Childbirth-Associated Fistula and Perineal Tears Repaired on Outreach Campaigns in Remote Democratic Republic of Congo

LUSSY score predictive of failure of surgical closure of obstetric rectovaginal fistula in the Democratic Republic of the Congo

INTRODUCTION

Rectovaginal fistula (RVF) is a complex debilitating condition that results from several etiologies, obstetric trauma being the most common. Occasionally RVF closure is non-successful. The objective of this study is to develop a predictive score to identify predictors of failure of surgical closure of obstetric RVF (FSCORVF) in the Democratic Republic of the Congo.

METHODS

This was an analytical cross-sectional study conducted on 268 patients with obstetric RVF who have received surgical management. We proceeded with a bivariate and then multivariate analysis. Score discrimination was assessed using the ROC curve and C-index and score calibration was done according to the Hosmer-Lemeshow test.

RESULTS

Surgical closure of RVF failed in 12.31% of cases (33/268). After logistic modelling, five criteria emerged as predictive factors of FSCORVF (LUSSY Score): the presence of moderate/severe fibrosis (aOR: 36.25; 95% CI: 1.88-699.37), combined RVF with other type of fistula (aOR: 61.41; 95% CI: 8.78-429.72), fistula size > 3 cm (aOR: 82.45; 95% CI: 10.48-648.58), per-operative hemorrhage (aOR: 27.84;; 95% CI: 5.08-152.47) and postoperative infection (aOR: 1161.35; 95% CI: 46.89-28765.47). A score of 0 to 22 was obtained with a value ≤ 9 points indicating a low risk of FSCORVF, a value between 10 and 12 defining a moderate risk and the value ≥ 13 points corresponding to a high risk of FSCORVF. The area under the ROC curve of the score is 0.9744 with a sensitivity of 90.91%, a specificity of 97.87%, a positive predictive value of 85.71% and a negative predictive value of 98.71%.

CONCLUSION

This study identified predictive factors for FSCORVF in the DRC, grouped in the LUSSY score. Complex fistulas (fistula size > 3 cm, severe fibrosis, combined fistulas) require advanced surgical routes different from the transvaginal and the transperineal ones used in the present study. Prevention of intraoperative hemorrhage and postoperative infections requires rigorous preparation, appropriate antibiotic prophylaxis, and strict postoperative follow-up.

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.