Predictors and outcome of surgical repair of obstetric fistula at a regional referral hospital, Mbarara, western Uganda

Abstract

BackgroundObstetric fistula although virtually eliminated in high income countries, still remains a prevalent and debilitating condition in many parts of the developing world. It occurs in areas where access to care at childbirth is limited, or of poor quality and where few hospitals offer the necessary corrective surgery.MethodsThis was a prospective observational study where all women who attended Mbarara Regional Referral Hospital in western Uganda with obstetric fistula during the study period were assessed pre-operatively for social demographics, fistula characteristics, classification and outcomes after surgery. Assessment for fistula closure and stress incontinence after surgery was done using a dye test before dischargeResultsOf the 77 women who were recruited in this study, 60 (77.9%) had successful closure of their fistulae. Unsuccessful fistula closure was significantly associated with large fistula size (Odds Ratio 6 95% Confidential interval 1.46-24.63), circumferential fistulae (Odds ratio 9.33 95% Confidential interval 2.23-39.12) and moderate to severe vaginal scarring (Odds ratio 12.24 95% Confidential interval 1.52-98.30). Vaginal scarring was the only factor independently associated with unsuccessful fistula repair (Odds ratio 10 95% confidential interval 1.12-100.57). Residual stress incontinence after successful fistula closure was associated with type IIb fistulae (Odds ratio 5.56 95% Confidential interval 1.34-23.02), circumferential fistulae (Odds ratio 10.5 95% Confidential interval 1.39-79.13) and previous unsuccessful fistula repair (Odds ratio 4.8 95% Confidential interval 1.27-18.11). Independent predictors for residual stress incontinence after successful fistula closure were urethral involvement (Odds Ratio 4.024 95% Confidential interval 2.77-5.83) and previous unsuccessful fistula repair (Odds ratio 38.69 95% Confidential interval 2.13-703.88).ConclusionsThis study demonstrated that large fistula size, circumferential fistulae and marked vaginal scarring are predictors for unsuccessful fistula repair while predictors for residual stress incontinence after successful fistula closure were urethral involvement, circumferential fistulae and previous unsuccessful fistula repair.

Residual urinary Incontinence after Successful Repair of Obstetric Fistula

“…7,9-12 Our results provide further evidence supporting the role of vaginal scarring and urethral involvement in predicting failure to close the fistula and residual incontinence following fistula closure. 5,7,8,10,12,13 They also support the smaller number of studies suggesting a negative prognostic role of bladder size and prior repair .6,7,12,13 So risk factors identified were involvement of the urethra, a small functional bladder capacity, increasing diameter of the fistula and the need for vaginal reconstruction. It is interesting to note that delivery method seemed protective for developing residual incontinence after fistula repair.…”

“…A number of papers have described surgical interventions, but often with much less success than that enjoyed in women without fistulas. [4][5][6][7] We found, as others have 8,9 no relationship between fistula size and successful closure after repair surgery. It is plausible that fistula size, independent of other factors, is not a predictor of repair outcome because even large defects can be surgically closed, whereas other factors such as prior repair or severe scarring (that may reduce the amount of viable tissue), or urethral involvement (that may affect sphincter mechanisms), cannot be easily addressed surgically.…”

High loss to follow-up following obstetric fistula repair surgery in rural Burundi: is there a way forward?

“…First, the conventional approach until now has been to report fi stula treatment outcomes at the time of hospital discharge only, and not beyond this time. Such outcomes are generally reported to be good, with fi stula closure rates of 73-93% reported from various other African settings, [13][14][15][16][17] compared to 87% in our setting. However, repair breakdowns are known to occur in the 6-month post-operative period, 8 invalidating these hospital discharge outcomes.…”

Factors Influencing Repair Outcomes of Vesicovaginal Fistula: A Retrospective Review of 139 Procedures

“…To solve this problem, the key is to decide which patient or fistula characteristics should be included in the classification system. Prior studies indicated that fistula repair outcomes were determined by certain fistula characteristics, such as fistula site, fistula size and degree of perifistula scarring [14][15][16][17] . Ayed et al [14] demonstrated that multiple fistula, fistula size and type and obstetrical etiology were associated with recurrent fistulas.…”