Determinants of Outcomes and Prognosis Score in Obstetric Vesico-Vaginal Fistula Repair

Abstract

An estimated 2 million women living in countries with limited resources currently have vesico-vaginal, recto-vaginal, or mixed types of fistulae because of the necrosis that occurs with obstructed labor. We evaluated factors readily assessed by the examining practitioner in a consecutive case series of surgical repairs of obstetrical fistulae, for the ability of those factors to stand as a prognostic guide, in a clinical score. Objectives: To identify the predictors of surgical repair outcomes and establish a Score combining these different determinants to facilitate the care of obstetric fistula. Methods: We conducted a multicentric prospective study between 2011 and 2014 in Democratic Republic of the Congo (DRC). Outcomes: We measured 3 months post-surgery in a series of 483 patients with obstetrical fistula repaired by the same surgeon included closure and failure appreciated by dye test. Multivariable generalized estimating equation models were used to generate adjusted odd ratios (OR) and 95% confidence intervals (CIs). The scores ranging from 3 to 14 were established from the outcomes determinants identified. Results: In total, 483 women were enrolled, and 390 cases were at their first surgery and were included in the obstetric fistula (OF) prognosis score and classification. Their mean age was 35 years at the time of the surgery and 25 years at the onset of OF. In 28.6%, the fistula patient was primigravida. Mean duration between onset of the fistula and surgical treatment was 8 years. In 24%, the fistula patients lived separated from their partners. Overall closure rate of the fistulas was 85.7%. Severe vaginal fibrosis (p < 0.01), big fistula size (<0.01), small distance from fistula to external urethral meatus (<0.01) and prior surgery (p < 0.48) predicted failed fistula closure. A clinical score ranging from 3 to 14 points is a prognostic score with a range of 1 to 4 for the distance between the fistula and the external meatus and the size, and a scale of 1 to 6 for fibrosis. 768Conclusions: This study demonstrated that the marked vaginal scarring; large fistula size and distance to urethral meatus are predictors for unsuccessful fistula repair. Due to the lack of a standard classification that is never unanimous among the different surgeons, this prognostic score allows the combination of the different determinants assessing the chances of success and can help the practitioners to orient the patients towards the determined skill scale to take care of the patients.

Obstetric vesico‐vaginal fistulas: Midvaginal and juxtacervical fistula repair outcomes in the Democratic Republic of Congo

“…Our postoperative success rates are slightly higher when compared with similar studies performed in the region 11–14 . The most comparable study to ours was conducted by Mubikayi et al 11 in the DRC and reported an overall 85.7% success rate for VVF repairs. Although the number of women included (n = 483), the sociodemographic variables, and geographical location of repair were all similar, the 10% lower postoperative success rate is most likely explained by several factors.…”

“…Generally, it can be expected that midvaginal VVF will have better postoperative outcomes when compared with juxtacervical VVF, owing mostly to their superior accessibility 10 . Our postoperative success rates are slightly higher when compared with similar studies performed in the region 11–14 . The most comparable study to ours was conducted by Mubikayi et al 11 in the DRC and reported an overall 85.7% success rate for VVF repairs.…”

“…Although the number of women included (n = 483), the sociodemographic variables, and geographical location of repair were all similar, the 10% lower postoperative success rate is most likely explained by several factors. First, the Mubikayi et al 11 study included a small cohort of rectovaginal fistulas and patients undergoing repeat surgical repair, which were both excluded from our study. Second, a 3‐month postoperative follow‐up period was used for their study whereas ours was only 2 weeks.…”

Magnitude of repair failure and associated factors among women undergone obstetric fistula repair in Bahir Dar Hamlin Fistula Center, Amhara Region, Northwest Ethiopia

“…This finding was higher than other studies conducted in different study areas like: Democratic Republic of the Congo (24%), Guinea (14.5%), Zambia (27.1%), Yirgalem of Ethiopia (18.3%). 2,13,20,21 The reason for the higher rate of repair failure might be because of the differences in diagnostic accuracy, evaluation and timely repair using procedures that exploit basic surgical principles and the application of interposition flaps. 22,23 Weight of women during repairing was the factor for OF repair failure.…”

“…This finding was also supported by other studies in different areas. 20,21,28 Among fistula repairing women who developed postoperative infection were almost 3 times more likely to experience fistula repairing failure than their counterparts. This finding was in agreement with previous studies.…”