Outcomes in obstetric fistula care: a literature review

Pregnancy outcomes following surgical repair of female genital fistula in Uganda

Background

Women developing genital fistula and undergoing fistula repair in sub-Saharan Africa and South Asia are largely of reproductive age, and fistula prevalence is highest in countries with high fertility and where social values are placed on childbearing. Optimizing women's health following female genital fistula and surgical repair requires further understanding of the risks to subsequent pregnancies and how to mitigate them, to enable women to achieve their desired family size without additional morbidity.

Objective

We sought to contribute to the postfistula repair evidence base through estimating rates of spontaneous abortion and stillbirth as well as the associated risk factors of these adverse outcomes in pregnancies following fistula repair.

Methods

We captured data on sociodemographic characteristics, obstetric and fistula history, and pregnancy and childbirth care and experiences, and outcomes for the first postrepair pregnancy from 302 women who became pregnant within 10 years following genital fistula repair, recruited from six fistula repair facilities in Uganda. We described sociodemographic characteristics, spontaneous abortion (pregnancy loss <20 weeks gestational age), and stillbirth (intrauterine fetal death at ≥20 weeks gestational age) and determined factors associated with these outcomes using logistic regression. We compared outcomes to two external data sources: a meta-analysis and propensity-score matched Ugandan women of reproductive-age.

Results

Overall, 14% (43/302) of the participants had spontaneous abortions and 5% (12/255) had stillbirths in postrepair pregnancies. The spontaneous abortion rate in our study was higher compared to a recent meta-analysis; however, the stillbirth rate was not. The stillbirth rate in our study was 2.5 percentage-points higher compared to the general population (95% CI 0.2-4.9, P=.036). Factors independently associated with increased risk of spontaneous abortion included fistula type, vaginal bleeding during pregnancy, any urine leakage, and educational attainment. Vesicovaginal fistula (VVF)-high (VVF types I and III) vs VVF-low (VVF type II Aa Ab Ba Bb) had significantly reduced odds of spontaneous abortion (adjusted odds ratios [aOR] 0.11, 95% CI 0.03-0.45, P=.002) and rectovaginal fistula and VVF-other (other or not indicated) had marginally reduced odds (aOR 0.38, 95% CI 0.012-1.14, P=.083 and aOR 0.26, 95% CI 0.05-1.25, P=.093, respectively). In bivariate analyses, any urine leakage, assisted vaginal delivery, and emergency cesarean section were highly correlated with stillbirth. Stillbirth risk was over-10-fold higher among individuals reporting urine leakage (OR 10.5, 95% CI 2.75-20.43, P=.001). Assisted vaginal birth and emergency cesarean birth were both associated with 17-fold increased odds of stillbirth (OR 16.93, 95% CI 1.45-198.08, P=.024 and 16.56, 95% CI 1.65-166.28, P=.017, respectively).

Conclusion

Our results demonstrate that in the study setting, greater attention to high-quality, comprehensive pregnancy care and birth planning are critical for improving outcomes among women who have undergone fistula repair, including facilitation of elective cesarean section which is recommended for postrepair births. Additional investments must be made to strengthen women's health access and knowledge that supports their postfistula repair reproductive goals.

Transvaginal repair of a rectovaginal fistula caused by transvaginal mesh prolapse surgery

Introduction

Transvaginal mesh surgery can cause mesh complications including rare rectovaginal fistula. We report a case of a rectovaginal fistula treated transvaginally without colostomy.

Case presentation

A 57-year-old female was referred to us due to post-hysterectomy prolapse and had transvaginal mesh surgery. She underwent transvaginal hysterectomy because of uterine prolapse at age 33 and had taken steroids to treat pemphigus. Two years later, she developed vaginal bleeding and discharge. Transvaginal mesh removal was planned to treat vaginal mesh exposure, but immediately before the operation digital rectal examination revealed rectovaginal fistula. Mesh removal and fistula closure were performed transvaginally without colostomy. Three years of follow-up showed no recurrence of mesh exposure, fistula, or prolapse.

Conclusion

Rectovaginal fistula following mesh surgery may be treated transvaginally without colostomy if infection is minimal. To evaluate mesh exposure on the posterior vaginal wall, rectal examination should be done along with vaginal examination.

Follow-up of obstetric fistula repair using Singapore fasciocutaneous flap and/or gracilis muscle flap

AIMS

To report on the follow-up of obstetric fistula repair using vascularized surgical flaps, namely the Singapore fasciocutaneous flap, the gracilis muscle flap, or a combination of both.

METHODS

This cross-sectional study reports on the follow-up of 60 patients after fistula repair with a vascularized surgical flap at the Fistula Care Center in Lilongwe, Malawi. The primary outcome was fistula closure based on patients' self-reported continence grade. Secondary outcomes were urinary incontinence based on a 1-h pad-weight test, quality of life based on the Incontinence Quality of Life (I-QOL) questionnaire, surgical complications, and the indication for additional surgery after repair.

RESULTS

Successful closure was achieved in 62% of cases and full continence was achieved in 12% of cases. Incontinence based on a 1-h pad weight test improved between surgery and follow-up. QOL scores based on the I-QOL were low but patients indicated moderate to great improvement in quality of life. Twenty-two (37%) patients experienced surgical complication, mostly minor wound breakdowns. No major complications were reported. Six (10%) patients were indicated for additional surgery during follow-up.

CONCLUSION

The relative safety of the surgical procedures is shown in the findings of this study, including no reports on major complications during follow-up. Vascularized flaps should be considered in complex fistula cases, especially in repeat cases and before considering urinary diversion as a last resort.

Bangladesh Fistula Mission Partnership: Leveraging Assets from the United States Agency for International Development and the Department of Defense to Address a Health Care Crisis in a Developing Nation

INTRODUCTION

Obstetric fistulae are a leading scourge for women in developing countries resulting, in severe individual suffering and devastating socio-economic repercussions for her family and community. The underlying causes of obstetric fistula stem from multiple factors to include poor nutrition, early marriage, insufficient education and inferior social status of women as well as substandard medical care. The US Agency for International Development (USAID) has invested more than $100 million globally since 2004 to address these factors as well as support women suffering with fistulae. The ultimate goal is to eradicate obstetric fistula in Bangladesh in the next 20 years. Despite these efforts, nearly 20,000 women in Bangladesh, still suffer with this malady.

METHODS

To close this gap, USAID and the Department of Defense (DOD) developed a novel Interagency Agreement (IAA) leveraging the surgical skills of military health professionals to scale-up the ongoing fistula care program. The agreement outlined three lines of effort: (1) treat existing fistulae by bolstering surgical capacity of the existing USAID fistula care program; (2) promote fistula mitigation with lectures and hands-on teaching of obstetric care as well as safe gynecologic surgery; and (3) assist with advocacy at higher levels of the Bangladesh government. A Bangladesh Fistula Mission Partnership working group was formed to design and implement this IAA. Critical partners from the US Embassy in Dhaka included USAID (Health, Legal, Contracting), the DOD (Office of Defense Cooperation), and Department of State (Regional Security Officer). Partners from the US Army included United States Army-Pacific Command (Surgeon, Legal, Finance, Security Cooperation, Contracting), Regional Health Command-Pacific (Operations, Legal, Public Affairs), and Tripler Army Medical Center (Department of OBGYN, Operations, Public Affairs). Institutional Review Board approval was not required as the treatments offered were standard of care.

RESULTS

The Tripler Army Medical Center (TAMC) health professionals executed the IAA with one pre-deployment site survey and two surgical missions in 2016-2017. The military team supported the surgical repair of 40 pelvic fistulae and perineal tears and provided operative management for an additional 25 patients with pelvic organ prolapse. Furthermore, the team conducted 19 professional lectures and multiple educational forums at hospitals in Kumudini, Khulna and the premier medical university in Dhaka for over 800 attendees including physicians, nurses and students to help prevent obstetric and surgical fistulae. Importantly, the team assisted USAID as subject matter experts in its advocacy to the Bangladesh Ministry of Health for improved maternity care and regulatory oversight. During the missions, the team enhanced their readiness by exercising individual and collective tasks while exposing personnel to the cultural context of the region.

CONCLUSION

This IAA was the first USAID funded and DoD-executed health mission in the US Indo-Pacific Command Area of Responsibility. Direct participation in the IAA enabled TAMC to support the US Indo-Pacific Command Theater Campaign Plan, the Department of Defense Instruction 2000.30 on Global Health Engagements, the USAID Country Development Cooperation Strategy, and the US Ambassadors Integrated Country Strategy Objectives in Bangladesh. This effort can serve as a model for future cooperation between USAID and the DoD.

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.

Provider Perspectives on Persistent Urinary Incontinence Following Obstetric Fistula Repair in Ethiopia

Each year an estimated 50,000 to 100,000 women worldwide are affected by obstetric fistula. This devastating but preventable maternal morbidity leaves women incontinent, stigmatized, isolated, and often with a still birth. While fistula rates in Ethiopia have declined in recent years, estimates range from 7 to 40 percent of women suffer from persistent urinary incontinence after successful closure of their fistula. Few studies have focused on the unique experiences and challenges that providers face treating fistula patients, particularly those who experience persistent urinary incontinence. The goal of this research is to characterize the fistula provider's accounts of how to manage, support, and understand their patient's experience. Semi-structured interviews were conducted with a purposive sample of fistula care providers in Mekelle and Addis Ababa, Ethiopia. The main themes that emerged were a perceived exacerbated impact on quality of life for women with persistent urinary incontinence; a “double hit” of isolation from both their community and from other recovered fistula patients; how the church both influences how patients internalize their injury and provides them with hope and support; and the need for comprehensive and compassionate fistula care. Understanding how providers perceive and relate to their patients provides valuable insight to the unique challenges of treating this population and may better inform treatment programmes to address the gap between patient needs and current fistula care models.

Continence, quality of life and depression following surgical repair of obstetric vesicovaginal fistula: a cohort study

OBJECTIVE

We evaluated residual incontinence, depression, and quality of life among Malawian women who had undergone vesicovaginal fistula (VVF) repair 12 or more months previously.

DESIGN

Prospective cohort study.

SETTING

Fistula Care Centre in Lilongwe, Malawi.

POPULATION

Women who had undergone VVF repair in Lilongwe, Malawi at least 12 months prior to enrolment.

METHODS

Self-report of urinary leakage was used to evaluate for residual urinary incontinence; depression was evaluated with the Patient Health Questionnaire-9; quality of life was evaluated with the King's Health Questionnaire.

MAIN OUTCOME MEASURES

Prevalence and predictors of residual incontinence, quality of life scores, and prevalence of depression and suicidal ideation.

RESULTS

Fifty-six women (19.3%) reported residual urinary incontinence. In multivariable analyses, predictors of residual urinary incontinence included: pre-operative Goh type 3 [adjusted risk ratio (aRR) 2.82; 95% confidence interval (CI) 1.61-5.27) or Goh type 4 1.08-2.78), positive postoperative cough stress test (aRR = 2.42; 95% CI 1.24-4.71) and the positive 1-hour postoperative pad test (aRR = 2.20; 95% CI 1.08-4.48). Women with Goh types 3 and 4 VVF reported lower quality of life scores. Depressive symptoms were reported in 3.5% of women; all reported residual urinary incontinence.

CONCLUSIONS

While the majority of women reported improved outcomes in the years following surgical VVF repair, those with residual urinary incontinence had a poorer quality of life. Services are needed to identify and treat this at-risk group.

TWEETABLE ABSTRACT

Nearly one in five women reported residual urinary incontinence at follow up, 12 or months after vesicovaginal fistula repair.

Feasibility and acceptability of the menstrual cup for non-surgical management of vesicovaginal fistula among women at a health facility in Ghana

OBJECTIVE

To assess the feasibility of the menstrual cup for short-term management of urinary leakage among women with vesicovaginal fistula (VVF).

METHODS

A repeated measures design compared volume of leakage with and without the cup via a 2-hr pad test among women with VVF seeking surgical repair at a health facility in Ghana. Subsequently a gynecological exam was administered to assess safety outcomes, followed by a questionnaire to assess acceptability and perceived efficacy. A paired t-test was used to analyze reduction of leakage in ml, and percent reduction was reported. Study limitations include observer bias while evaluating adverse outcomes and the possibility of social desirability bias during questionnaire administration that might overestimate the effect of the cup and women's acceptability.

RESULTS

Of the 32 patients screened, 11 were eligible (100% consent rate). At baseline, mean (±SD) leakage in ml was 63.2 (±49.2) (95% CI: 30.2-96.3) over two hours, while the mean leakage over two hours of use of the cup was 16.8 (±16.5) (95% CI: 5.7-27.9). The mean difference of 46.4 (±52.1) ml with use of the cup (95% CI: 11.4-81.4) was statistically significant (p = 0.02). With the cup, women experienced an average 61.0% (±37.4) (95% CI: 35.9-86.2) leakage reduction, a difference 10/11 users (91.0%) perceived in reduced leakage. One participant, reporting four previous surgical attempts, experienced a 78.7% leakage reduction. Acceptability was high-women could easily insert (8/11), remove (8/11), and comfortably wear (11/11) the cup and most (10/11) would recommend it. No adverse effects attributable to the intervention were observed on exam, although some women perceived difficulties with insertion and removal. Data collection tools were appropriate with slight modification advised.

CONCLUSION

A larger trial is warranted for a more robust evaluation of the menstrual cup for management of urinary leakage due to VVF among women who have not yet accessed surgery or for whom surgery was not successful.

Pubococcygeal Sling versus Refixation of the Pubocervical Fascia in Vesicovaginal Fistula Repair: A Retrospective Review

Urethral incontinence is an issue for approximately 10–15% of women with an obstetric fistula. Various surgical interventions to prevent this exist, including the pubococcygeal sling and refixation of the pubocervical fascia. Neither has been evaluated in comparison to one another. Therefore, this retrospective evaluation for superiority was performed. The primary outcome was urinary stress incontinence, and secondary outcomes were operative factors. There were 185 PC slings, but 12 were excluded because of urethral plications. There were 50 RPCF procedures, but 3 were excluded because of urethral plications. Finally, there were 32 cases with both PC sling and RPCF procedures. All groups demonstrated a higher than expected fistula repair rate with negative dye tests in 84% of the PC sling group, 89.9% in the RPCF group, and 93.8% in the RPCF and PC groups. There were no statistically significant differences found in continence status between the three groups. Of those who underwent PC slings, 49% were found to have residual stress incontinence. Of those who underwent RPCF, 47.8% had stress incontinence. Of those with both techniques, 43.8% had residual stress incontinence. Pad weight was not significantly different between the groups. As there is no statistically significant difference, we cannot recommend one procedure over the other as an anti-incontinence procedure. The use of both simultaneously is worth investigating.

Profile and outcome of patients with recurrent urogenital fistula in a fistula centre in Nigeria

INTRODUCTION AND HYPOTHESIS

Management of a recurrent urogenital fistula is very challenging and requires experienced surgeons. The aim of this study was to describe the characteristics, success rates, and associated factors related to surgical repairs of patients with recurrent urogenital fistulas by an experienced team at a fistula centre in Nigeria.

METHODS

This was a retrospective cohort study of 154 patients that had repeat urogenital fistula repairs at the National Obstetric Fistula Centre, Abakaliki, Nigeria, between January 2014 and December 2016. Information was retrieved from their hospital records. Successful repair was defined by continent status at 3 months after repair. Data were analyzed with SPSS version 20 by IBM Inc., and p < 0.05 was taken as statistically significant. Chi-square test was used to determine the association between the factors and successful repair.

RESULTS

The mean age was 36.27 ± 12.96 years. Obstetric fistula occurred in 92.2% of the patients. The success rates for the first, second, third, and fourth repeat repairs were 68.8%. 56.2%, 50%, and 0% respectively. Significant factors were the number of previous attempts at repair (χ² = 20.44, p = 0.002), age group (χ² = 16.95, p = 0.03), Waaldijk's classification (χ² = 13.31, p = 0.04), duration of fistula (χ² = 19.6, p = 0.03), surgeons' experience (χ² = 7.11, p = 0.04), and place of previous attempt at repair (χ² = 6.35, p = 0.02). There were no complications in 86.4%.

CONCLUSIONS

The success rate was good. Patients who had previous failed repairs at the fistula centre had better outcomes after the repeat surgeries. Centralizing fistula care will enhance optimal outcomes. It may also boost training and research in this specialty.

Treatment of Rectovaginal Fistula Using Sphincteroplasty and Fistulectomy

Aim

To assess the results of the treatment of rectovaginal fistulas with incontinence and impaired anal tonus.

Materials and Methods

This study comprised three rectovaginal fistula groups that were treated using sphincteroplasty and fistulectomy: group 1: eight women with simple rectovaginal fistula due to birth trauma; group 2: six rectovaginal fistula cases that were associated with chronic inflammatory diseases; and group 3: five cases with at least one failed repair attempt. In the second step, operations that took place before the year 2000 were compared to the operations that took place after the year 2000 in terms of demographic and clinical characteristics.

Results

All of the simple rectovaginal fistula cases healed after the operation. Five of the group 2 patients healed after the operation. However, 1 patient with Crohn's disease needed to undergo reoperation, but successfully healed after 6 months. On the contrary, 3 patients in group 3 healed (60%) whereas 2 of them failed to heal. Clinical characteristics of the patients were different between the groups (before and after the year 2000).

Conclusion

The choice of operation must be done according to the patient's underlying pathology. Proper management of associated inflammatory diseases and systemic disorders is recommended for necessary complex cases.

Development and preliminary validation of a post-fistula repair reintegration instrument among Ugandan women

BACKGROUND

Obstetric fistula is a debilitating and traumatic birth injury affecting 2-3 million women globally, mostly in sub-Saharan Africa and Asia. Affected women suffer physically, psychologically and socioeconomically. International efforts have increased access to surgical treatment, yet attention to a holistic outcome of post-surgical rehabilitation is nascent. We sought to develop and pilot test a measurement instrument to assess post-surgical family and community reintegration.

METHODS

We conducted an exploratory sequential mixed-methods study, beginning with 16 in-depth interviews and four focus group discussions with 17 women who underwent fistula surgery within two previous years to inform measure development. The draft instrument was validated in a longitudinal cohort of 60 women recovering from fistula surgery. Qualitative data were analyzed through thematic analysis. Socio-demographic characteristics were described using one-way frequency tables. We used exploratory factor analysis to determine the latent structure of the scale, then tested the fit of a single higher-order latent factor. We evaluated internal consistency and temporal stability reliability through Raykov's ρ and Pearson's correlation coefficient, respectively. We estimated a series of linear regression models to explore associations between the standardized reintegration measure and validated scales representing theoretically related constructs.

RESULTS

Themes central to women's experiences following surgery included resuming mobility, increasing social interaction, improved self-esteem, reduction of internalized stigma, resuming work, meeting their own needs and the needs of dependents, meeting other expected and desired roles, and negotiating larger life issues. We expanded the Return to Normal Living Index to reflect these themes. Exploratory factor analysis suggested a four-factor structure, titled 'Mobility and social engagement', 'Meeting family needs', 'Comfort with relationships', and 'General life satisfaction', and goodness of fit statistics supported a higher-order latent variable of 'Reintegration.' Reintegration score correlated significantly with quality of life, depression, self-esteem, stigma, and social support in theoretically expected directions.

CONCLUSION

As more women undergo surgical treatment for obstetric fistula, attention to the post-repair period is imperative. This preliminary validation of a reintegration instrument represents a first step toward improving measurement of post-surgical reintegration and has important implications for the evidence base of post-surgical reintegration epidemiology and the development and evaluation of fistula programming.

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.

Use of a postoperative pad test to identify continence status in women after obstetric vesicovaginal fistula repair: a prospective cohort study

OBJECTIVE

Determine whether a 1-hour pad test at discharge can identify continence status within 120 days of obstetric vesicovaginal fistula (VVF) repair.

DESIGN

Prospective cohort study.

SETTING

Fistula Care Centre in Lilongwe, Malawi.

POPULATION

Women with VVF who underwent repair between January 2012 and December 2014.

METHODS

Data on demographics, obstetric history, physical exam findings, operative management, postoperative findings, and follow up evaluations were collected on women with VVF repair.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and a receiver operating curve (ROC) were calculated to assess the utility of using a discharge pad test at three thresholds to identify women likely to be continent at follow up.

RESULTS

After VVF repair, 346 women had a 1-hour pad test performed at the time of hospital discharge and completed follow up within 120 days of repair. Of these, 79.8% (n = 276) were completely continent, whereas 20.2% (n = 70) had some degree of incontinence. The sensitivity and specificity of a negative 1-hour pad test at predicting continence is 68.1% and 82.9%, respectively. With this prevalence, a negative pad test at a 1.5-g threshold demonstrates a high predictive value (PPV = 94.0%, 95% CI 90.0-96.9) in detecting women with continence after repair.

CONCLUSIONS

At the 1.5-g threshold, a negative pad test at discharge identifies 94% of women who will remain continent after VVF repair. Adding the pad test to fistula care can identify women who are likely to remain continent and may not need further therapies in settings where resources are limited and follow up after repair is difficult.

TWEETABLE ABSTRACT

A negative pad test after repair is associated with continued continence at follow up.

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.

Beyond repair - family and community reintegration after obstetric fistula surgery: study protocol

Background

Obstetric fistula is a debilitating birth injury that affects an estimated 2–3 million women globally, most in sub-Saharan Africa and Asia. The urinary and/or fecal incontinence associated with fistula affects women physically, psychologically and socioeconomically. Surgical management of fistula is available with clinical success rates ranging from 65–95 %. Previous research on fistula repair outcomes has focused primarily on clinical outcomes without considering the broader goal of successful reintegration into family and community.

The objectives for this study are to understand the process of family and community reintegration post fistula surgery and develop a measurement tool to assess long-term success of post-surgical family and community reintegration.

Methods

This study is an exploratory sequential mixed-methods design including a preliminary qualitative component comprising in-depth interviews and focus group discussions to explore reintegration to family and community after fistula surgery. These results will be used to develop a reintegration tool, and the tool will be validated within a small longitudinal cohort (n = 60) that will follow women for 12 months after obstetric fistula surgery. Medical record abstraction will be conducted for patients managed within the fistula unit. Ethical approval for the study has been granted.

Discussion

This study will provide information regarding the success of family and community reintegration among women returning home after obstetric fistula surgery. The clinical and research community can utilize the standardized measurement tool in future studies of this patient population.

[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.

Urogenital fistula reviewed: a marker of severe maternal morbidity and an indicator of the quality of maternal healthcare delivery

BACKGROUND

While obstetric fistula has been recognized as a major maternal morbidity since the 1980s, it has become an indicator of access to and quality of women' s health care.

FINDINGS

Obstetric fistula still exists in low-income countries (LIC) because health care systems fail to provide adequate family planning, skilled birth attendance, basic and emergency obstetric care, and affordable treatment of fistula, while concurrently lacking social networks to serve as safety nets for affected girls and women [WHO, 2007].

CONCLUSION

This review explores the most recent published experience with respect to the definition of fistula, its diagnosis, treatment, and management, and further steps for prevention of fistula on a global scale.

Quantifying uncertainty in intervention effectiveness with structured expert judgement: an application to obstetric fistula

OBJECTIVE

To demonstrate a new application of structured expert judgement to assess the effectiveness of surgery to correct obstetric fistula in a low-income setting. Intervention effectiveness is a major input of evidence-informed priority setting in healthcare, but information on intervention effectiveness is generally lacking. This is particularly problematic in the context of poorly resourced healthcare settings where even efficacious interventions fail to translate into improvements in health. The few intervention effectiveness studies related to obstetric fistula treatment focus on the experience of single facilities and do not consider the impact of multiple factors that may affect health outcomes.

DESIGN

We use the classical model of structured expert judgement, a method that has been used to quantify uncertainty in the areas of engineering and environmental risk assessment when data are unavailable. Under this method, experts quantify their uncertainty about rates of long-term disability in patients with fistula following treatment in different contexts, but the information content drawn from their responses is statistically conditioned on the accuracy and informativeness of their responses to a set of calibration questions. Through this method, we develop best estimates and uncertainty bounds for the rate of disability associated with each treatment scenario and setting.

PARTICIPANTS

Eight experts in obstetric fistula repair in low and middle income countries.

RESULTS

Estimates developed using performance weights were statistically superior to those involving a simple averaging of expert responses. The performance-weight decision maker's assessments are narrower for 9 of the 10 calibration questions and 21 of 23 variables of interest.

CONCLUSIONS

We find that structured expert judgement is a viable approach to investigating the effectiveness of medical interventions where randomised controlled trials are not possible. Understanding the effectiveness of surgery performed at different types of facilities can guide programme planning to increase access to fistula treatment.

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.

Good clinical outcomes from a 7-year holistic programme of fistula repair in Guinea

Objectives

Female genital fistula remains a public health concern in developing countries. From January 2007 to September 2013, the Fistula Care project, managed by EngenderHealth in partnership with the Ministry of Health and supported by USAID, integrated fistula repair services in the maternity wards of general hospitals in Guinea. The objective of this article was to present and discuss the clinical outcomes of 7 years of work involving 2116 women repaired in three hospitals across the country.

Methods

This was a retrospective cohort study using data abstracted from medical records for fistula repairs conducted from 2007 to 2013. The study data were reviewed during the period April to August 2014.

Results

The majority of the 2116 women who underwent surgical repair had vesicovaginal fistula (n = 2045, 97%) and 3% had rectovaginal fistula or a combination of both. Overall 1748 (83%) had a closed fistula and were continent of urine immediately after surgery. At discharge, 1795 women (85%) had a closed fistula and 1680 (79%) were dry, meaning they no longer leaked urine and/or faeces. One hundred and fifteen (5%) remained with residual incontinence despite fistula closure. Follow-up at 3 months was completed by 1663 (79%) women of whom 1405 (84.5%) had their fistula closed and 80% were continent. Twenty-one per cent were lost to follow-up.

Conclusion

Routine programmatic repair for obstetric fistula in low resources settings can yield good outcomes. However, more efforts are needed to address loss to follow-up, sustain the results and prevent the occurrence and/or recurrence of fistula.

Objectifs

La fistule génitale féminine reste un problème de santé publique dans les pays en développement. De janvier 2007 à septembre 2013, le projet Fistula Care, géré par Engender Health en partenariat avec le Ministère de la Santé et soutenu par l’USAID, a intégré les services de réparation de fistules dans les maternités des hôpitaux généraux en Guinée. L'objectif de cet article est de présenter et de discuter les résultats cliniques de sept années de travail impliquant 2116 femmes traitées dans trois hôpitaux à travers le pays.

Méthodes

Il s'agit d'une étude de cohorte rétrospective utilisant des données extraites des dossiers médicaux de réparations de fistules menées de 2007 à 2013. Les données de l’étude ont été analysées au cours de la période allant d'avril à août 2014.

Résultats

La majorité des 2116 femmes qui ont subi une réparation chirurgicale avaient une fistule vésico vaginale (n = 2 045, 97%) et 3% avaient une fistule recto vaginale ou une combinaison des deux. Au total, 1748 (83%) femmes ont eu leur fistule refermée et sont devenues continentes d'urine immédiatement après la chirurgie. À la sortie, 1795 femmes (85%) avaient une fistule fermée et 1680 (79%) étaient sèches, c'est à dire qu'elles n'avaient plus de fuite d'urine et/ou de matières fécales. 115 (5%) femmes avaient toujours une incontinence résiduelle malgré la fermeture de la fistule. Le suivi à trois mois a été complété par 1663 (79%) femmes dont 1405 (84,5%) ont eu leur fistule fermée et 80% étaient continentes. 21% ont été perdues au suivi.

Conclusion

La réparation programmatique de routine de la fistule obstétricale dans les régions à faibles ressources peut donner de bons résultats. Toutefois, davantage d'efforts sont nécessaires pour remédier à la perte au suivi, maintenir les résultats et prévenir l'apparition et/ou la réapparition de fistules.

Objetivos

La fístula genital femenina continúa siendo una preocupación de salud pública en países en vías de desarrollo. Entre Enero 2007 y Septiembre 2013, el proyecto Fistula Care, manejado por EngenderHealth junto con el Ministerio de Salud de Guinea, y financiado por USAID, integró los servicios de reparación de fistula en las maternidades de hospitales generales en Guinea. El objetivo de este artículo es presentar y discutir los resultados clínicos de 7 años de trabajo con 2116 mujeres intervenidas en tres hospitales del país.

Métodos

Estudio retrospectivo de cohortes utilizando datos tomados de historias clínicas de reparaciones de fístula realizadas entre el 2007 y el 2013. Los datos del estudio se revisaron durante el periodo entre Abril y Agosto 2014.

Resultados

La mayoría de las 2116 mujeres que se sometieron a la reparación quirúrgica tenían una fistula vesico-vaginal (n = 2045, 97%) y 3% tenían una fístula recto-vaginal o una combinación de ambas. En general, 1748 (83%) tenían la fístula cerrada y eran continentes inmediatamente después de la cirugía. En el momento del alta, 1795 mujeres (85%) tenían la fistula cerrada y 1680 (79%) estaban secas, es decir que ya no perdían orina y/o heces. 115 (5%) continuaron teniendo incontinencia residual a pesar de que la fistula estaba cerrada. El seguimiento a los tres meses se completó para 1663 (79%) mujeres, de las cuales 1405 (84.5%) tenían la fistula cerrada y 80% eran continentes. Un 21% fueron perdidas durante el seguimiento.

Conclusión

La reparación rutinaria programada de la fístula obstétrica en lugares con pocos recursos puede dar buenos resultados. Sin embargo, se requieren más esfuerzos para resolver la pérdida durante el seguimiento, mantener los resultados y prevenir la aparición y/o reaparición de la fístula.

Bilateral double ureters with bladder neck diverticulum in a nigerian woman masquerading as an obstetric fistula

A 43-year-old woman presented with 20-year history of leakage of urine per vaginam. She had one failed repair attempt. Pelvic examination with dye test showed leakage of clear urine suggestive of ureterovaginal fistula. The preoperative intravenous urogram revealed duplex ureter and cystoscopy showed normally cited ureteric orifices with two other ectopic ureteric openings and bladder diverticula. The definitive surgery performed was ureteric reimplantation (ureteroneocystostomy) of the two distal ureteric to 2 cm superiolateral to the two normal orifices and diverticuloplasty. There was resolution of urinary incontinence after surgery. Three months after surgery, she had urodynamic testing done (cystometry), which showed 220 mLs with no signs of instability or leakage during filling phase but leaked on coughing at maximal bladder capacity. This is to showcase some diagnostic dilemma that could arise with obstetric fistula, which is generally diagnosed by clinical assessment.