 77 years) and 32.8% of patients were aged between 20 and 29 years. The mean age of the fistula at repair was 10 years (range: 3.5 months and 56 years). At the time of fistula, 61.7% of patients had delivered vaginally and 28.7% by caesarean section and 8.2% of patients had a haemostasis hysterectomy. Labour lasted at least 3 days in 47.3% of these patients for the fistula birth. Deliveries took place either at home (27.4%) or in a health facility (72.6%); 83.6% of newborns resulting from these births had died. Taken as a whole, urogenital fistulas are more common than genito-digestive fistulas. Urethro-vaginal (26.2%) and vesico-uterine (24.7%) anatomoclinical entities were predominant among urogenital fistulas. A total of 1416 fistulas were surgically repaired in 1267 patients. These repairs were successful for 1226 (86.6%) fistulas. The main surgical route used was transvaginal (68.8%).

CONCLUSION

In the DRC, obstetric fistula is common in young adult women. It often results from vaginal delivery, after prolonged labour. Fistula births often result in the death of newborns. Uro-genital obstetric fistulas are the most frequent with predominance of urethro-vaginal and vesico-uterine anatomoclinical entities. Fistulas remain untreated for a long time. Mostly done transvaginally, surgical repair gives a good result.

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.

Factors associated with reintegration trajectory following female genital fistula surgery in Uganda

BACKGROUND

A female genital fistula, primarily caused by prolonged obstructed labor or after cesarean delivery in resource-limited countries, affects 500,000 to 2,000,000 women worldwide. Fistula is preventable with timely access to high-quality obstetrical care. Access to surgical repair of a female genital fistula has greatly increased over time. However, research surrounding postrepair reintegration, the process of returning to an individual's normal life, remains limited, and further efforts are needed to understand the factors shaping women's ability to rebuild their relationships and lives following repair.

OBJECTIVE

This study aimed to characterize the 12-month reintegration trajectory after female genital fistula repair by participant sociodemographic and clinical characteristics.

STUDY DESIGN

This study analyzed quantitative survey and medical record data of women (N=60) participating in a longitudinal cohort study assessing recovery after genital fistula repair in Uganda, with baseline and 4 quarterly follow-up assessments in 12 months. The primary outcome of reintegration was assessed using a 19-item postfistula repair reintegration instrument (range, 0-100) where a higher score represents better reintegration. Predictors of interest included parity and living children, quality of life, depressive symptoms at baseline, self-esteem, stigma, trauma, physical symptoms, and social support. We described participant baseline characteristics using means and proportions and estimated a series of mixed-effects linear regression models, including interactions of characteristics with time to understand how these characteristics influence reintegration trajectory in the 12 months after repair.

RESULTS

The participants' physical and psychosocial morbidities at baseline were high; more than 80% of participants reported fistula-related physical symptoms, 82% of participants described their general health as poor, and measures of self-esteem, overall social support, and overall quality of life were low. The mean reintegration score at baseline was 33 (standard deviation, 20), which increased to 78 (standard deviation, 19) at 12 months after fistula repair. The participant sociodemographic characteristics statistically associated with reintegration included any living children (β, 1.08; 95% confidence interval, -0.08 to 2.23). Moreover, psychosocial factors significantly affected reintegration with steeper trajectories for women with depressive symptoms (β, 0.89; 95% confidence interval, 0.02-1.75) or women experiencing internalized stigma (β, 0.05; 95% confidence interval, -0.00 to 0.11) and less steep for those with higher self-esteem (β, -0.11; 95% confidence interval, -0.24 to 0.01), overall social support (β, -0.06; 95% confidence interval, -0.12 to -0.01), and partner support (β, -0.21; 95% confidence interval, -0.35 to -0.07).

CONCLUSION

Understanding the prominent factors associated with differences in reintegration trajectories across the year after genital fistula surgery has the potential to inform interventions that mitigate challenges and improve women's postrepair recovery experiences.

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.

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.

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.

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.