|
1
|
Pfiffner SE, Musa A, Winer IS, Harb AN. Endoureteral ablation: A novel technique to occlude the ureter in patients with urinary tract fistulae. World J Radiol 2024; 16:708-711. [PMID: 39801666 PMCID: PMC11718524 DOI: 10.4329/wjr.v16.i12.708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 11/27/2024] [Accepted: 12/06/2024] [Indexed: 12/27/2024] Open
Abstract
Urinary fistulae are abnormal connections between the urinary system and adjacent body parts, often resulting from factors such as infection, radiation, malignancy, protracted labor, gynecologic surgery, and gastrointestinal tract surgery. These fistulae can lead to persistent urinary incontinence, skin breakdown, social humiliation, psychosocial trauma, and severe infections. Current treatments include surgical repair, urinary diversion, and ureteral embolization, though these can have complications and are not always successful or feasible for all patients. This manuscript proposes a novel approach to correcting urinary fistulae: Endoureteral ablation using laser or radiofrequency ablation. These techniques, known for treating various conditions, show promise in causing fibrosis to occlude fistulae. Early success in animal and human models suggests endoureteral ablation as a potentially more effective, less invasive, and cost-effective alternative to current methods, especially for patients unfit for surgery. However, further studies are needed to establish its viability and effectiveness.
Collapse
Affiliation(s)
- Samantha E Pfiffner
- Department of Radiology, Wayne State University School of Medicine, Detroit, MI 48201, United States
| | - Arif Musa
- Department of Radiology, Detroit Medical Center/Wayne State University, Detroit, MI 48201, United States
| | - Ira S Winer
- Department of Oncology, Obstetrics and Gynecology, Detroit Medical Center/Wayne State University, Detroit, MI 48201, United States
| | - Ali N Harb
- Department of Radiology, Interventional Radiology, Detroit Medical Center/Wayne State University, Detroit, MI 48201, United States
| |
Collapse
|
|
2
|
Zeleke LB, Welsh A, Abeje G, Khajehei M. Treatment outcomes of obstetrical fistula surgical repair in low- and middle-income countries: A scoping review. Int J Gynaecol Obstet 2024; 167:491-500. [PMID: 38881203 DOI: 10.1002/ijgo.15724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 05/21/2024] [Accepted: 05/26/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Obstetrical fistula is an abnormal opening between the reproductive tract and lower urinary and/or gastrointestinal tract resulting from obstetrical complications, affecting nearly two million women worldwide. It imposes physical, economic, social, and mental consequences on the affected women. Treatment outcomes vary and, mostly, surgical treatment results in improved quality of life and successful subsequent pregnancy for survivors. OBJECTIVES The review aimed to chart and examine the treatment outcomes of obstetrical fistula surgical repair in low- and middle-income countries. SEARCH STRATEGY This is a scoping review study to identify treatment outcomes of obstetrical fistula surgical repair in low- and middle-income countries. The search was conducted from databases (PUBMED, Embase, CINAHL, Scopus, and Web of Science), and gray literature (Google Scholar, Google, and conference proceedings). SELECTION CRITERIA The eligibility criteria were constructed using a participant, concept, and context framework and included study types of primary research, reviews, and reports. Studies without full text and in languages other than English were excluded. DATA COLLECTION AND ANALYSIS The relevant characteristics of the included studies were extracted on an Excel spreadsheet and analyzed to chart treatment outcomes. MAIN FINDINGS The review examined the full text of 57 studies on the treatment outcomes of obstetrical fistula. The findings were grouped into two themes: early and late outcomes. The early outcomes included incontinence, surgical-site infection, urine retention, hemorrhage, and retained catheter. The late outcomes included fistula recurrence, residual incontinence, quality of life, reproductive issues, mental health, family and social support, and financial status. CONCLUSION The treatment outcomes of obstetrical fistula can be grouped into short-term and long-term outcomes. Although this review found adequate studies for the analysis, most study designs were poor. Stronger studies are recommended in the future to guide policy and decision-making. We would like to suggest that researchers conduct systematic reviews and meta-analyses independently for short-term and long-term outcomes.
Collapse
Affiliation(s)
- Liknaw Bewket Zeleke
- College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Alec Welsh
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Gedefaw Abeje
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Marjan Khajehei
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, Australia
- Western Sydney University, Sydney, Australia
| |
Collapse
|
|
3
|
Zeleke LB, Welsh A, Abeje G, Khejahei M. Proportions and determinants of successful surgical repair of obstetric fistula in low- and middle-income countries: A systematic review and meta-analysis. PLoS One 2024; 19:e0303020. [PMID: 38722847 PMCID: PMC11081269 DOI: 10.1371/journal.pone.0303020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 04/17/2024] [Indexed: 05/13/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Liknaw Bewket Zeleke
- College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
- Faculty of Medicine, School of Women’s and Children’s Health, University of New South Wales Sydney, Kensington, Australia
| | - Alec Welsh
- Faculty of Medicine, School of Women’s and Children’s Health, University of New South Wales Sydney, Kensington, Australia
| | - Gedefaw Abeje
- School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Marjan Khejahei
- Faculty of Medicine, School of Women’s and Children’s Health, University of New South Wales Sydney, Kensington, Australia
- Women’s and Newborn Health, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, Australia
- Western Sydney University, Sydney, Australia
| |
Collapse
|
|
4
|
Strassmann V, Silva-Alvarenga E, Emile SH, Garoufalia Z, DaSilva G, Wexner SD. Gracilis Muscle Interposition: A Valuable Tool for the Treatment of Failed Repair of Post-partum Rectovaginal Fistulas-A Single-Center Experience. Am Surg 2023; 89:6366-6369. [PMID: 37216694 DOI: 10.1177/00031348231175481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Rectovaginal fistulas (RVFs) account for approximately 40% of anorectal complications from obstetrical trauma. Treatment can be challenging requiring multiple surgical repairs. Interposition of healthy transposed tissue (lotus or Martius flap or gracilis muscle) has been used for recurrent RVF. We aimed to review our experience with gracilis muscle interposition (GMI) for post-partum RVF. METHODS A retrospective analysis of patients who underwent GMI for post-partum RVF from February 1995 to December 2019 was undertaken. Patient demographics, number of prior treatments, comorbidities, tobacco use, postoperative complications, additional procedures, and outcome were assessed. Success was defined as absence of leakage from the repair site after stoma reversal. RESULTS Six of 119 patients who underwent GMI did so for recurrent post-partum RVF. Median age was 34.2 (28-48) years. All patients had at least 1 previously failed procedure [median: 3 (1-7)] including endorectal advancement flap, fistulotomy, vaginoplasty, mesh interposition, and sphincteroplasty. All patients underwent fecal diversion prior to or at initial procedure. Success was achieved in 4/6 (66.7%) patients; 2 underwent further procedures (1 fistulotomy and 1 rectal flap advancement) for a final 100% success rate as all ileostomies were reversed. Morbidity was reported in 3 (50%) patients, including wound dehiscence, delayed rectoperineal fistula, and granuloma formation in one each, all managed without surgery. There was no morbidity related to stoma closure. CONCLUSIONS Gracilis muscle interposition is a valuable tool for recurrent post-partum RVF. Our ultimate success rate in this very small series was 100% with a relatively low morbidity rate.
Collapse
Affiliation(s)
- Victor Strassmann
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
| | - Emanuela Silva-Alvarenga
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
- Cleveland Clinic Florida, Martin Health, Port St. Lucie, Florida
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
| | - Giovanna DaSilva
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
| |
Collapse
|
|
5
|
Kumsa H, Mislu E, Arage MW, Abera A, Hailu T, Tenaw LA. Successful surgical closure and continence rate of obstetric fistula in Africa: systematic review and meta-analysis. Front Glob Womens Health 2023; 4:1188809. [PMID: 37854165 PMCID: PMC10579803 DOI: 10.3389/fgwh.2023.1188809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 09/13/2023] [Indexed: 10/20/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Henok Kumsa
- School of Midwifery, College of Midwifery, Woldia University, Woldia, Ethiopia
| | - Esuyawkal Mislu
- School of Midwifery, College of Midwifery, Woldia University, Woldia, Ethiopia
| | | | - Atitegeb Abera
- School of Public Health, College of Midwifery, Woldia University, Woldia, Ethiopia
| | - Tilahun Hailu
- School of Public Health, College of Midwifery, Woldia University, Woldia, Ethiopia
| | - Lebeza Alemu Tenaw
- School of Public Health, College of Midwifery, Woldia University, Woldia, Ethiopia
| |
Collapse
|
|
6
|
El Ayadi AM, Nalubwama H, Painter C, Kakaire O, Miller S, Barageine J, Byamugisha J, Obore S, Korn A, Harper CC. Contraceptive preferences and adoption following female genital fistula surgery in Uganda: a mixed-methods study. Reprod Health 2023; 20:121. [PMID: 37598146 PMCID: PMC10439586 DOI: 10.1186/s12978-023-01663-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 08/07/2023] [Indexed: 08/21/2023] Open
Abstract
BACKGROUND Female genital fistula, largely caused by prolonged obstructed labour, is treated by surgical repair. Preventing pregnancy for a minimum period post-repair is recommended to ensure adequate healing and optimize post-repair outcomes. METHODS We examined contraceptive preferences and use among Ugandan fistula patients (n = 60) in the year following genital fistula surgery using mixed-methods. Sexual activity, contraceptive use and pregnancy status were recorded quarterly for 12 months after surgery. In-depth interviews among purposively selected participants (n = 30) explored intimate relationships, sexual experiences, reproductive intentions, and contraceptive use. RESULTS Median participant age was 28 years and almost half (48%) were married or living with partners. Counselling was provided to 97% of participants on delaying sexual intercourse, but only 59% received counselling on contraception. Sexual activity was reported by 32% after 6 months and 50% after 12 months. Eighty-three percent reported not trying for pregnancy. Among sexually active participants, contraceptive use was low at baseline (36%) but increased to 73% at 12 months. Six (10%) women became pregnant including two within 3 months post-repair. Interview participants who desired children immediately were young, had fewer children, experienced stillbirth at fistula development, and felt pressure from partners. Women adopted contraception to fully recover from fistula surgery and avoid adverse outcomes. Others simply preferred to delay childbearing. Reasons cited for not adopting contraception included misconceptions related to their fertility and to contraceptive methods and insufficient or unclear healthcare provider advice on their preferred methods. CONCLUSIONS A high proportion of patients were not counselled by healthcare providers on contraception. Provision of comprehensive patient-centred contraceptive counselling at the time of fistula surgery and beyond is important for patients to optimize healing from fistula and minimize recurrence, as well as to meet their own reproductive preferences.
Collapse
Affiliation(s)
- Alison M El Ayadi
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94518, USA.
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA.
| | - Hadija Nalubwama
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Caitlyn Painter
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94518, USA
| | - Othman Kakaire
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94518, USA
| | - Justus Barageine
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Susan Obore
- Urogynaecology Division, Mulago National Teaching and Referral Hospital, Kampala, Uganda
| | - Abner Korn
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94518, USA
| | - Cynthia C Harper
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, 94518, USA
| |
Collapse
|
|
7
|
Johnson EE, O’Connor N, Hilton P, Pearson F, Goh J, Vale L. Interventions for treating obstetric fistula: An evidence gap map. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001481. [PMID: 36963005 PMCID: PMC10021774 DOI: 10.1371/journal.pgph.0001481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/19/2022] [Indexed: 01/27/2023]
Abstract
Obstetric fistula is prevalent in low- and middle-income countries, with between 50,000 and 100,000 new cases each year. The World Health Organization aims to eradicate it by 2030 but a clear idea of the extant evidence is unavailable. This evidence map compiled evidence on treatments for obstetric fistula to identify potential knowledge gaps. The protocol for this work was published on the Open Science Framework (DOI: 10.17605/OSF.IO/H7J35). A survey was developed, piloted and distributed online through organisations with an interest in obstetric fistula and snowballing. Results informed the evidence map framework. Searches were run on MEDLINE, Embase, CENTRAL, Global Index Medicus and ScanMedicine on 16 February 2022 to identify potentially eligible systematic reviews, randomised controlled trials, cohort studies and case-control studies. Forward and backward citation chaining was undertaken on relevant systematic reviews and included studies. Studies were screened, coded and assessed for risk of bias by a single reviewer, with a second checking a proportion. The evidence map results were compared to survey results. Thirty-nine people responded to the survey, half of which were clinicians. Of 9796 records identified, 37 reports of 28 studies were included in the evidence map. Many included studies were at some risk of bias; for observational studies, this was predominantly due to lack of controlling for confounders. Most studies (71%) assessed surgical interventions alone. Reporting on other intervention types was limited. Regarding outcome measures most important to survey respondents, 24 studies reported on cure/improvement in obstetric fistula and 20 on cure/improvement in urinary incontinence. Reporting on quality of life, faecal incontinence and sexual function was limited. There is currently little robust evidence to guide patients and practitioners on the most effective treatment option for obstetric fistula. Further research is required to address evidence gaps identified.
Collapse
Affiliation(s)
- Eugenie Evelynne Johnson
- Population Health Scien ces Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Nicole O’Connor
- Population Health Scien ces Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Paul Hilton
- Cochrane Incontinence, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Fiona Pearson
- Population Health Scien ces Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- NIHR Innovation Observatory, The Catalyst, Newcastle upon Tyne, United Kingdom
| | - Judith Goh
- Griffith University School of Medicine, Queensland, Australia
| | - Luke Vale
- Population Health Scien ces Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| |
Collapse
|
|
8
|
Bihon AM, Meikena HK, Serka S. Survival Modeling on the Determinants of Time to Recovery from Obstetric Fistula: The Case of Mekelle Hamlin Fistula Center, Ethiopia. Int J Reprod Med 2022; 2022:8313575. [PMID: 36419907 PMCID: PMC9678468 DOI: 10.1155/2022/8313575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 10/06/2022] [Indexed: 10/20/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Abera Molla Bihon
- Department of Statistics, College of Natural and Computational Sciences, Hawassa University, Ethiopia
| | - Henok Kumsa Meikena
- Department of Midwifery, College of Health Sciences, Woldia University, Ethiopia
| | - Selamawit Serka
- Department of Statistics, College of Natural and Computational Sciences, Hawassa University, Ethiopia
| |
Collapse
|
|
9
|
Yeshitila YG, Daniel B, Desta M, Kassa GM. Obstructed labor and its effect on adverse maternal and fetal outcomes in Ethiopia: A systematic review and meta-analysis. PLoS One 2022; 17:e0275400. [PMID: 36178921 PMCID: PMC9524671 DOI: 10.1371/journal.pone.0275400] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 09/15/2022] [Indexed: 01/22/2023] Open
Abstract
Background Obstructed labor is one of the five major causes of maternal mortality and morbidity in developing countries. In Ethiopia, it accounts for 19.1% of maternal death. The current review aimed to assess maternal and perinatal outcomes of obstructed labor in Ethiopia. Methods Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed for this systematic review and meta-analysis. A literature search was made using PubMed/MEDLINE, CINAHL, Summon country-specific search, and Cochrane Libraries’ online databases. Search terms were adverse outcome, obstructed labor, maternal outcome, fetal outcome, and Ethiopia. The Newcastle-Ottawa scale (NOS), based on a star scoring system, was used to assess the quality of the included studies. The meta-analysis was conducted using STATA 16 software. The pooled prevalence of an adverse maternal outcome, fetal outcome, and association between adverse outcome and obstructed labor was calculated using a random-effects model. Egger’s test and funnel plot were used to evaluate publication bias. Result Eighty-seven studies were included in this review, with an overall sample size of 104259 women and 4952 newborns. The pooled incidence of maternal death was estimated to be 14.4% [14.14 (6.91–21.37). The pooled prevalence of uterine rupture and maternal near-miss was 41.18% (95% CI: 19.83, 62.54) and 30.5% [30.5 (11.40, 49.59) respectively. Other complications such as postpartum hemorrhage, sepsis, obstetric fistula, hysterectomy, bladder injury, cesarean section, and labor abnormalities were also reported. The pooled prevalence of perinatal death was 26.4% (26.4 (95% CI 15.18, 37.7). In addition, the association of obstructed labor with stillbirth, perinatal asphyxia, and meconium-stained amniotic fluid was also demonstrated. Conclusions In Ethiopia, the incidence of perinatal and maternal mortality among pregnant women with obstructed labor was high. The rate of maternal death and maternal near miss reported in this review was higher than incidences reported from high-income and most low and middle-income countries. Uterine rupture, postpartum hemorrhage, sepsis, fistula, hysterectomy, and bladder injury were also commonly reported. To improve the health outcomes of obstructed labor, it is recommended to address the three delay models: enhancing communities’ health-seeking behavior, enhancing transportation for an obstetric emergency with different stakeholders, and strengthening the capacity of health facilities to handle obstetric emergencies.
Collapse
Affiliation(s)
- Yordanos Gizachew Yeshitila
- School of Nursing, College of Medicine and Health Science, Arba Minch University, Arba Minch, Ethiopia
- * E-mail:
| | - Beniam Daniel
- School of Nursing, College of Medicine and Health Science, Arba Minch University, Arba Minch, Ethiopia
| | - Melaku Desta
- Department of Midwifery, College of Medicine and Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Getachew Mullu Kassa
- College of Medicine and Health Science, Debre Markos University, Debre Markos, Ethiopia
| |
Collapse
|
|
10
|
Lussiez A, Nardos R, Lowry A. Rectovaginal Fistula Management in Low-Resource Settings. Clin Colon Rectal Surg 2022; 35:390-395. [PMID: 36111077 PMCID: PMC9470294 DOI: 10.1055/s-0042-1746187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Rectovaginal fistula (RVF) is an abnormal connection between the rectum and vagina that affects women globally. In low- and middle-income countries (LMIC), RVF is most commonly due to obstetric complications such as prolonged labor or perineal tears, female genital mutilation and trauma such as sexual violence or iatrogenic surgical injuries. Women affected by this condition suffer from debilitating physical symptoms, social isolation, economic disempowerment, psychological trauma, low self-esteem, and loss of role fulfillment. Lack of accessible, high-quality, and effective healthcare is a major barrier to timely and safe obstetric care and to care for subsequent complications such as RVF. Additionally, social, cultural, financial, and systemic barriers put women at risk of acquiring fistula and contribute to delays in seeking and receiving care. Literature evaluating RVF repair in those able to access care offers limited information about management and outcomes. It is difficult to ascertain which surgical techniques are used. To reduce the burden of this often-preventable disease, appropriate investment in healthcare infrastructure to strengthen maternal care in LMICs is paramount. Furthermore, more standardized reporting of severity and treatment approach along with outcome data are critical to improving the quality of care for patients impacted by RVF.
Collapse
Affiliation(s)
- Alisha Lussiez
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Rahel Nardos
- Division of Female Pelvic Medicine and Reconstructive Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Ann Lowry
- Division of Colon and Rectal Surgery, University of Minnesota, Bloomington, Minnesota
| |
Collapse
|
|
11
|
Nardos R, Jacobson L, Garg B, Wall LL, Emasu A, Ruder B. Characterizing persistent urinary incontinence after successful fistula closure: the Uganda experience. Am J Obstet Gynecol 2022; 227:70.e1-70.e9. [PMID: 35283092 DOI: 10.1016/j.ajog.2022.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/25/2022] [Accepted: 03/02/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Obstetric fistula is a devastating childbirth injury. Despite successful closure of the fistula, 16% to 55% of women suffer from persistent urinary incontinence after surgery. OBJECTIVE This study assessed the type and severity of persistent incontinence after successful fistula closure and its impact on the quality of life of Ugandan women post-fistula treatment. STUDY DESIGN This cross-sectional study enrolled women with a history of obstetric fistula repair who continued to have persistent urinary incontinence (cases, N=36) and women without incontinence (controls, N=52) after successful fistula closure. Data were collected in central and eastern Uganda between 2017 and 2019. All the participants completed a semistructured questionnaire. Cases underwent a clinical evaluation and a 2-hour pad test and completed a series of incontinence questionnaires, including two novel tools designed to assess the severity of incontinence in low-literacy populations. RESULTS Cases were more likely to have acquired a fistula during their first delivery (63% vs 37%, P=.02), were younger when they developed a fistula (20.3±5.8 vs 24.8±7.5 years old, P=.003), and were more likely to have had >2 fistula surgeries (67% vs 2%, P≤.001). Cases reported a much higher rate of planned home birth for their index pregnancy compared to controls (44% vs 11%), though only 14% of cases and 12% of controls actually delivered at home. Cases reported higher rates of pain with intercourse (36% vs 18%, P=.05), but recent sexual activity status (intercourse within the previous six months) was not significantly different between the groups (47% vs 62%, P=.18). Among cases, 67% reported stress incontinence, 47% reported urgency incontinence, and 47% reported mixed incontinence. The cough stress test was successfully done with 92% of the cases, and of these, almost all (97%) had a positive cough stress test. More than half (53%) rated their incontinence as "very severe," which was consistent with objective findings. The 24-hour voiding diary indicated both high urinary frequency (average 14) and very frequent leakage episodes (average 20). Two-hour pad-tests indicated that 86% of cases had >4 g change in pad weight within 2 hours. Women with more severe incontinence reported a more negative impact on their quality of life. The mean score of the International Consultation on Incontinence Questionnaire-Quality of Life was 62.77±12.76 (range, 28-76, median=67), with a higher score indicating a greater impact on the quality of life. There was also a high mental health burden, with both cases and controls reporting high rates of suicidal ideation at any point since developing fistula (36% vs 31%, P=.67). CONCLUSION Women with obstetric fistulas continue to suffer from severe persistent urinary incontinence even after successful fistula closure. Both stress and urgency incontinence are highly prevalent in this population. Worsening severity of incontinence is associated with a greater negative impact on the quality of life.
Collapse
Affiliation(s)
- Rahel Nardos
- Department of Obstetrics and Gynecology-Center for Global Health and Social Responsibility, University of Minnesota, Minneapolis, MN.
| | - Laura Jacobson
- Oregon Health & Science University-Portland State School of Public Health, Portland, OR
| | - Bharti Garg
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
| | - L Lewis Wall
- Departments of Obstetrics and Gynecology and Anthropology, Washington University, Saint Louis, MI
| | | | - Bonnie Ruder
- Terrewode Women's Fund, Eugene, OR; Oregon State University, Corvallis, OR
| |
Collapse
|
|
12
|
Paluku J, Bruce P, Kamabu E, Kataliko B, Kasereka J, Dube A. Childbirth-Associated Fistula and Perineal Tears Repaired on Outreach Campaigns in Remote Democratic Republic of Congo. Int J Womens Health 2021; 13:1025-1031. [PMID: 34744461 PMCID: PMC8565886 DOI: 10.2147/ijwh.s332040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/08/2021] [Indexed: 12/04/2022] Open
Abstract
Purpose To describe the demographics and evaluate the repair of childbirth-associated injuries leading to incontinence in patients in remote Democratic Republic of Congo (DRC). Patients and Methods Four surgical outreach campaigns were organised between March 2018 and October 2019. These campaigns specifically targeted women with incontinence secondary to childbirth-associated injuries. Patients were recruited on a voluntary basis, and locations included Katako-kombe (Sankuru province), Wamba (Haut Uelé province), Karawa (North Ubangi province) and Kipaka (Maniema province). Necessary care was provided along with informal teaching with local healthcare professionals. Results A total of 481 patients,14–71 years old with a mean of 32 years of age, were included in this study. The average duration of incontinence associated with a childbirth injury was 6.8 years. Vesicovaginal fistulas (277/481; 57.6%) and perineal tears (148/481; 30.8%) were predominant, while the combination of vesicovaginal and rectovaginal fistulas were seen in only 5 (1.0%) patients. Vaginal delivery (259/481; 53.9%), caesarean section (120/481; 25.0%) and laparotomy (hysterectomy) (102/481; 21.2%) were identified as the causes of the fistulas treated during the surgical campaign. Vesicovaginal fistulas were more likely to require complex repairs, as compared to rectovaginal fistulas and perineal tears (P-value <0.0001). As well, vesicovaginal fistulas were less likely to result in successful resolution of the incontinence when compared to rectovaginal fistulas and perineal tears (P-value < 0.0001). Conclusion Vesicovaginal fistulas are predominant among childbirth injuries encountered in remote DRC with poorly managed vaginal deliveries being the leading cause. Cure rate of fistulas and perineal tears is high during outreach campaigns; however, long-term follow-up is limited. There remains a need to train and mentor rural medical professionals in the DRC on adequate management of obstetric emergencies.
Collapse
Affiliation(s)
- Justin Paluku
- Department of Obstetrics and Gynecology, HEAL Africa Tertiary Hospital, Goma, North Kivu, Democratic Republic of Congo.,Department of Obstetrics and Gynecology, University of Goma (UNIGOM), Goma, North Kivu, Democratic Republic of Congo
| | - Phoebe Bruce
- Department of Undergraduate Medical Education, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Eugénie Kamabu
- Department of Internal Medicine, HEAL Africa Tertiary Hospital, Goma, North Kivu, Democratic Republic of Congo
| | - Benjamin Kataliko
- Department of Obstetrics and Gynecology, HEAL Africa Tertiary Hospital, Goma, North Kivu, Democratic Republic of Congo
| | - Jonathan Kasereka
- Department of Surgery, HEAL Africa Tertiary Hospital, Goma, North Kivu, Democratic Republic of Congo
| | - Annie Dube
- Department of Undergraduate Medical Education, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| |
Collapse
|
|
13
|
Characteristics of Obstetric and Iatrogenic Urogenital Fistulas in Burkina Faso: A Cross-Sectional Study. Adv Urol 2021; 2021:8838146. [PMID: 33531896 PMCID: PMC7840248 DOI: 10.1155/2021/8838146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 01/06/2021] [Accepted: 01/13/2021] [Indexed: 11/18/2022] Open
Abstract
Objective To compare the sociodemographic, clinical, and therapeutic characteristics of obstetric urogenital fistulas (OF) and iatrogenic urogenital fistulas (IF) treated in seven centers in Burkina Faso. Material and Methods. We carried out a cross-sectional study over a seven years' period (January 1, 2010 to December 31, 2016). We considered as iatrogenic all urogenital fistulas (UGF) occurred after elective caesarean section, gynecologic surgery (hysterectomy, myomectomy, and prolapse repair), or induced abortion. UGF following vaginal delivery after prolonged labor without obstetric maneuvers or caesarean section were considered as obstetric. UGF caused by other mechanisms (emergency caesarian section, congenital, and traumatic) were excluded from this study. The statistical analysis was carried out using version 14 of the STATA software. A logistic regression model was used to compare the two groups. Results 310 cases of UGF were included. IF accounted for 25.8% (n = 80) versus 74.2% (n = 230) for OF. The median age was 35 years for IF and 35.38 years for OF. The vesicovaginal fistulas were predominant (74.5%) in the two groups. All circumferential fistulas were found in the OF group. OF were frequently associated with residence in rural areas (OR = 1.8; CI = [1.05–3.1]), low level of education (OR = 5.4; CI = [2.3–12.9]), and a height under 158 cm (OR = 3.4 CI = [1.7–6.6]). Vaginal sclerosis was less common among IF (OR = 2.2; CI = [1–4.6]). The failure of surgical treatment after 3 months was more associated with OF (OR = 4.7; CI = [1.1–20.5]). Conclusion OF were the most common, frequently affecting short women living in rural area and with low level of schooling. Fistulas were also more severe in the OF group. IF gave better results after surgical repair.
Collapse
|
|
14
|
Streit-Ciećkiewicz D, Nowakowski Ł, Grzybowska ME, Futyma K. Predictive value of classification systems and single fistula-related factors in surgical management of vesicovaginal fistula. Neurourol Urodyn 2020; 40:529-537. [PMID: 33305857 DOI: 10.1002/nau.24594] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 10/11/2020] [Accepted: 11/26/2020] [Indexed: 01/20/2023]
Abstract
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.
Collapse
Affiliation(s)
| | - Łukasz Nowakowski
- 2nd Department of Gynecology, Medical University of Lublin, Lublin, Poland.,Department of Gynaecology, 1st Military Clinical Hospital with the Polyclinic in Lublin, Poland
| | - Magdalena E Grzybowska
- Department of Gynecology, Gynecologic Oncology and Gynecologic Endocrinology, Medical University of Gdańsk, Gdansk, Poland
| | - Konrad Futyma
- 2nd Department of Gynecology, Medical University of Lublin, Lublin, Poland
| |
Collapse
|
|
15
|
Awareness and Its Associated Factors of Obstetrics Fistula among Antenatal Care Attendees in Injibara Town Health Institutions, Awi Zone, North West, Ethiopia, 2019. J Pregnancy 2020; 2020:7306108. [PMID: 32695515 PMCID: PMC7350180 DOI: 10.1155/2020/7306108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/15/2020] [Indexed: 11/17/2022] Open
Abstract
Background Obstetric fistula is abnormal passageway between the vagina and bladder or rectum, and it has the most devastating effects on physical, social, and economic levels and represents a major public health issue of thousands of women, which failed to provide accessible and appropriate intrapartum care for women within a developing country, particularly in Ethiopia. Therefore, we tried to assess the awareness and its associated factors of obstetrics fistula among pregnant mothers attending antenatal care clinics. Methods A health institutional-based cross-sectional study was employed from March 4 to 29/2019 among 413 pregnant women. Data was collected by a systematic random sampling technique and entered into a computer using Epi data 3.5, edited and analyzed using Statistical Package of Social Sciences 23.0 version. Bivariate and multivariate logistic regression analyses were employed to estimate the crude and adjusted odds ratio with a confidence interval of 95% and p value of less than 0.05 considered statically significant. Result This study identified that 39.5% with 95% confidence interval (34.6-44.6%) of pregnant women had good awareness about obstetrics fistula. Multivariate logistic regression analysis showed that living in urban [AOR = 1.98, 95% CI = 1.07 - 3.69], attending formal education [AOR = 2.11, 95% CI = 1.06 - 4.12], having history antenatal care [AOR = 3.87, 95% CI = 1.60 - 9.68], and childbirth at health institution [AOR = 7.10, 95% CI = 2.52 - 2.02] were significantly associated with awareness of obstetrics fistula. Conclusion and recommendation. This study showed that awareness of obstetrics fistula was low. Residency, education, and occupation of the women, having history of antenatal care and childbirth at health institution was significantly associated with awareness of obstetrics fistula. Still, there is a gap on awareness of obstetrics fistula; therefore, it is good to emphasize on providing information on maternal health care issues, particularly about obstetrics fistula.
Collapse
|
|
16
|
Abstract
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.
Collapse
Affiliation(s)
- Rachel Pope
- Division of Global Women's Health, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Meghan Beddow
- Division of Global Women's Health, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
|
17
|
Abstract
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.
Collapse
|
|
18
|
Bernard L, Giles A, Fabiano S, Giles S, Hudgins S, Olson A, Shrime MG, Feldman S, Riviello R. Predictors of Obstetric Fistula Repair Outcomes in Lubango, Angola. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1726-1733. [PMID: 30987849 DOI: 10.1016/j.jogc.2019.01.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 01/28/2019] [Accepted: 01/30/2019] [Indexed: 11/30/2022]
Abstract
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.
Collapse
Affiliation(s)
- Laurence Bernard
- Harvard T.H. Chan School of Public Health, Boston, MA; Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON.
| | - Andrew Giles
- Harvard T.H. Chan School of Public Health, Boston, MA; Department of Surgery, McMaster University, Hamilton, ON
| | - Sam Fabiano
- Pan-African Academy of Christian Surgeons, Bongolo, Gabon
| | - Stacey Giles
- Centro Evangélico de Medicina do Lubango, Lubango, Angola
| | - Sarah Hudgins
- Centro Evangélico de Medicina do Lubango, Lubango, Angola
| | - Annelise Olson
- Centro Evangélico de Medicina do Lubango, Lubango, Angola
| | - Mark G Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - Sarah Feldman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA
| | - Robert Riviello
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Center for Surgery and Public Health,(,) Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
|
19
|
Yismaw L, Alemu K, Addis A, Alene M. Time to recovery from obstetric fistula and determinants in Gondar university teaching and referral hospital, northwest Ethiopia. BMC Womens Health 2019; 19:5. [PMID: 30616532 PMCID: PMC6323782 DOI: 10.1186/s12905-018-0700-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 12/12/2018] [Indexed: 11/10/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Leltework Yismaw
- Department of Public Health, Debre Markos University, Debre Markos, Ethiopia
| | - Kassahun Alemu
- Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Abebaw Addis
- Department of Reproductive Health, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Muluneh Alene
- Department of Statistics, Mizan-Tepi University, Teppi, Ethiopia
| |
Collapse
|
|
20
|
Epiu I, Alia G, Mukisa J, Tavrow P, Lamorde M, Kuznik A. Estimating the cost and cost-effectiveness for obstetric fistula repair in hospitals in Uganda: a low income country. Health Policy Plan 2018; 33:999-1008. [PMID: 30252051 PMCID: PMC6263022 DOI: 10.1093/heapol/czy078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2018] [Indexed: 12/16/2022] Open
Abstract
In Africa, about 33 000 cases of obstetric fistula occur each year. Women with fistula experience debilitating incontinence of urine and/or faeces and are often socially ostracized. Worldwide, Uganda ranks third among countries with the highest burden of obstetric fistula. Obstetric fistula repair competes for scarce resources with other healthcare interventions in resource-limited settings, even though it is surgically efficacious. There is limited documentation of its cost-effectiveness in the most affected settings. We therefore sought to assess the cost-effectiveness of surgical intervention for obstetric fistula in Uganda so as to provide appropriate data for policy-makers to prioritize fistula repair and reduce women's suffering in similarly burdened countries. We built a decision-analytic model from the perspective of Uganda's National Health System to estimate the cost-effectiveness of vesico-vaginal and recto-vaginal fistula surgery vs a competing strategy of no surgery for Ugandan women with fistula. Long-term disability outcomes were assessed based on a lifetime Markov state-transition cohort and effectiveness of surgery. Surgical costs were estimated by micro-costing local Ugandan health resources. Disability weights associated with vesico-vaginal, recto-vaginal fistula and mortality rates among the general population in Uganda were based on published sources. The cost of providing fistula repair surgery in Uganda was estimated at $378 per procedure. For a hypothetical 20-year-old woman, surgery was estimated to decrease the lifetime disability burden from 8.53 DALYs to 1.51 DALYs, yielding a cost per DALY averted of $54. The results were robust to variations in model inputs in one-way and probabilistic sensitivity analyses. Surgery for obstetric fistula appears highly cost-effective in Uganda. In similar low-income countries, governments and non-governmental organizations need to prioritize training and strengthening surgical capacity to increase access to fistula surgical care, which would be an important step towards achieving universal health coverage.
Collapse
Affiliation(s)
- Isabella Epiu
- NIH Fogarty Global Health Fellow, University of California Global Health Institute, CA, USA and Director Health Solutions International, Kampala, Uganda
| | - Godfrey Alia
- Department of Obstetrics and Gynecology, Mulago National Referral Hospital, Kampala, Uganda
| | - John Mukisa
- Clinical Epidemiology Unit, Makerere University College of Health Sciences, Uganda
| | - Paula Tavrow
- Bixby Program in Population and Reproductive Health, University of California at Los Angeles, CA, USA
| | - Mohammed Lamorde
- Prevention Care and Treatment, Infectious Disease Institute, Makerere University College of Health Sciences, Uganda
| | - Andreas Kuznik
- Department of Health Economics and Outcomes Research, Regeneron Pharmaceuticals, Tarrytown, NY, USA
| |
Collapse
|
|
21
|
Kopp DM, Wilkinson J, Bengtson A, Chipungu E, Pope RJ, Moyo M, Tang JH. Fertility outcomes following obstetric fistula repair: a prospective cohort study. Reprod Health 2017; 14:159. [PMID: 29179770 PMCID: PMC5704560 DOI: 10.1186/s12978-017-0415-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 11/13/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Obstetric fistula (OF) is a maternal morbidity associated with high rates of stillbirth, amenorrhea, and sexual dysfunction. Limited data exists on the reproductive outcomes of women in the years following a fistula repair. The objective of this study is to describe the fertility outcomes and family planning practices in a population of Malawian women 1-4 years after fistula repair. METHODS Women who had enrolled into a clinical database of OF patients and undergone OF repair between January 1, 2012 and July 31, 2014 were recruited and enrolled to complete a home-based survey of their demographic and reproductive health data 1-4 years after their repair. Pregnancy, amenorrhea, and sexual function were described using frequency analysis, and we compared antimüllerian hormone (AMH) concentrations between women with menses or pregnancy with women with amenorrhea or no pregnancy using Wilcoxon rank sum tests. RESULTS Of 297 women with a prior OF repair, 148 had reproductive potential and were included in this analysis. Overall 30 women of these women (21%) became pregnant since their fistula repair, with most pregnancies ending with cesarean delivery. Of the 32 women who were amenorrheic at the time of repair, 25 (78.1%) had resumption of menses. Only 11 (8.6%) of sexually active women reported dyspareunia, and among women who were not trying to conceive, 53.1% were currently using a method of family planning. No significant differences were found in AMH concentrations between those who were pregnant or had menses versus those without pregnancy or menses, respectively. CONCLUSIONS In this long-term follow-up study of women after OF repair, many women were able to achieve a pregnancy with a live birth, have normal menses, be sexually active, and access contraception. These achievements will further assist a population of women whose reintegration and restoration of dignity is closely tied to their ability to achieve their reproductive goals. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02685878 .
Collapse
Affiliation(s)
- Dawn M Kopp
- UNC Project-Malawi, Lilongwe, Malawi.,UNC Department of Obstetrics & Gynecology, Chapel Hill, NC, USA
| | - Jeffrey Wilkinson
- Fistula Care Center, Lilongwe, Malawi. .,Baylor College of Medicine Department of Obstetrics & Gynecology, Scurlock Tower, 1 Baylor Plaza, Houston, TX, 77030, USA.
| | | | - Ennet Chipungu
- Fistula Care Center, Lilongwe, Malawi.,Malawi College of Medicine Department of Obstetrics & Gynaecology, Blantyre, Malawi
| | - Rachel J Pope
- Malawi College of Medicine Department of Obstetrics & Gynaecology, Blantyre, Malawi
| | | | - Jennifer H Tang
- UNC Project-Malawi, Lilongwe, Malawi.,UNC Department of Obstetrics & Gynecology, Chapel Hill, NC, USA
| |
Collapse
|
|
22
|
Raassen TJIP, Ngongo CJ, Mahendeka MM. Diagnosis and management of 365 ureteric injuries following obstetric and gynecologic surgery in resource-limited settings. Int Urogynecol J 2017; 29:1303-1309. [PMID: 29022054 PMCID: PMC6132689 DOI: 10.1007/s00192-017-3483-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 09/09/2017] [Indexed: 11/26/2022]
Abstract
Introduction Ureteric injuries are among the most serious complications of pelvic surgery. The incidence in low-resource settings is not well documented. Methods This retrospective review analyzes a cohort of 365 ureteric injuries with ureterovaginal fistulas in 353 women following obstetric and gynecologic operations in 11 countries in Africa and Asia, all low-resource settings. The patients with ureteric injury were stratified into three groups according to the initial surgery: (a) obstetric operations, (b) gynecologic operations, and (c) vesicovaginal fistula (VVF) repairs. Results The 365 ureteric injuries in this series comprise 246 (67.4%) after obstetric procedures, 65 (17.8%) after gynecologic procedures, and 54 (14.8%) after repair of obstetric fistulas. Demographic characteristics show clear differences between women with iatrogenic injuries and women with obstetric fistulas. The study describes abdominal ureter reimplantation and other treatment procedures. Overall surgical results were good: 92.9% of women were cured (326/351), 5.4% were healed with some residual incontinence (19/351), and six failed (1.7%). Conclusions Ureteric injuries after obstetric and gynecologic operations are not uncommon. Unlike in high-resource contexts, in low-resource settings obstetric procedures are most often associated with urogenital fistula. Despite resource limitations, diagnosis and treatment of ureteric injuries is possible, with good success rates. Training must emphasize optimal surgical techniques and different approaches to assisted vaginal delivery.
Collapse
|
|
23
|
Identifying Patients With Vesicovaginal Fistula at High Risk of Urinary Incontinence After Surgery. Obstet Gynecol 2017; 128:945-953. [PMID: 27741181 DOI: 10.1097/aog.0000000000001687] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
|
|
24
|
Ouedraogo I, Payne C, Nardos R, Adelman AJ, Wall LL. Obstetric fistula in Niger: 6-month postoperative follow-up of 384 patients from the Danja Fistula Center. Int Urogynecol J 2017; 29:345-351. [PMID: 28600757 PMCID: PMC5847061 DOI: 10.1007/s00192-017-3375-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 07/28/2016] [Indexed: 11/25/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The impoverished West African country of Niger has high rates of obstetric fistula. We report a 6-month postoperative follow-up of 384 patients from the Danja Fistula Center and assess factors associated with operative success or failure. METHODS The medical records of 384 women who had completed a 6-month follow-up after fistula surgery were reviewed. Cases were categorized as "easy," "of intermediate complexity," or "difficult" based on a preoperative points system. Data were analyzed using simple chi-squared statistics and logistic regression. RESULTS The patients were predominantly of Hausa ethnicity (73%), married young (average 15.9 years), had teenage first pregnancies (average first delivery 16.9 years), and experienced prolonged labor (average 2.3 days) with poor outcomes (89% stillbirth rate). The average parity was four. Patients commonly developed their fistula during their first delivery (43.5%), but over half sustained a fistula during a subsequent delivery (56.5%). Prior fistula surgery elsewhere (average 1.75 operations) was common. The overall surgical success ("closed and dry") was 54%. When the 134 primary operations were analyzed separately, the overall success rate was 80%. Increasing success was seen with decreasing surgical difficulty: 92% success for "easy" cases, 68% for "intermediate" cases, and 57% success for "difficult" cases. Success decreased with increasing numbers of previous attempts at surgical repair. CONCLUSIONS These data provide further evidence that clinical outcomes are better when primary fistula repair is performed by expert surgeons in specialist centers with the support of trained fistula nurses.
Collapse
Affiliation(s)
- Itengre Ouedraogo
- The Danja Fistula Center, Danja, Niger
- The Worldwide Fistula Fund, Chicago, IL, USA
| | | | - Rahel Nardos
- The Worldwide Fistula Fund, Chicago, IL, USA
- Department of Obstetrics and Gynecology, Oregon Health and Sciences University, Portland, OR, USA
| | - Avril J Adelman
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - L Lewis Wall
- The Worldwide Fistula Fund, Chicago, IL, USA.
- Department of Anthropology, Washington University in St. Louis, Campus Box 1114, One Brookings Drive, St. Louis, MO, 63110, USA.
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA.
| |
Collapse
|
|
25
|
Mubikayi L, Matson DO, Lokomba V, Mboloko J, Kamba JP, Tozin R. Determinants of Outcomes and Prognosis Score in Obstetric Vesico-Vaginal Fistula Repair. ACTA ACUST UNITED AC 2017. [DOI: 10.4236/ojog.2017.77078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
|
26
|
Désalliers J, Paré ME, Kouraogo S, Corcos J. Impact of surgery on quality of life of women with obstetrical fistula: a qualitative study in Burkina Faso. Int Urogynecol J 2016; 28:1091-1100. [DOI: 10.1007/s00192-016-3235-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 12/05/2016] [Indexed: 11/24/2022]
|
|
27
|
Delamou A, Delvaux T, Beavogui AH, Toure A, Kolié D, Sidibé S, Camara M, Diallo K, Barry TH, Diallo M, Leveque A, Zhang WH, De Brouwere V. Factors associated with the failure of obstetric fistula repair in Guinea: implications for practice. Reprod Health 2016; 13:135. [PMID: 27821123 PMCID: PMC5100224 DOI: 10.1186/s12978-016-0248-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/19/2016] [Indexed: 12/04/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Alexandre Delamou
- Ecole de Santé Publique, Université libre de Bruxelles (ULB), Bruxelles, Belgium. .,Centre national de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea. .,Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Therese Delvaux
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Abdoul Habib Beavogui
- Centre national de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea
| | - Abdoulaye Toure
- Department of Public Health, Faculty of Medicine, University of Conakry, Conakry, Guinea
| | - Delphin Kolié
- Centre national de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea
| | - Sidikiba Sidibé
- Centre national de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea.,Department of Public Health, Faculty of Medicine, University of Conakry, Conakry, Guinea
| | - Mandian Camara
- Centre Médicosocial Jean Paul II de Conakry, Conakry, Guinea
| | | | | | | | - Alain Leveque
- Ecole de Santé Publique, Université libre de Bruxelles (ULB), Bruxelles, Belgium
| | - Wei-Hong Zhang
- Ecole de Santé Publique, Université libre de Bruxelles (ULB), Bruxelles, Belgium
| | - Vincent De Brouwere
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| |
Collapse
|
|
28
|
Dennis AC, Wilson SM, Mosha MV, Masenga GG, Sikkema KJ, Terroso KE, Watt MH. Experiences of social support among women presenting for obstetric fistula repair surgery in Tanzania. Int J Womens Health 2016; 8:429-39. [PMID: 27660492 PMCID: PMC5019876 DOI: 10.2147/ijwh.s110202] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective An obstetric fistula is a childbirth injury resulting in uncontrollable leakage of urine and/or feces and can lead to physical and psychological challenges, including social isolation. Prior to and after fistula repair surgery, social support can help a woman to reintegrate into her community. The aim of this study was to preliminarily examine the experiences of social support among Tanzanian women presenting with obstetric fistula in the periods immediately preceding obstetric fistula repair surgery and following reintegration. Patients and methods The study used a mixed-methods design to analyze cross-sectional surveys (n=59) and in-depth interviews (n=20). Results Women reported widely varying levels of social support from family members and partners, with half of the sample reporting overall high levels of social support. For women experiencing lower levels of support, fistula often exacerbated existing problems in relationships, sometimes directly causing separation or divorce. Many women were assertive and resilient with regard to advocating for their fistula care and relationship needs. Conclusion Our data suggest that while some women endure negative social experiences following an obstetric fistula and require additional resources and services, many women report high levels of social support from family members and partners, which may be harnessed to improve the holistic care for patients.
Collapse
Affiliation(s)
| | - Sarah M Wilson
- Duke Global Health Institute, Duke University; Department of Veterans Affairs, Mid-Atlantic Mental Illness Research, Education and Clinical Center; Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Mary V Mosha
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | | | - Kathleen J Sikkema
- Duke Global Health Institute, Duke University; Department of Psychology and Neuroscience, Duke University, Durham, NC, USA; Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | | | | |
Collapse
|
|
29
|
Hillary CJ, Osman NI, Hilton P, Chapple CR. The Aetiology, Treatment, and Outcome of Urogenital Fistulae Managed in Well- and Low-resourced Countries: A Systematic Review. Eur Urol 2016; 70:478-92. [PMID: 26922407 DOI: 10.1016/j.eururo.2016.02.015] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/03/2016] [Indexed: 11/28/2022]
Abstract
CONTEXT Urogenital fistula is a global healthcare problem, predominantly associated with obstetric complications in low-resourced countries and iatrogenic injury in well-resourced countries. Currently, the published evidence is of relatively low quality, mainly consisting retrospective case series. OBJECTIVE We evaluated the available evidence for aetiology, intervention, and outcomes of urogenital fistulae worldwide. EVIDENCE ACQUISITION We performed a systematic review of the PubMed and Scopus databases, classifying the evidence for fistula aetiology, repair techniques, and outcomes of surgery. Comparisons were made between fistulae treated in well-resourced countries and those in low-resourced countries. EVIDENCE SYNTHESIS Over a 35-yr period, 49 articles were identified using our search criteria, which were included in the qualitative analysis. In well-resourced countries, 1710/2055 (83.2%) of fistulae occurred following surgery, whereas in low-resourced countries, 9902/10398 (95.2%) were associated with childbirth. Spontaneous closure can occur in up to 15% of cases using catheter drainage and conservative approaches are more likely to be successful for nonradiotherapy fistulae. Of patients undergoing repairs in well-resourced countries, the median overall closure rate was 94.6%, while in low-resourced countries, this was 87.0%. Closure was significantly more likely to be achieved using a transvaginal approach then a transabdominal technique (90.8% success vs 83.9%, Fisher's exact test; p=0.0176). CONCLUSIONS It is difficult to conclude whether any specific route of surgery has advantage over any other, given the selection of patients to a particular procedure is based upon individual fistula characteristics. However, surgical repair should be carried out by experienced fistula surgeons, well versed in all techniques as the primary attempt at repair is likely to be the most successful. PATIENT SUMMARY Urogenital fistulae are a common problem worldwide; however, the available evidence on fistula management is poor in quality. We searched the current literature and identified that 95% of fistulae occur following childbirth in low-resourced countries, whereas 80% of fistulae are associated with surgery in well-resourced countries, where successful repair is also more likely to be achieved. The first attempt at repair is often the most successful and therefore fistula surgery should be centralised to hospitals with the most experience.
Collapse
Affiliation(s)
| | - Nadir I Osman
- Academic Urology Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Paul Hilton
- Department of Urogynaecology, Newcastle University, Newcastle, UK
| | | |
Collapse
|
|
30
|
Abstract
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.
Collapse
|
|
31
|
Egziabher TG, Eugene N, Ben K, Fredrick K. Obstetric fistula management and predictors of successful closure among women attending a public tertiary hospital in Rwanda: a retrospective review of records. BMC Res Notes 2015; 8:774. [PMID: 26654111 PMCID: PMC4676892 DOI: 10.1186/s13104-015-1771-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 11/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Globally, 50,000-100,000 women develop obstetric fistula annually. At least 33,000 of these women live in Sub-Saharan Africa where limitations in quality obstetric care and fistula corrective repairs are prevalent. Among women with fistula seeking care at public health facilities in resource-limited settings, there is paucity of data on quality of care received. The aim of this study was to characterize obstetric fistula among Rwandan women managed at a public tertiary hospital and evaluate for predictors of successful fistula closures. METHODS A retrospective review of records for all obstetric fistula women managed at a public referral health facility between 2007 and 2013 was performed. Patient socio-demographics, obstetric characteristics and fistula repair outcomes data were reviewed. A multivariate logistic regression model was used to analyse for predictors of successful fistula repair outcomes. RESULTS A total of 272 women aged between 16 to 78 years and with a mean age of 34.6 years were included. Of these, 93 (34.2 %), 48 (17.6 %), 65 (24 %) and 64 (23 %) women had vesico-vaginal fistula, recto-vaginal fistula, urethro-vaginal fistula and vesico-uteral fistula types, respectively. Successful fistula closure was achieved among 86.3 %. Women with fistula who reported being in labour for ≥3 days, having ≥1 previous fistula repair attempt, and having lived with the fistula for >1 year, had significantly lower odds of successful repair outcomes. CONCLUSIONS Among 272 women with obstetric fistula managed in this study, 69.5 and 26.5 % of their fistula were causally associated with obstructed labour complications and iatrogenic factors, respectively. Successful fistula closure rates of about 89 % among women of index repair attempt were achieved. Conversely, reported histories of ≥3 days in labour, ≥1 previous failed attempts at repair and a fistula duration of >1 year, were significant determinants of failed fistula closures. To effectively mitigate obstetric fistula burden in Rwanda, a comprehensive package of services including quality emergency obstetric care, increased availability of and access to quality fistula repair, active surveillance to identify community-based women with fistula and a strong political will towards effective fistula care, are recommended.
Collapse
Affiliation(s)
| | - Ngoga Eugene
- Rwanda Military Hospital, P.O. BOX 3377, Kigali, Rwanda.
| | - Karenzi Ben
- Rwanda Military Hospital, P.O. BOX 3377, Kigali, Rwanda.
| | | |
Collapse
|
|
32
|
Cowgill KD, Bishop J, Norgaard AK, Rubens CE, Gravett MG. Obstetric fistula in low-resource countries: an under-valued and under-studied problem--systematic review of its incidence, prevalence, and association with stillbirth. BMC Pregnancy Childbirth 2015; 15:193. [PMID: 26306705 PMCID: PMC4550077 DOI: 10.1186/s12884-015-0592-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 07/15/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Obstetric fistula (OF) is a serious consequence of prolonged, obstructed labor in settings where emergency obstetric care is limited, but there are few reliable, population-based estimates of the rate of OF. Stillbirth (SB) is another serious consequence of prolonged, obstructed labor, yet the frequency of SB in women with OF is poorly described. Here, we review these data. METHODS We searched electronic databases and grey literature for articles on OF in low-resource countries published between January 1, 1995, and November 16, 2014, and selected for inclusion 19 articles with original population-based OF incidence or prevalence data and 44 with reports of frequency of SB associated with OF. RESULTS OF estimates came from medium- and low-HDI countries in South Asia and Africa, and varied considerably; incidence estimates ranged from 0 to 4.09 OF cases per 1000 deliveries, while prevalence estimates were judged more prone to bias and ranged from 0 to 81.0 OF cases per 1000 women. Reported frequency of SB associated with OF ranged from 32.3 % to 100 %, with estimates from the largest studies around 92 %. Study methods and quality were inconsistent. CONCLUSIONS Reliable data on OF and associated SB in low-resource countries are lacking, underscoring the relative invisibility of these issues. Sound numbers are needed to guide policy and funding responses to these neglected conditions of poverty.
Collapse
Affiliation(s)
- Karen D Cowgill
- College of Nursing, Seattle University, Seattle, WA, USA.
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | | | | | - Craig E Rubens
- Global Alliance to Prevent Prematurity and Stillbirth, Seattle Children's, Seattle, WA, USA.
| | - Michael G Gravett
- Global Alliance to Prevent Prematurity and Stillbirth, Seattle Children's, Seattle, WA, USA.
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA.
| |
Collapse
|
|
33
|
Borazjani A, Tadesse H, Ayenachew F, Goldman HB, Damaser MS, Wall LL. Validation of a culturally compliant voiding platform for urodynamics in African vesicovaginal fistula patients. Int Urogynecol J 2014; 26:749-55. [PMID: 25477141 DOI: 10.1007/s00192-014-2575-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 11/04/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Most patients in regions where obstetric vesicovaginal fistulas (VVF) are endemic void using a squatting posture. Additionally, many patients continue to have lower urinary tract symptoms (LUTS) following fistula closure. We designed and validated a prototype platform that allows urodynamic studies to be performed in a squatting position and conducted a pilot study to assess uroflowmetry in this patient population. METHODS Sixteen patients with persistent LUTS following fistula surgery were recruited. Posture measurements were taken in each patient's natural voiding posture on the ground and were then repeated using the platform. Nine patients with persistent urinary incontinence also underwent uroflowmetry. The data were compared with normal values in different nomograms. Paired t tests were used to determine significant differences in posture. One-way ANOVA was used to determine statistical significance between flow rate values. RESULTS Only the heel-to-heel distance (H-H) measure of posture was significantly increased on the platform compared with on the ground. The mean corrected Qmax was 0.89 ± 0.46. Flow rate values were significantly lower than mean normal flow rates obtained from the nomograms. In general, the patients' uroflowmetry patterns were similar to those indicative of impaired detrusor function. CONCLUSION A platform for conducting urodynamic studies in a squatting posture was successfully validated in the VVF patient population. The finding of increased H-H on the platform is expected, since the patient must accommodate a large funnel for urine collection. The pilot data suggest that patients with persistent urinary incontinence following VVF closure may also have significant voiding dysfunction.
Collapse
Affiliation(s)
- Ali Borazjani
- Global Innovations for Reproductive Health & Life, Cleveland, OH, USA,
| | | | | | | | | | | |
Collapse
|
|
34
|
Barageine JK, Tumwesigye NM, Byamugisha JK, Almroth L, Faxelid E. Risk factors for obstetric fistula in Western Uganda: a case control study. PLoS One 2014; 9:e112299. [PMID: 25401756 PMCID: PMC4234404 DOI: 10.1371/journal.pone.0112299] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 10/14/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Two million women worldwide are living with genital fistula with an annual incidence of 50,000-100,000 women. Risk factors for obstetric fistula are context bound. Studies from other countries show variation in the risk factors for obstetric fistula. This study was conducted to identify risk factors for obstetric fistula in western Ugandan context. METHODS A case control study comparing background factors of women with obstetric fistula (cases) and women without fistula (controls) was conducted in western Uganda. Data was collected using face-to-face interviews. Univariate, bivariate and multivariate analysis was conducted using Stata 12. RESULTS Altogether, 420 respondents (140 cases and 280 controls) participated in the study. Duration of labour was used to form the product terms when assessing for interaction and confounding since it was one the most significant factors at bivariate level with a narrow confidence interval and was hence considered the main predictor. After adjusting for interaction and confounding, significant risk factors associated with development of obstetric fistula in western Uganda were: Caesarean section (adjusted odds ratio [AOR] = 13.30, 95% CI = 6.74-26.39), respondent height of 150 cm or less (AOR = 2.63, 95% CI = 1.35-5.26), baby weight of 3.5 kg or more (AOR = 1.52, 95% CI = 1.15-1.99), prolonged labour (AOR = 1.06, 95% CI = 1.04-1.08. A quarter of the fistulas had resulted from iatrogenic complication during caesarean section. Compared to no education, post primary level of education was protective against obstetric fistula (AOR = 0.31, 95% CI = 0.13-0.72) and there was no difference between respondents without education and those with primary level education. CONCLUSIONS Surgeons contribute to a big proportion (25%) of fistula cases hence caesarean section being a risk factor in this region. Other risk factors include; prolonged labour, weight of the baby of 3.5 kg or more, respondent height of 150 cm or less (short stature), and low or no education are risk factors for obstetric fistula in western Ugandan.
Collapse
Affiliation(s)
- Justus Kafunjo Barageine
- Department of Obstetrics and Gynecology, School of medicine, Makerere University College of Health Sciences/Mulago National Referral Hospital, Kampala, Uganda
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Nazarius Mbona Tumwesigye
- Department of epidemiology and biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Josaphat K. Byamugisha
- Department of Obstetrics and Gynecology, School of medicine, Makerere University College of Health Sciences/Mulago National Referral Hospital, Kampala, Uganda
| | - Lars Almroth
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
| | - Elisabeth Faxelid
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
|
35
|
Morhason-Bello IO, Ojengbede OA, Adedokun BO, Okunlola MA, Oladokun A. Uncomplicated midvaginal vesico-vaginal fistula repair in ibadan: a comparison of the abdominal and vaginal routes. Ann Ib Postgrad Med 2014; 6:39-43. [PMID: 25161453 PMCID: PMC4110999 DOI: 10.4314/aipm.v6i2.64051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Obstetric fistula is a resultant effect of prolonged obstructed labour. The best surgical management of simple uncomplicated fistula determines the outcome of care. OBJECTIVE To compare outcome of uncomplicated mid-vaginal fistula between vaginal and abdominal route of repair. MATERIALS AND METHOD This was a hospital based retrospective study conducted at the University College Hospital, Ibadan from January, 2000 till December, 2006. RESULT Of the 71 midvaginal fistulae managed, 40.8% had abdominal repair while the remainder were through vaginal approach. The overall repair success rate was 79.2% with comparable outcome in both groups-78.3% for the abdominal and 80% for the vaginal group (p=0.999). The duration of hospital stay did not differ significantly between the groups (p=0.972). Post operative complications were found in 41.4% of the abdominal group compared to none in the vaginal group (p<0.001). The complications were failed repair (20.7%) and urinary tract infection (20.7%). The mean estimated blood loss was 465.5ml in the abdominal group compared to 332.9ml for the vaginal group (p=0.303). CONCLUSION Despite the comparable surgical repair outcome of the two methods, the vaginal approach is associated with lesser blood loss and lower risk of post-operative complications. It is recommended that the vaginal route should be employed in the repair of uncomplicated midvaginal fistula unless there are other compelling reasons to the contrary.
Collapse
Affiliation(s)
- I O Morhason-Bello
- Dept. of Obstetrics and Gynaecology, University College Hospital, Ibadan, Oyo State, Nigeria
| | - O A Ojengbede
- Dept. of Obstetrics and Gynaecology, University College Hospital, Ibadan, Oyo State, Nigeria
| | - B O Adedokun
- Dept. of Epidemiology, Medical Statistics, and Environmental, Health, College of Medicine, Ibadan, Oyo State, Nigeria
| | - M A Okunlola
- Dept. of Obstetrics and Gynaecology, University College Hospital, Ibadan, Oyo State, Nigeria
| | - A Oladokun
- Dept. of Obstetrics and Gynaecology, University College Hospital, Ibadan, Oyo State, Nigeria
| |
Collapse
|
|
36
|
Raassen TJIP, Ngongo CJ, Mahendeka MM. Iatrogenic genitourinary fistula: an 18-year retrospective review of 805 injuries. Int Urogynecol J 2014; 25:1699-706. [PMID: 25062654 PMCID: PMC4234894 DOI: 10.1007/s00192-014-2445-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 05/26/2014] [Indexed: 11/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Genitourinary fistula poses a public health challenge in areas where women have inadequate access to quality emergency obstetric care. Fistulas typically develop during prolonged, obstructed labor, but providers can also inadvertently cause a fistula when performing obstetric or gynecological surgery. METHODS This retrospective study analyzes 805 iatrogenic fistulas from a series of 5,959 women undergoing genitourinary fistula repair in 11 countries between 1994 and 2012. Injuries fall into three categories: ureteric, vault, and vesico-[utero]/-cervico-vaginal. This analysis considers the frequency and characteristics of each type of fistula and the risk factors associated with iatrogenic fistula development. RESULTS In this large series, 13.2 % of genitourinary fistula repairs were for injuries caused by provider error. A range of cadres conducted procedures resulting in iatrogenic fistula. Four out of five iatrogenic fistulas developed following surgery for obstetric complications: cesarean section, ruptured uterus repair, or hysterectomy for ruptured uterus. Others developed during gynecological procedures, most commonly hysterectomy. Vesico-[utero]/-cervico-vaginal fistulas were the most common (43.6 %), followed by ureteric injuries (33.9 %) and vault fistulas (22.5 %). One quarter of women with iatrogenic fistulas had previously undergone a laparotomy, nearly always a cesarean section. Among these women, one quarter had undergone more than one previous cesarean section. CONCLUSIONS Women with previous cesarean sections are at an increased risk of iatrogenic injury. Work environments must be adequate to reduce surgical error. Training must emphasize the importance of optimal surgical techniques, obstetric decision-making, and alternative ways to deliver dead babies. Iatrogenic fistulas should be recognized as a distinct genitourinary fistula category.
Collapse
|
|
37
|
Abstract
PURPOSE OF REVIEW To highlight the lack of consistency in the terminology and indicators related to obstetric fistula care and to put forward a call for consensus. RECENT FINDINGS Recent studies show at least some degree of statistical correlation between outcome and the following clinical factors: degree of scarring/fibrosis, fistula location, fistula size, damage to the urethra, presence of circumferential fistula, bladder capacity, and prior attempt at fistula repair. SUMMARY Consensus about basic definitions of clinical success does not yet exist. Opinions vary widely about the prognostic parameters for success or failure. Commonly agreed upon definitions and outcome measures will help ensure that site reviews are accurate and conducted fairly. To properly compare technical innovations with existing methods, agreement must be reached on definitions of success. Standardized indicators for mortality and morbidity associated with fistula repair will improve the evidence base and contribute to quality of care.
Collapse
|
|
38
|
|
|
39
|
Manganiello M, Hughes CD, Hagander L, Bayne D, Pierre JH, Buckley JC, Meara JG. Urologic disease in a resource-poor country. World J Surg 2013; 37:344-8. [PMID: 23052811 DOI: 10.1007/s00268-012-1818-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Understanding the role that urologic disease plays within central Haiti could lead to the development of sustainable and regionally appropriate urologic care. We aim to document the prevalence of urologic surgical disease presenting for treatment in central Haiti. METHODS The present study is based on a retrospective review of surgical case logs at five Partners in Health and Zanmi Lasante hospitals in central Haiti. Data were collected from June 30, 2009, through July 29, 2010, and included patient demographics, disease processes, interventions required, surgeon name, and surgeon training (urologic trained versus non-urologic trained). RESULTS Urologic surgical disease comprised 498/5,539 (9.0 %) of all surgical cases in central Haiti from July 2009-July 2010. A total of 492 diagnoses and 498 urologic procedures on 469 patients were recorded. Most common diagnoses included hydrocele (33.3 %), phimosis (23.0 %), benign prostatic hyperplasia (10.8 %), and cryptorchidism (7.3 %). Hydrocelectomy was the most commonly performed procedure (160/498, 32.1 %), followed by circumcision (117/498, 23.4 %) and open prostatectomy (38/498, 7.6 %). Surgeon training (urologic versus non-urologic) was determined for 360/498 (72.3 %) of surgical cases. Urologic trained surgeons performed 55/360 (15.3 %) of all surgical procedures. Among patients who underwent prostatectomy, urology surgeons performed 14/31 (45.2 %) of open prostatectomies, and non-urology surgeons performed 17/31 (54.8 %). Urologists performed all transurethral resections of the prostate (9 vs. 0; p = 0.0051). CONCLUSIONS Urologic surgical diseases comprise a substantial source of morbidity for patients in central Haiti. Understanding the scale and scope of urologic disease is important in developing health systems to adequately address the regional burden of surgical disease in limited-resource settings.
Collapse
Affiliation(s)
- Marc Manganiello
- Institute of Urology, Lahey Clinic, 41 Mall Road, Burlington, MA 01805, USA.
| | | | | | | | | | | | | |
Collapse
|
|
40
|
Frajzyngier V, Li G, Larson E, Ruminjo J, Barone MA. Development and comparison of prognostic scoring systems for surgical closure of genitourinary fistula. Am J Obstet Gynecol 2013; 208:112.e1-11. [PMID: 23201329 PMCID: PMC3573873 DOI: 10.1016/j.ajog.2012.11.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 11/03/2012] [Accepted: 11/26/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The purpose of this study was to test the diagnostic performance of 5 existing classification systems (developed by Lawson, Tafesse, Goh, Waaldijk, and the World Health Organization) and a prognostic scoring system that was derived empirically from our data to predict fistula closure 3 months after surgery. STUDY DESIGN Women with genitourinary fistula (n = 1274) who received surgical repair services at 11 health facilities in sub-Saharan Africa and Asia were enrolled in a prospective cohort study. Using one-half of the sample, we created multivariate generalized estimating equation models to obtain weighted prognostic scores for components of each existing classification system and the empirically derived scoring system. With the second one-half, we developed receiver operating characteristic curves using the prognostic scores and calculated areas under the curves (AUCs) and 95% confidence intervals (CIs) for each system. RESULTS Among existing systems, the scoring systems that represented the World Health Organization, Goh, and Tafesse classifications had the highest predictive accuracy: AUC, 0.63 (95% CI, 0.57-0.68); AUC, 0.62 (95% CI, 0.57-0.68), and AUC, 0.60 (95% CI, 0.55-0.65), respectively. The empirically derived prognostic score achieved similar predictive accuracy (AUC, 0.62; 95% CI, 0.56-0.67); it included significant predictors of closure that are found in the other classification systems, but contained fewer, nonoverlapping components. The differences in AUCs were not statistically significant. CONCLUSION The prognostic values of existing urinary fistula classification systems and the empirically derived score were poor to fair. Further evaluation of the validity and reliability of existing classification systems to predict fistula closure is warranted; consideration should be given to a prognostic score that is evidence-based, simple, and easy to use.
Collapse
|
|
41
|
|
|
42
|
Abstract
OBJECTIVE To determine predictors of fistula repair outcomes 3 months postsurgery. METHODS We conducted a multicountry prospective cohort study between 2007 and 2010. Outcomes, measured 3 months postsurgery, included fistula closure and residual incontinence in women with a closed fistula. Potential predictors included patient and fistula characteristics and context of repair. Multivariable generalized estimating equation models were used to generate adjusted risk ratios (RRs) and 95% confidence intervals (CIs). RESULTS Women who returned for follow-up 3-month postsurgery were included in predictors of closure analyses (n=1,274). Small bladder size (adjusted RR 1.57, 95% CI 1.39-1.79), prior repair (adjusted RR 1.40, 95% CI 1.11-1.76), severe vaginal scarring (adjusted RR 1.56, 95% CI 1.20-2.04), partial urethral involvement (adjusted RR 1.36, 95% CI 1.11-1.66), and complete urethral destruction or circumferential defect (adjusted RR 1.72, 95% CI 1.33-2.23) predicted failed fistula closure. Women with a closed fistula at 3-month follow-up were included in predictors of residual incontinence analyses (n=1,041). Prior repair (adjusted RR 1.37, 95% CI 1.13-1.65), severe vaginal scarring (adjusted RR 1.35, 95% CI 1.10-1.67), partial urethral involvement (adjusted RR 1.78, 95% CI 1.27-2.48), and complete urethral destruction or circumferential defect (adjusted RR 2.06, 95% CI 1.51-2.81) were significantly associated with residual incontinence. CONCLUSION The prognosis for genital fistula closure is related to preoperative bladder size, previous repair, vaginal scarring, and urethral involvement.
Collapse
|
|
43
|
Frajzyngier V, Ruminjo J, Barone MA. Factors influencing urinary fistula repair outcomes in developing countries: a systematic review. Am J Obstet Gynecol 2012; 207:248-58. [PMID: 22475385 DOI: 10.1016/j.ajog.2012.02.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 02/03/2012] [Accepted: 02/13/2012] [Indexed: 10/28/2022]
Abstract
We reviewed literature examining predictors of urinary fistula repair outcomes in developing country settings, including fistula and patient characteristics, and perioperative factors. We searched Medline for articles published between January 1970 and December 2010, excluding articles that were (1) case reports, cases series or contained 20 or fewer subjects; (2) focused on fistula in developed countries; and (3) did not include a statistical analysis of the association between facility or individual-level factors and surgical outcomes. Twenty articles were included; 17 were observational studies. Surgical outcomes included fistula closure, residual incontinence after closure, and any incontinence (dry vs wet). Scarring and urethral involvement were associated with poor prognosis across all outcomes. Results from randomized controlled trials examining prophylactic antibiotic use and repair outcomes were inconclusive. Few observational studies examining perioperative interventions accounted for confounding by fistula severity. We conclude that a unified, standardized evidence-base for informing clinical practice is lacking.
Collapse
|
|
44
|
|
|
45
|
Munoz O, Bowling CB, Gerten KA, Taryor R, Norman AM, Szychowski JM, Richter HE. Factors Influencing Post-Operative Short-Term Outcomes of Vesicovaginal Fistula Repairs in a Community Hospital in Liberia. ACTA ACUST UNITED AC 2011; 4:259-265. [PMID: 22229049 DOI: 10.1016/j.bjmsu.2011.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES: To assess factors influencing short-term outcomes of vesicovaginal fistula (VVF) repairs in community-dwelling women of Liberia, Africa. METHODS: Forty patients who underwent VVF repairs were analyzed. Primary outcome was continence status at 14 days post repair. Factors influencing continence status were characterized. RESULTS: The mean duration of leakage was 9.6 ± 8.3 years, (3 months-28 years). Thirteen (33%) had previous repairs, and 6 (15%) had multiple fistula sites. Twenty-eight (70%) were continent at catheter removal. First time repairs had a higher continence rate compared to women with previous repairs, 78% and 54% respectively (p= 0.15). Seven (47%) juxtaurethral repairs were considered failures, while only one (9%) juxtacervical fistulas remained incontinent (p= 0.069). Controlling for duration of leakage, women with previous repairs were significantly less likely to be continent (p = 0.04; adjusted OR = 0.07; 95% CI: 0.005, 0.83). CONCLUSIONS: Patients with previous VVF repairs and juxtaurethral fistulae experience lower success rates; surgery remains an effective treatment for many VVF patients.
Collapse
Affiliation(s)
- Oxana Munoz
- Department of Surgery, Division of Urology, University of Alabama, Birmingham; Birmingham, AL
| | | | | | | | | | | | | |
Collapse
|
|
46
|
Abstract
PURPOSE OF REVIEW This review offers a comprehensive summary of the recent publications on the treatment of vesicovaginal fistula. Most reports are related to obstetric fistula in the developing world but in the developed world fistula treatment remains a challenge. RECENT FINDINGS The quality of the research in this field is improving. Efforts are being made to improve the classification of fistula as a prognostic tool. Surgical innovations are few in this field. Laparoscopic approaches are reported but only on a very limited amount of patients. SUMMARY The surgical management of fistula remains a two-track item: the gigantic experience on obstetric fistula of fistula surgeons in Africa and Asia and the limited experience of some Western centres with mostly a small series of iatrogenic fistula. Advances are made in both worlds. The previously isolated fistula surgeons are now better organized and they stimulate scientific research in countries with very limited resources. The centres in the developed world explore new surgical approaches such as laparoscopy and minimally invasive treatments.
Collapse
|
|
47
|
Joshi S, Bhalerao A, Somalwar S, Chaudhary S. A rare case of irreparable vesico-vaginal fistula of 45 years duration successfully managed by urinary diversion. J Midlife Health 2011; 2:37-9. [PMID: 21897738 PMCID: PMC3156500 DOI: 10.4103/0976-7800.83272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
In developing countries most of the fistulas occur as a catastrophic complication of obstructed labor in young women. Constant dribbling, wetness, and stink lead to social outcasting of patients of vesico-vaginal fistula (VVF) making their life miserable. In most of the cases, timely surgery taking all required precautions is successful. In small number of cases, fistula is irreparable. Under such circumstances urinary diversion helps. Very few cases are reported in literature, where patients have endured fistula for more than 40 years. A case report of a patient of VVF, who suffered for 45 years without seeking any treatment because of prevailing circumstances is presented here. The fistula was irreparable. Urinary diversion was the only option available. She was successfully managed by urinary diversion with an ileal conduit. Now patient is leading a contented life.
Collapse
Affiliation(s)
- Sulabha Joshi
- Departments of Obstetrics and Gynaecology, NKP Salve Institute of Medical Sciences, Nagpur, India
| | | | | | | |
Collapse
|
|
48
|
Sagna ML, Hoque N, Sunil T. Are some women more at risk of obstetric fistula in Uganda? Evidence from the Uganda Demographic and Health Survey. J Public Health Afr 2011; 2:e26. [PMID: 28299067 PMCID: PMC5345499 DOI: 10.4081/jphia.2011.e26] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 05/26/2011] [Indexed: 11/23/2022] Open
Abstract
With only four years left for the Millennium Development Goal's 2015 deadline for reducing poor maternal health outcomes, developing countries are still bearing a huge burden of maternal morbidity worldwide. Estimates show that over 2 million women worldwide are suffering from obstetric fistula, the majority of which live in sub-Saharan Africa, Southeast Asia, and the Arab region. The purpose of this study is to shed a light on obstetric fistula by examining risk factors associated with this morbidity in Uganda. Descriptive and multivariate analyses were conducted using data from the 2006 Uganda Demographic and Health Survey. Older age at first sexual intercourse was significantly associated with a lower risk of obstetric fistula (OR=0.302) compared to younger age at first intercourse (7–14 years). Lack of autonomy was negatively associated with the risk of obstetric fistula; women who have problems securing permission from their husband to go seek care (OR=1.658) were more likely to suffer from this morbidity. Significant differentials in obstetric fistula have also been observed based on the region of residence: women living in Central (OR=4.923), East Central (OR=3.603), West Nile (OR=2.049), and Southwest (1.846) more likely to suffer from obstetric fistula than women living in North Central. Findings demonstrate the importance of improving geographical accessibility to maternal health care services, and emphasize the need to reinforce intervention programs, which seek to address gender inequalities.
Collapse
Affiliation(s)
| | - Nazrul Hoque
- Department of Demography, University of Texas at San Antonio, Texas
| | - Thankam Sunil
- Department of Sociology, University of Texas at San Antonio, Texas, USA
| |
Collapse
|
|
49
|
Sjøveian S, Vangen S, Mukwege D, Onsrud M. Surgical outcome of obstetric fistula: a retrospective analysis of 595 patients. Acta Obstet Gynecol Scand 2011; 90:753-60. [PMID: 21542810 DOI: 10.1111/j.1600-0412.2011.01162.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of the study was to investigate obstetric fistula in terms of patient demographics, fistula characteristics and predictors of surgical outcome. DESIGN Retrospective cross-sectional study. SETTING Fistula referral hospital in eastern Democratic Republic of Congo. Population. Five hundred and ninety-five women receiving fistula repair from November 2005 to November 2007. METHODS Review of patient records for information on patient demographics, obstetric history, clinical data for index pregnancy, fistula characteristics and surgical information. Cross-tabulations and multivariate logistic regression models were used to predict surgical outcome. MAIN OUTCOME MEASURES Fistula closure and incontinence despite fistula closure. Results. 82.9% had developed fistula following obstructed labor, 17.1% after medical interventions of which 71.1% involved cesarean section or peripartum hysterectomy. Median age at fistula development was 23 years; 40.8% were primiparous and 43.2% were parity three or more. Women took a median of two years to seek treatment. Closure rate was 87.1%, with 15.6% remaining incontinent. Failure to close the fistula was significantly associated with previous repairs, amount of fibrosis and fistula size. Compared with primary repairs, the odds ratio of failure was almost five times greater for three or more repairs (odds ratio 4.7, 95% confidence interval 2.2-10.0). Incontinence was significantly associated with previous repairs, amount of fibrosis and fistula location. Compared with fistulas with a high location, the odds ratio of incontinence for low, circumferential fistulas was 6.3 (95% confidence interval 2.5-16.4). CONCLUSIONS Fistula in Democratic Republic of Congo was found in both primiparous and multiparous women, indicating a need for increased access to obstetric care for all pregnant women. Fistulas repaired for the first time, with no fibrosis and size <2 cm, had the best surgical outcome.
Collapse
Affiliation(s)
- Solbjørg Sjøveian
- Section for International Health, Institute of General Practice and Community Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | | | | |
Collapse
|
|
50
|
Capes T, Ascher-Walsh C, Abdoulaye I, Brodman M. Obstetric Fistula in Low and Middle Income Countries. ACTA ACUST UNITED AC 2011; 78:352-61. [DOI: 10.1002/msj.20265] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
|