Objective: To measure depression over time using the Patient Health Questionnaire 9 (PHQ-9) and identify characteristics associated with persistent depression. Methods:A database of women undergoing obstetric fistula repair was used to examine associations between depression and variables such as demographics, type of fistula, and postoperative continence status. Results:A total of 797 patients completed the PHQ-9 at the initial preoperative assessment; 365 (45.8%) had a PHQ-9 score of 5 or higher, indicating depression.Preoperatively, depression was associated with women aged 18-34 years, with no children, and with fistula for 5 years or less. Postoperatively, depression was associated with persistent incontinence. Over time, however, depression was rarely found among women returning for follow-up. Conclusion:Postoperative depression decreased over time in women who returned for follow-up, either due to selection bias or due to improved adjustment to one's circumstances. This study underscores the need for ongoing follow-up, especially for those not presenting for care or with persistent incontinence.
ObjectiveTo describe and compare baseline renal anatomy and renal function in patients with obstetric fistulas, and to evaluate whether preoperative renal testing and imaging may aid with operative decision making.DesignA prospective cohort study.SettingFistula Care Centre in Malawi.PopulationWomen with an obstetric fistula.MethodsBaseline creatinine testing and renal ultrasounds were performed. Surgeons completed a short questionnaire on the usefulness of creatinine and renal ultrasound on operative decision making.Main outcome measuresBaseline creatinine and renal ultrasound findings.ResultsFour surgeons performed operations on 85 patients. The mean creatinine in patients with vesicovaginal fistulas (VVF) was 0.60 ng/ml versus patients with uretero‐vaginal fistulas (UVF) (0.79 ng/ml, P = 0.012). When a grade 3 or more hydronephrosis is absent on renal ultrasound, the negative predictive value of the presence of UVF is 93.3% (95% confidence interval [CI] 88.6–96.2) with a specificity of 97.2% (95% CI 90.3–99.6). In cases of UVF, surgeons found the renal ultrasound results useful or very useful 87.5% of the time, and the creatinine useful or very useful 75% of the time.ConclusionIn this pilot study, most patients with obstetric fistulas presented with a normal creatinine. In the absence of a grade 3 hydronephrosis or above on renal ultrasound, the probability of not having a UVF is 93.3%. Surgeons should consider performing preoperative renal ultrasound testing in all patients with an obstetric fistula, particularly in women with a prior laparotomy, as this population has risk factors for ureterovaginal fistula.Tweetable abstractMost patients with obstetric fistulas have normal renal function. Preoperative renal ultrasounds should be performed.
Background: As part of a larger study on the outcomes of obstetric fistula surgery, a review on patient outcomes when using gracilis muscle and/or Singapore flaps was conducted. Methods: The database queried includes over 1700 patients. Fifty-five cases were identified having had either a gracilis muscle and or a Singapore flap as part of the repair. Results: Twenty-one patients had a Singapore flap only. Median age was 26 years (19-55), four had one prior repair and two had two prior repair attempts. Nine cases were Goh type 3 and nine were Goh type 4 indicating urethral involvement. 71% (n=15) were >3 centimeters in diameter. Median estimated blood loss (ebl) was 200 ml and average OR time was 2.5 hours. Median catheter duration 17 days (13-25). 81% (n=17) were dye test negative, with an average pad weight of 19.2 grams. 19 patients had a gracilis muscle flap alone with median age of 43 (23-70). Four had one previous repair, one had four previous repairs. Nine were Goh type 3 and eight were Goh type 4. 70% (n=12) had a fistula >3 cm in diameter and 88% (n=15) had type iii considerations (previous repair attempt, circumferential, or severe scarring). Median ebl was 250 ml and average operative time was two hours and 30 minutes. Median catheter duration was 17 days (14-31). 82% (n=14) had negative dye tests, with average pad weight of 19 grams. 16 patients had both a Singapore and a gracilis. Median age was 31 (15-70), nine were Goh type 3, seven were Goh type 4. 87.5% (n=14) had a fistula that was more than 3 cm in diameter and 87.5% (n=14) were type iii. Median ebl was 300 ml (250-1000 ml), and average operative time was 3 hours and 45 minutes. 81% (n=13) had a negative dye test, with two patients going home positive and returning negative over the course of four months. Average pad weight was 18.9 grams. Conclusion: For large fistulas with a significant amount of vaginal tissue loss, the Singapore flap is a potential option for improved outcomes. For recurrent cases and those with poor quality tissue, the gracilis muscle may lead to overall improved outcomes. Overall, these techniques are useful for complex obstetric fistula cases where outcomes are generally less favorable. Further prospective studies are needed.
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