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This study aimed to analyze factors associated with obstetric fistula care-seeking behavior in Guinea, based on data from the 2018 Demographic and Health Survey. Women aged 15-49 years who reported having obstetric fistula constituted the study population, statistical analysis was using Stata 16.0 software. Multivariate logistic regression was used to identify the factors associated with fistula care-seeking behavior. Among women with obstetric fistula, 78.9% sought care; 21.1% of those who sought care underwent repair. Factors associated with care-seeking behavior were being divorced (AOR =8.08; 95% CI:1.56-41.84), having a job (AOR =3.23; 95% CI: 1.11-9.44), being a member of a poor household (AOR =6.49; 95% CI:1.21-34.82) and whose fistula had appeared 6 days or more after the occurrence of the causal circumstance (AOR =3.63 95% CI: 1.28-10.28). This study suggests that the foundations on which fistula prevention and treatment programs are built should be reviewed, taking into account the factors highlighted by this study., Competing Interests: The Authors declared no conflict of interest, (African Journal of Reproductive Health © 2024.)

Background: Studies on fertility desires among fistula patients in the Democratic Republic of Congo (DRC) have been conducted on fewer patients. Furthermore, these studies have adopted a univariate descriptive approach. This study aims to examine the determinants of fertility desires among patients with fistula in the DRC., Methods: This cross-sectional study included women aged 15-49 whose fistulas were repaired by the Panzi Hospital mobile team in seven DRC regions between 2013 and 2018. Univariate and bivariate descriptive analyses were performed using the frequency distribution table and the chi-square test. Adjusted odds ratios with their 95 confidence intervals from logistic regression were used to analyze factors associated with fertility desire after fistula repair. All analyses were stratified by parity level for all women aged 15-49 and 20-34 years., Results: Of the 1,646 women aged 15-49 and 808 aged 20-34, 948 (57.6%) and 597 (73.8%), respectively, wanted to have children after fistula repair. Among women aged 15-49 and 20-34 years, the desire to have children was parity-specific. It was negatively associated with age at all parity levels. In women with low parity, the desire for children was significantly negatively associated with a high number of surgeries, abortions, and fistula duration. It tended to decrease with time, but was particularly high in 2014 and 2017. It was high among the Protestant women. Among medium-parity women, it was significantly lower in urban areas and among widows, but higher among women who had more than two abortions. Among high-parity women, it was negatively associated with education level., Conclusion: To help women with fistula achieve or approach their desired number of children, our findings suggest that (1) counseling is needed for women with a high desire for children; (2) the human, material, and financial resources needed to eliminate fistula in the DRC should be made available; and (3) medical and nursing staff should be sufficiently and effectively trained to minimize the number of unsuccessful surgeries performed on women with fistula., (© 2024. The Author(s).)

Introduction: With global cesarean section rates rising, there's concern about increase in obstetric vesico-uterine fistula (OVUF). Very little is known about this anatomoclinical entity of obstetric fistula in Africa in general and in DRC in particular. Our purpose was to describe the epidemiological, clinical, and therapeutic aspects of OVUF in the Democratic Republic of the Congo (DRC)., Methods: This was a descriptive cross-sectional study. Data were collected from patients who presented with OVUF across seven provinces of the DRC (North Kivu, Haut-Uélé, Kasai Central, Kwilu, Maniema, Nord-Ubangi and Sankuru) from January 2017 to December 2022. Study variables were epidemiological, clinical, and therapeutic features., Results: Of 1,267 patients presenting with obstetric fistulas, 355 (28.0%) had OVUF. The mean age was 32.9 ± 11.6 years, 80.6% of patients (286/355) lived in rural areas, and the majority had a low level of education (40% no formal education, 30.1% primary school, 28.7% secondary school). In total, 64.8% of patients were primiparous (230/355) and in all (100%) cases, OVUF was caused iatrogenically during cesarean delivery. Majority (76.3%) of patients laboured for one day or less (mean duration 1.0 ± 0.5 days) before giving birth, and the fetus died in 58.3% of cases. In 35.8% of cases, the fistula had lasted more than 10 years (mean age 10.1 ± 10.0 years) before repair. A proportion of 88.2% (n = 313) of OVUF was isolated while 11.3% (n = 40) was associated with a uretero-vaginal fistula. In 82.8% (n = 294) of cases the OVUF was single. The average fistula size was 2.4 ± 1.0 cm (range: 0.5 and 5.5 cm) and 274 (77.2%) fistulas measured between 1.5 and 3 cm, with 14.9% (n = 53) of them larger than 3 cm. Fibrosis was present in 65.1% of cases, cervical involvement was absent in 97.7% and post-operative complications were absent in 94.4%. In all cases, the OVUF was surgically repaired abdominally with a success rate of 97.5% (346/355)., Conclusion: The proportion of OVUF is relatively high in the DRC. Most affected patients were young, under-educated, primiparous women living in rural areas. Cesarean section was the sole identified cause of OVUF which was isolated, single, without fibrosis, in majority of cases. Abdominal repair of OVUF was very effective, with good results in almost all cases. Teaching young doctors working mainly in remote areas how to perform safe cesarean section is needed to reduce incidence of OVUF in DRC., (© 2024. The Author(s).)

Introduction: Urogenital fistula is a physically, socially and psychologically devastating condition for the patient. In developed countries, these fistulae are typically related to gynecological surgery, pelvic pathology like malignancy or post radiation therapy. In contrast, classical teaching is that urogenital fistulae in the developing countries like India are usually associated with prolonged labor and obstetric complications. This retrospective study conducted at a tertiary care health Institute shows a paradigm shift in epidemiology, etiology and management of genitourinary fistulae in India in recent times., Methods: This retrospective study included patients undergoing surgical repair for various genitourinary fistulae at our institute from 2016 to 2022. Epidemiology, etiology, site, size and number of fistulae, clinical presentation, and management records of these patients were recorded and reviewed retrospectively., Results: In our study, the mean age of the patients was 38.4 ± 10.2 years. Vesicovaginal Fistula (VVF) was found to be most common fistula in the study population (87.5%) followed by vesicouterine (7.1%) and urethrovaginal fistula (5.4%). The causes of genitourinary fistula were iatrogenic (73.2%), carcinoma of cervix (16.1%), obstructed prolonged labor (7.1%), and genitourinary tuberculosis (3.57%). Among the 48 vesicovaginal fistulas that underwent surgery, 45.8% were treated using a transvaginal approach, 29.2% were managed through a laparoscopic transabdominal repair, and 25% were addressed using a robotic approach. Recurrence occurred in 7.1% of the operated patients., Conclusion: Enhanced healthcare services in the country have contributed to a decrease in the incidence of obstructed labor, subsequently reducing related injuries. Iatrogenic injuries resulting from gynecological surgeries and carcinoma cervix have given rise to more complex fistulas, necessitating the implementation of advanced treatment strategies., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Our aim is to describe the epidemiological, anatomoclinical and therapeutic profile of obstetric fistula (OF) in the Democratic Republic of the Congo (DRC)., Methodology: This was a descriptive retrospective study that collected 1416 obstetric fistulas in 1267 patients in seven provinces of the DRC, treated between January 2017 and December 2022. The variables studied were epidemiological, anatomoclinical and therapeutic., Results: The mean age of patients at the time of surgical repair was 33.2 years (range: 15 and 77 years) and 32.8% of patients were aged between 20 and 29 years. The mean age of the fistula at repair was 10 years (range: 3.5 months and 56 years). At the time of fistula, 61.7% of patients had delivered vaginally and 28.7% by caesarean section and 8.2% of patients had a haemostasis hysterectomy. Labour lasted at least 3 days in 47.3% of these patients for the fistula birth. Deliveries took place either at home (27.4%) or in a health facility (72.6%); 83.6% of newborns resulting from these births had died. Taken as a whole, urogenital fistulas are more common than genito-digestive fistulas. Urethro-vaginal (26.2%) and vesico-uterine (24.7%) anatomoclinical entities were predominant among urogenital fistulas. A total of 1416 fistulas were surgically repaired in 1267 patients. These repairs were successful for 1226 (86.6%) fistulas. The main surgical route used was transvaginal (68.8%)., Conclusion: In the DRC, obstetric fistula is common in young adult women. It often results from vaginal delivery, after prolonged labour. Fistula births often result in the death of newborns. Uro-genital obstetric fistulas are the most frequent with predominance of urethro-vaginal and vesico-uterine anatomoclinical entities. Fistulas remain untreated for a long time. Mostly done transvaginally, surgical repair gives a good result., (© 2024 John Wiley & Sons Ltd.)

Purpose: Vesicovaginal fistulae (VVF) have a significant negative impact on quality of life, with failed surgical repair resulting in ongoing morbidity. Our aim was to characterize the rate of VVF repair and repair failures over time, and to identify predictors of repair failure., Methods: We completed a population-based, retrospective cohort study of all women who underwent VVF repair in Ontario, Canada, aged 18 and older between 2005 and 2018. Risk factors for repair failure were identified using multivariable cox proportional hazard analysis; interrupted time series analysis was used to determine change in VVF repair rate over time., Results: 814 patients underwent VVF repair. Of these, 117 required a second repair (14%). Mean age at surgery was 52 years (SD 15). Most patients had undergone prior gynecological surgery (68%), and 76% were due to iatrogenic injury. Most repairs were performed by urologists (60%). Predictors of VVF re-repair included iatrogenic injury etiology (HR 2.1, 95% CI 1.3-3.45, p = 0.009), and endoscopic repair (HR 6.1, 95% CI 3.1-11.1, p < 0.05,); protective factors included combined intra-abdominal/trans-vaginal repair (HR 0.51, 95% CI 0.3-0.8, p = 0.009), and surgeon years in practice (21 + years-HR 0.5, 95% CI 0.3-0.9, p = 0.005). Age adjusted annual rate of VVF repair (ranging from 0.8 to 1.58 per 100,000 women) and re-repair did not change over time., Conclusions: VVF repair and re-repair rates remained constant between 2005 and 2018. Iatrogenic injury and endoscopic repair predicted repair failure; combined intra-abdominal/trans-vaginal repair, and surgeon years in practice were protective. This suggests surgeon experience may protect against VVF repair failure., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Obstetric fistula repair failure can result in increased depression, social isolation, financial burden for the woman, and fistula care programs. However, there is limited, comprehensive evidence on obstetric fistula repair failure in Sub-Saharan African countries. This systematic review and meta-analysis aimed to determine the pooled prevalence of obstetric fistula repair failure and associated factors among women who underwent surgical repair in Sub-Saharan African countries., Methods: To identify potential articles, a systematic search was done utilizing online databases (PubMed, Hinari, and Google Scholar). The Preferred Reporting Items for Systematic Review and Meta-Analysis Statement (PRISMA) guideline was used to report the review's findings. I2 test statistics were employed to examine study heterogeneity. A random-effects model was used to assess the pooled prevalence of obstetric fistula repair failure, and the association was determined using the log odds ratio. Publication bias was investigated using the funnel plot and Egger's statistical test at the 5% level of significance. Meta-regression and subgroup analysis were done to identify potential sources of heterogeneity. The data were analyzed using STATA version 17 statistical software., Results: A total of 24 articles with 9866 study participants from 13 Sub-Saharan African countries were included in this meta-analysis. The pooled prevalence of obstetric fistula repair failure in sub-Saharan Africa was 24.92% [95% CI: 20.34-29.50%]. The sub-group analysis by country revealed that the highest prevalence was in Angola (58%, 95% CI: 53.20-62.80%) and the lowest in Rwanda (13.9, 95% CI: 9.79-18.01%). Total urethral damage [OR  =  3.50, 95% CI: 2.09, 4.91], large fistula [OR = 3.09, 95% CI: (2.00, 4.10)], duration of labor [OR = 0.45, 95% CI: 0.27, 0.76], and previous fistula repair [OR = 2.70, 95% CI: 1.94, 3.45] were factors associated with obstetric fistula repair failure., Conclusion: Women who received surgical treatment for obstetric fistulas in Sub-Saharan African countries experienced more repair failures than the WHO standards. Obstetric fistula repair failure was affected by urethral damage, fistula size, duration of labor, types of fistula, and history of previous repairs. Therefore, we suggest policy measures specific to each country to provide special attention to the prevention of all risk factors, including poor nutrition, multiparty, obstructed labor, and maternal age, which can result in conditions like large fistulas, urethral damage, and repeat repair, in order to reduce obstetric fistula repair failure., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Hareru et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background and Objectives: Vesicovaginal fistulas (VVFs) are an abnormal communication between the vagina and bladder and the most common type of acquired genital fistulas. This review will address the prevalence, impact, and management challenges of VVFs. Materials and Methods: Epidemiologic studies examining VVFs are considered. In addition, publications addressing the treatment of VVFs are reviewed. Results: VVFs in developing countries are often caused by obstructed labor, while most VVFs in developed countries have iatrogenic causes, such as hysterectomy, radiation therapy, and infection. The reported prevalence of VVFs is approximately 1 in 1000 post-hysterectomy patients and 1 in 1000 deliveries. VVFs affect every aspect of quality of life, including physical, mental, social, and sexual aspects. Prevention of VVFs is essential. Early diagnosis is necessary to reduce morbidity. Nutrition, infection control, and malignancy detection are important considerations during evaluation and treatment. Conservative and surgical treatment options are available; however, these approaches should be customized to the individual patient. The success rate of combined conservative and surgical treatments exceeds 90%. Conclusions: VVFs are considered debilitating and devastating. However, they are preventable and treatable; key factors include the avoidance of prolonged labor, careful performance of gynecologic surgery, and early detection.

Objectives: We aimed to report the background of patients with vesicovaginal fistulas (VVFs) at our center, which has treated a relatively large number of such patients in Japan, as well as the ingenuity and outcomes of vesicovaginal fistula closure (VVFC). We also investigated the causes of VVFs., Methods: A retrospective review was performed for 28 patients with VVFs treated at our center. Age, body mass index, etiology, site of fistula, and postoperative outcomes were investigated., Results: Twenty-one (75%) fistulas occurred following hysterectomy. The overall success rate of VVFC was 85.7%, and the success rate limited to the first attempt was 89.5%. In 68% of cases, no bladder injury suspected as the cause of VVF was noticed during the surgery. Energy devices were used in all 12 patients for whom information on the type of device used for hysterectomy was confirmed., Conclusions: To our knowledge, this is the first report to evaluate a relatively large number of VVFCs in Japan. Although VVF is thought to be caused by bladder injury during hysterectomy, delayed thermal damage might also result in this pathology, even if there is no apparent intraoperative bladder injury., (© 2023 The Authors. International Journal of Urology published by John Wiley & Sons Australia, Ltd on behalf of The Japanese Urological Association.)

Aim: To evaluate the epidemiological, etiological and evolutionary profile of vesico-vaginal fistulas (VVF) in university hospitals in Senegal., Patients and Method: This is a retrospective, descriptive, single-center study, collecting the records of patients followed for VVF between January 2014 and December 2019 at the Urology and Andrology Department of the Centre hospitalier universitaire Aristide Le Dantec, Dakar, Senegal. The following parameters were studied: age, geographical origin, parity, and etiology of VVF. To assess the evolution of the epidemiological and etiological profile of VVF, we compared our results with those of series published by our structure., Results: Forty-five (45) VVFs were identified over a period of 6 years. This represents an annual average of 7.5 fistulas. The average age was 40±15.13 years with extremes of 13 years and 75 years; 17 patients (37.8%) were older than 45 years. The average parity was 3 with extremes from 0 to 12 children. Multiparous women represented 68.8% of the patients. Obstetric VVF (OVF) was more frequent (48.9%) followed by iatrogenic VVF (33.3%). The mean age was higher in the IVF group compared to the VVF group (32 years) (P = 0.0004). Thirty patients were from the Dakar region and its suburbs (66.6%). The etiology of VVF did not vary according to the geographical origin of the patients (P=NS). VVF was frequently associated with the management of cervical cancer in 42.2% of cases. Comparison of our current data with previous series shows a reduction in the annual incidence of VVF. VVFs, although they have decreased significantly, are still predominant. There is a constant increase in the number of IVF., Conclusion: There is an evolution of the epidemiological and etiological profile marked by a decrease in the frequency of VVFs and an increase in that of IVFs. It is also worth noting the frequent association between cervical cancer and VVF., Level of Evidence: Level 4: retrospective study., (Copyright © 2023. Published by Elsevier Masson SAS.)

Introduction: Obstetric fistula (OF) remains a major public health problem in low-income countries. This study aimed to investigate the sociodemographic, clinical, and therapeutic characteristics of obstetric urogenital fistulas in a regional teaching hospital in Burkina Faso., Methods: a retrospective cross-sectional study from 1 st January 2015 to 31 st December 2019 included 50 women who underwent OF surgery repair in the regional teaching hospital of Ouahigouya in Burkina Faso. Case identification was completed by self-reported constant urine leakage and was confirmed by clinical assessment. Data on socio-demographic, clinical, and therapeutic characteristics have been collected from the hospital medical records and analyzed., Results: the mean age of the patients was 29.40 ± 9.4 years (range 15 -55 years). The majority of patients were in the age group between (15-25) years old (44%). Forty-three patients (86%) were residing in rural areas and forty-seven patients (94%) were housekeepers. Twenty-six patients (52%) were primiparous. The majority of patients had received no prenatal care 29 (58%). The majority of patients had a spontaneous vaginal delivery 36 (72%). The duration of labor was greater than 48 hours in 31 (62%) patients. Vesicovaginal fistulas (VVF) accounted for 80% of cases. Ten (20%) patients had previously undergone surgery for the same fistula. The mean size of the fistulas was 1.8±1.4 cm (range 0.5 - 6 cm). At three months of follow-up, the successful closure rate was 68%. Sixteen (32%) patients have experienced a failure of fistula closure., Conclusion: the majority of fistula survivors were women of reproductive age who were living in rural areas and housekeepers. Mothers having no antenatal care, and having prolonged labor were at increased risk of developing OF. The majority of fistulas were simple fistulas and the most common type of OF was VVF. Surgical outcomes showed a high failure rate., Competing Interests: The authors declare no competing interests., (Copyright: Tiéoulé Mamadou Traore et al.)

Background: The prevalence and impact of fistulas are more common in developing countries with limited access to emergency obstetric care. As a result, women in these settings often experience adverse psychosocial factors. The purpose of this study was to describe the characteristics of Congolese women who developed urogenital fistula following Cesarean sections (CS) to determine the characteristics associated with two etiologies: (1) prolonged obstructed labor; and (2) a complication of CS following obstructed labor., Methods: We performed a cross-sectional study on abstracted data from all patients with urogenital fistula following CS who received care during a surgical campaign in a remote area of the Democratic Republic of the Congo (DRC). Descriptive analyses characterized patients with fistula related to obstructed labor versus CS. Univariate and multivariate logistic regression models identified factors associated with obstetric fistula after cesarean delivery following obstructed labor. Variables were included in the logistic regression models based upon biological plausibility., Results: Among 125 patients, urogenital fistula etiology was attributed to obstructed labor in 77 (62%) and complications following CS in 48 (38%). Women with a fistula, attributed to obstructed labor, developed the fistula at a younger age (p = .04) and had a lower parity (p = .02). Attempted delivery before arriving at the hospital was associated with an increased risk of obstetric fistula after cesarean delivery following obstructed labor (p < .01)., Conclusion: CS are commonly performed on women who arrive at the hospital following prolonged obstructed labor and fetal demise, and account for almost 40% of urogenital fistula. Obstetric providers should assess maternal status upon arrival to prevent unnecessary CS and identify women at risk of developing a fistula., (© 2023. The Author(s).)

Introduction: In the Western world today, urogenital fistula, including vesicovaginal fistula (VVF), is rare. However, while it remains significant in developing parts of the world due to prolonged and obstructed labor, in this study, we systematically reviewed the existing literature, discussing VVF occurrence, its etiology, and outcomes., Material and Methods: We used electronic databases to search relevant articles from 2010-2020. The screening was performed with the help of Covidence. Relevant data from included studies were extracted in excel sheets, and final analysis was done using CMA-3 using proportion with 95% confidence interval (CI)., Results: Fifteen studies reported the VVF among the fistula series. The pooled result showed 76.57% cases of VVF (CI, 65.42-84.96), out of which 27.54% were trigonal, 55.70% supra-trigonal, and the rest with a varied description like circumferential, juxta-cervical, juxta-urethral. Obstetric etiology was commonly reported with 19.29% (CI, 13.26-27.21) with cesarean section and 31.14% (CI, 18.23-47.86) with obstructed labor. Hysterectomy was the commonly reported etiology among gynecological etiology (46.52%, CI; 36.17-57.19). Among different surgical treatments employed for fistula closure, 49.50% were by abdominal approach (CI, 37.23-61.82), and 42.31% by vaginal approach (CI, 31.82-53.54). Successful closure of fistula was reported in 87.09% of the surgeries (CI, 84.39-89.38)., Conclusion: The vesicovaginal fistula is the most common type of genitourinary fistula. Major causes of fistula are gynecological surgery, obstructed labor, and cesarean section. The vaginal approach and abdominal are common modalities of repair of fistula with favorable outcomes in the majority of the patients., (© 2021. Society for Reproductive Investigation.)

Objective: To assess function and disability among women in Rwanda and Democratic Republic of Congo living with fistula and identify characteristics associated with higher disability scores., Methods: Women presenting for fistula care were recruited. Eligible participants underwent a physical examination to classify fistula type and completed the WHO Disability Assessment Schedule 2.0 questionnaire to ascertain the impact of fistula on function across six domains: cognition, mobility, self-care, getting along, life activities, and participation. Disability scores were calculated (where 0 = no disability and 100 = complete disability). Participants were grouped according to no, low, or high disability status; results were examined to determine the domains most affected., Results: Among 69 participants, fistula type included: vesicovaginal (59.4%), ureterovaginal (14.5%), total absence of proximal urethra (11.6%), and rectovaginal (14.5%). Median disability score was 43.0/100 (interquartile range 26.0-67.0); 83% exhibited high disability status. Life activities and participation in society domains were most affected. Women with rectovaginal fistula reported the lowest scores, and those with total absence of proximal urethra reported the highest scores., Conclusion: WHO Disability Assessment Schedule 2.0 represents a simple, robust measure of global disability status, aligns with research efforts to estimate maternal disability, and may inform health needs and resource allocation for this population. In this study, disability was common, varied by fistula type, and affected physical, mental, and social domains., (© 2021 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Purpose: To evaluate the incidence of vesicovaginal fistula (VVF) in France., Methods: We conducted a retrospective analysis of prospectively and systematically collected data from January 2010 to December 2018 in the French Hospital Discharge Database. We used ICD-10 code "N820" to identify new VVF diagnoses. VVF incidence was calculated using estimations of the French population. We compared age on diagnosis, medical history of pelvic tumoral disease, radiotherapy, hysterectomy and childbirth, according to three subgroups: surgical repair attempt (SRA), long-term catheter and/or nephrostomies (LTC) or immediate surgical urinary diversion (ISUD). We focused on the patients diagnosed in 2017 to better analyse VVF aetiologies and outcomes (7-year hindsight and 1 year of follow-up). Chi-squared and Kruskal-Wallis tests were, respectively, used for qualitative and quantitative data comparisons., Results: Of the 196 million hospital stays out of 50 million French citizens hospitalised from 2010 to 2018, 5499 women were hospitalised for VVF. The estimated incidence of VVF was 2.3/100,000 women-year. Approximately half of the patients underwent SRA (48.4%); 39.8% had LTC and 11.9% had ISUD. Patients were younger in the SRA subgroup (53.4 ± 14.7 years p < 0.001) with a lower rate of pelvic cancer (p < 0.001) or radiotherapy (p < 0.001) and a higher rate of hysterectomies (p > 0.001). In 2017, two-thirds of the VVF diagnosed were secondary to pelvic surgery. Mean management time was 9.2 ± 10.6 months. After SRA, 5.4% underwent incontinence surgery and 5.0% underwent secondary surgical urinary diversion., Conclusions: VVF is not a rare pathology in France, mainly due to pelvic surgery. Its management is complex and not well defined., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To examine the ability of a previously published risk score to predict incontinence at discharge in women with vesicovaginal fistulas (VVF) and to examine how the score correlates with an independent assessment of surgical skill., Methods: This is a retrospective cohort study including cases from January to June 2018. We evaluated operative records for factors associated with incontinence at hospital discharge, as well as relationships between a risk score cut-point of 20 or more and surgical skill level. All women with VVF undergoing vaginal repair were included., Results: A total of 176 individuals underwent repair; 23 were performed by beginner, 85 by intermediate, 47 by advanced, and 21 by expert surgeons. Factors found significantly associated with incontinence at hospital discharge included Goh classification, fistula size, circumferential fistula, and vaginal scarring. A score of 20 or more predicted residual incontinence with a negative predictive value of 92% (odds ratio 7.75, 95% confidence interval 2.95-22.34). Applying the score cut-point of 20 or more, we found an increased proportion of "high-risk" cases allocated to surgeons with an increasing level of expertise., Conclusion: The correlation we observed between a risk score cut-point of 20 or more, continence status, and an independent assessment of surgical skill is promising. Although the risk score is not meant to replace clinical judgment, it may provide a surgical trainee with an objective method of determining whether to operate or refer for optimal outcomes., (© 2021 International Federation of Gynecology and Obstetrics.)

Objectives: This study aimed to compare the rates of major and minor complications for vesicovaginal fistula (VVF) repair based on surgeon specialty and to identify risk factors for adverse outcomes., Methods: This was a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program between the years 2014 and 2019. Cases were identified using Current Procedural Terminology codes for VVF repair. Minor and major complication rates for VVF repair were compared between 2 cohorts defined by surgeon specialty: gynecology versus urology. Additional outcomes included readmissions and reoperations. Multivariable logistic regression analysis was performed to investigate risk factors for complications., Results: A total of 319 VVF repairs were included in the analysis, of which 115 (36.1%) were performed by gynecologists and 204 (63.9%) by urologists. There were no significant differences in the demographic or medical characteristics between the gynecology and urology cohorts except for race. Gynecologists performed more concomitant hysterectomies (10.4% vs 1.0%, P < 0.001) and apical suspension procedures (6.1% vs 0%, P < 0.001). There were no differences in minor (7.8% vs 6.4%, P = 0.623) or major (2.6% vs 3.4%, P = 1.000) complications between the cohorts. The overall readmission rate was 4.7%, and the reoperation rate was 2.2% with no differences between specialties. On multivariable logistic regression analysis, body mass index and concurrent hysterectomy were risk factors for major or minor complications with no increased risk associated with surgeon specialty or route of surgery., Conclusions: Complication rates did not differ for VVF repairs performed by gynecologists compared with urologists. Readmission and reoperation rates were low for both groups., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2022 American Urogynecologic Society. All rights reserved.)

Introduction: Vesico-vaginal fistula (VVF) is a global healthcare problem that has a high prevalence in developing countries. The aim of this work is to study the epidemiological, clinical and therapeutic characteristics of VVF post-obstetric and gynecologic procedures in order to identify the predictive factors of surgical treatment failure., Methods: Data were collected from 132 VVF patients in our institution between 1985 and 2017. VVF was classified according to Zmerli's classification. Patients underwent surgical treatment and were evaluated after a follow-up period of 6 months. Successful treatment was defined as the absence of urine leakage whereas recurrence was defined as the presence of urine leakage immediately after the surgery or after a period of dryness with a confirmed VVF. Risk factors of surgical treatment failure were identified., Results: The average age of patients was 44 years. The patients were multiparous in 62% of cases. VVF was consecutive to hysterectomy in 62.1% of cases, and after childbirth in 34%. VVF was retro-trigonal in 99 cases (75%) and trigonal in 33 cases (25%). The average size of the fistula was 1cm (0.3-2cm). VVF repair was performed by vaginal approach in 68% of cases and abdominal approach in 32% of cases. Treatment failure was noted in 36 patients (27%). Predictive factors of treatment failure were: vaginal fibrosis (P<0.001); trigonal location of the fistula (P<0.001); large diameter of the VVF>1cm (P<0.001); and complex and complicated fistulas (P=0.02)., Conclusion: Although Tunisia is a developing country, the main cause of VVF was not obstetrical. Treatment failure, noted in almost one third of cases, was, in our series, correlated with the quality of the vaginal tissue, the size and the location of the fistula, and its complexity., Level of Proof: 4., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Objective: To compare the oncological outcomes and major complications of laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) for stage IB1 cervical cancer (FIGO 2009) with a tumour size less than 2 cm., Methods: We retrospectively compared the oncological outcomes and major complications of 1207 stage IB1 cervical cancer patients with a tumour size less than 2 cm who received LRH (n = 546) or ARH (n = 661) in 37 hospitals., Results: (1) There was no significant difference in 3-year overall survival (OS; 97.3% vs. 98.5%, P = 0.288) or 3-year disease-free survival (DFS; 95.1% vs. 95.4%, P = 0.792) between LRH (n = 546) and ARH (n = 661).(2) The rate of any 1 complication refers to the incidence of one or more complications in a patient, which was higher with LRH than ARH (OR = 4.047, 95% CI = 2.035-8.048, P < 0.001). Additionally, intraoperative complications occurred with LRH (OR = 12.313, 95% confidence intervals [CI] = 1.571-96.493, P = 0.017), and postoperative complications (OR = 3.652, 95% CI = 1.763-7.562, P < 0.001) were higher with LRH than ARH. The ureteral injury rate was higher with LRH than with ARH (1.50% vs. 0.20%, OR = 9.814, 95% CI = 1.224-78.712, P = 0.032). The ureterovaginal fistula rate was higher with LRH than ARH. The rates of obturator nerve injury, bladder injury, vesicovaginal fistula, rectovaginal fistula, venous thromboembolism, bowel obstruction, chylous leakage, pelvic haematoma, and haemorrhage were similar between the groups., Conclusions: The oncological outcomes of LRH and ARH for stage IB1 cervical cancer patients with a tumour size less than 2 cm do not differ significantly. However, incidences of any 1 complication, intraoperative complications, and postoperative complications were higher with LRH than ARH, with complications manifesting mainly as ureteral injury and uterovaginal fistula., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Introduction: Vesicovaginal fistula (VVF) has devastating effects on a woman's hygiene, self-esteem, interpersonal relationships, and environment disrupting all elements of her health. Despite VVF being a persistent condition, very few researches have been conducted in Nigeria to determine the quality of life (QoL) of these patients. This study was carried out with the aim of assessing the QoL of VVF patients receiving care in a repair center in Sokoto, Northwest Nigeria., Materials and Methods: This was cross-sectional study conducted at a VVF repair center in Sokoto. Study population comprised of patients who had undergone VVF repair at the health facility. The total number of study participants present at the facility was 81, and all were recruited into the study. The study assessed socio-demographics and QoL of the respondents. Data obtained were entered into IBM software package and subsequently analyzed. Level of significance was set at 5%., Results: The environmental domain had the highest mean score of 51.7 ± 11.8 while psychological domain had the least score of 41.3 ± 14.3. The mean overall QoL and general health were 49.5 ± 10.2. There was a moderate positive correlation between physical domain score and Age, (r = 0.258, P < 0.005). There was also a positive correlation between psychological domain score and Husband's educational status (r pb = 0.241, P < 0.05). Social relationship domain score positively correlated with being married (r pb = 0.414, P < 0.01)., Conclusion: Older study participants had higher mean scores for physical and psychological domains, while younger study participants had higher overall QoL and general health scores compared with older study participants. Future research should compare the pre and postoperative QoL of women who undergo repair of obstetric fistula., Competing Interests: None

The advent of Covid-19 pandemic adversely affected many programs worldwide, public health, including programming for obstetric fistula were not spared. Obstetric fistula is an abnormal connection between the vagina and the bladder or the rectum resulting from obstetric causes, mainly prolonged obstructed labour. Zimbabwe has two obstetric fistula repair centers. Because the program uses specialist surgeons from outside the country, the repairs are organized in quarterly camps with a target to repair 90 women per quarter. This study aimed at assessing the impact of restrictions on movement and gathering of people brought about by the Cocid-19 pandemic and to characterize participants of the camp which was held in the midst of the Covid-19 pandemic at Mashoko Hospital. Specifically it looked at how Covid-19 pandemic affected programming for obstetric fistula repair and characterized participants of the fistula camp held in November to December 2020 at one of the repair centers. A review of the dataset and surgical log sheets for the camp and national obstetric fistula dataset was conducted. Variables of interest were extracted onto an excel spreadsheet and analyzed for frequencies and proportions. Data were presented in charts, tables and narratives. The study noted that Covid-19 pandemic negatively affected performance of fistula repairs greatly with only 25 women repaired in 2020 as compared to 313 in 2019. Ninety women were called to come for repairs but 52 did not manage to attend due to reasons related to the restriction of the Covid-19 pandemic lockdown. Two thirds of those women suffered from urinary incontinence while the other third had fecal incontinence. The successful repair rate was 92%. This study concluded that the pandemic greatly affected programming of fistula repair in the country and recommended the Ministry of Health and Child Care to institute measures to resume programming as soon as the situation allows., Competing Interests: The authors declare that no competing interests exist.

Objective: To assess the characteristics of women presenting with genitourinary fistula over a 5-year period in Kigali, Rwanda. Genitourinary (GU) fistula is a devastating condition that can result from difficult vaginal deliveries or as a surgical complication. Rwanda has seen notable increases in cesarean section rates as a result of a successful universal health care system. It is unclear how the increase in cesarean section rates may influence the types of fistula diagnosed., Materials and Methods: A cross-sectional study was conducted of women presenting for evaluation to the International Organization for Women and Development in Kigali, Rwanda, between February 1, 2013 and October 31, 2017. Data were collected from medical records, including demographics, surgical history, physical exam findings, and surgical intervention., Results: Two thousand ninety-one women presented for evaluation during the study period, of these 630 (30%) were diagnosed with GU fistula. Of the fistula diagnosed, 392 (62%) were vesicovaginal fistula, 185 (29%) were vesicouterine or vesicocervical, and 56 (9%) were ureterovaginal fistula. The percent of GU fistula that involved the ureter, uterus, and/or cervix significantly increased over the time period: 29.6% in 2013, 34.6% in 2014; 43.0% in 2015, 42.9% in 2016, and 45.3% in 2017., Conclusion: There was a significant increase in the proportion of vesicouterine, vesicocervical, and ureterovaginal fistula presenting in Rwanda over the 5-year period, with the majority occurring after cesarean section., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The objective of this study is to determine the predictors for urinary retention after vesicovaginal fistula surgery., Methods: This was a retrospective case-control study of women who underwent vesicovaginal fistula repair between January 2014 and December 2017 at the Fistula Care Centre in Lilongwe, Malawi. Cases were defined as patients with documented urinary retention, defined as a postvoid residual that is 50% greater than the total void of at least 100 mL. The cases and controls were matched by the 3 components of the Goh classification system in a ratio of 1:5. Univariate analysis was used to detect differences between demographic, clinical characteristics, and operative techniques between cases and control. Logistic regression analysis was performed for estimation of odds ratios (ORs)., Results: There were no statistically significant differences between the 40 cases and 187 controls, when comparing age, gravidity, parity, body mass index, and length of postoperative catheterization. The median amount of postvoid residual noted at the time of diagnosis was 240 mL (range, 55-927 mL). Odds for urinary retention was 3 times higher among those with vertical closure than patients with horizontal closure of the bladder (OR, 2.91; 95% confidence interval, 1.35-6.20). Patients with prior fistula repairs were significantly less likely to develop urinary retention compared to those receiving surgery for the first time (OR, 0.27; 95% confidence interval, 0.10-0.67)., Conclusions: Vertical closure of the bladder and patients without a history of prior fistula repairs are predictors for developing urinary retention after fistula repair surgery., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Each year, between 50,000 and 100,000 women worldwide develop obstetric fistulae. Approximately 2 million girls across Asia and Africa are estimated to be affected by this condition. However, there is no reliable data on its prevalence in South-East Asia region (SEAR)., Objectives: The objective of this study is to systematically review and synthesize the data on the prevalence and management of obstetric fistula in SEAR., Methods: We searched for the literature that described the prevalence and management practices of obstetric fistula in SEAR. We followed the PRISMA guidelines to select the articles for the review. The quality and relevance were assessed by two reviewers independently using the SIGN checklist. A total of five articles and reports were selected for the review. To review the management practices, we found 63 original studies that were included in the review., Results: We found five community-based studies estimating the prevalence of obstetric fistula in SEAR; 3 studies were from India, one from Bangladesh and one from Nepal. The pooled prevalence according to self-reports was 1.11 (3 studies including 671,133 participants, 95% confidence interval [CI] 1.09, 1.14) per 100 women. The pooled prevalence of obstetric fistula based on the clinical examination was 0.10 (3 studies involving 4547 participants, 95% CI 0.01, 0.20) per 100 women. The value was close to the pooled estimate based on the smaller studies., Conclusion: More studies are needed to estimate reliable community-based prevalence data and also need to develop evidence-based management guidelines., Competing Interests: None

Background: To determine the causes of fistula and to share our experience in treating urogenital fistula and its surgical outcome., Methods: This was a retrospective study done at Kathmandu Model Hospital from January 2014 to June 2019 including 261 patients operated for fistula. The patients were analyzed for age, type of fistula, cause, treatment and surgical outcome., Results: Out of 261 patients operated, 59.38% cases had obstetric fistula, 38.69% had iatrogenic and 1.92% had traumatic fistula. Most of the patients with obstetric fistula were between 21 to 25 years of age whereas iatrogenic fistulae were between 46-50 years of age. The majority (54.84%) of obstetric fistulae were vesicovaginal fistula (54.84%) while the commonest type (77.36%) of iatrogenic fistula was vault fistula after abdominal hysterectomy., Conclusions: This study showed that obstructed and neglected labor was still the major cause of genitourinary fistula in Nepal nevertheless iatrogenic fistula following pelvic surgery is increasing. The surgical outcome of repair of fistula was good.

Objective: To describe epidemiologic, anatomic and clinical characteristics of urogenital and rectovaginal fistula and the issue of their surgical management in Togo., Material and Methods: A retrospective study permit us to collect the operated cases during five years in the national center of obstetrical fistula. The parameters evaluated were sociodemographic aspects of patients, clinical characteristics and the issue of surgical repair., Results: The number of patients who enderwent surgery was 197, during 217 surgical interventions. The middle age of patients was 40,7 years with extrems of 18 and 70 years. The main causes of fistula were obstetrical (95%) and 3,5% were caused by surgery. Concerning anatomoclinic characteristic, vesicovaginal fistula was the most comon type representing 87,3%, where vesicouterine fistula represented 4,1%. Multiparity has been a risk factor for obstetrical fistula and ceasarien section was necessary in 70% with a high rate of fœtal mortality (88,2%). Surgical management was late in majority of cases, estimated at 10 years between occurrence of fistula and its reparation. The recovry rate was 78,1%., Conclusion: Urogenital fistula are principaly caused by obstetric conditions in Togo and multiparity is a risk factor. Treatment is often late but has a good rate of recovery. Their prevention goes through the fight against dystocia., Level of Evidence: IV., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Objective: This study aimed to assess the risks of intraoperative and postoperative urologic complications between laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH)., Methods: Using the database of the National Health Insurance Service (NHIS) and Health Insurance Review & Assessment (HIRA), we identified all Korean women who underwent radical hysterectomy between 2006 and 2018. Intraoperative and postoperative urologic complications were compared between the ARH and LRH groups., Results: A total of 11,399 patients were identified to ARH and 8435 patients to LRH. Urologic complications occurred in 292 of 19,774 patients (1.48%) who underwent radical hysterectomy. LRH was associated with higher complication rates than ARH, although with a borderline significance (OR: 1.23; 90% CI: 1.02-1.51, p = 0.066). There was no difference in intraoperative urologic complications between the ARH and the LRH groups (OR: 1.1 95% CI: 0.86-1.43, p < 0.435). The incidence of postoperative urologic complications was significantly higher in the LRH group (OR: 2.01; 95% CI: 1.18-3.47, p = 0.009). In terms of postoperative urologic complications, the risk of ureterovaginal fistula was not significant between the two groups (OR: 1.53; 95% CI: 0.54-4.24, p = 0.403), whereas the risk of vesicovaginal fistula was significantly higher in the LRH group (OR: 2.24; 95% CI: 1.09-4.58, p = 0.028). There were no significant differences in the overall and urinary tract-specific complications between ARH and LRH in groups under 40 years of age and during the second half (2013-2018), with 2012 as the boundary., Conclusion: Among specific urologic complications, the incidence of vesicovaginal fistula was significantly higher in the LRH group than in the ARH group., Competing Interests: Declaration of competing interest There are no conflicts of interest relevant to this study., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: Obstetric vesicovaginal fistulae (VVFs) occur frequently as a result of childbirth in developing countries, but occurrence of VVFs in developed countries is rare and is generally observed after hysterectomy. Moreover, there are no reports regarding the effect of post-hysterectomy VVF repair on the patients' mental health in developed countries. Our study aimed to confirm the effect of post-hysterectomy VVF repair on Japanese iatrogenic VVF patients' mental health., Methods: A retrospective chart review was performed for 31 patients who underwent post-hysterectomy VVF repair. Each patient's urinary incontinence and mental state were evaluated using two questionnaires, the International Consultation on Incontinence Questionnaire-Short Form and the Hospital Anxiety and Depression Scale questionnaires, respectively, at baseline and at 3 or 6 months post-surgery. The Wilcoxon signed-rank test was used to compare the pre- and post-repair scores of each questionnaire, while McNemar's test was used to compare the pre- and post-repair proportions of patients with anxiety and depression., Results: Of the 31 patients, 13 (41.9%) underwent hysterectomy because of malignancies. All questionnaire scores showed significant improvement after VVF repair. The prevalence of clinical anxiety and depression decreased from 51.6% to 16.1% (P < 0.01) and from 51.6% to 12.9% (P < 0.01), respectively, after VVF repair, and urine leakage through fistulae was not observed in any patient after VVF repair., Conclusions: Our results suggest that iatrogenic VVF can have severe impacts on patients' mental health, but VVF repair can significantly improve it.

Many obstetric fistula patients remain untreated or present late to treatment despite increasing surgical availability in Uga nda. We explored women's perceptions of the cause of their obstetric fistula and their treatment seeking behaviours, including barriers and facilitators to timely care access. In-depth interviews and focus group discussions were conducted from June-August 2014 among 33 women treated for obstetric fistula at Mulago Hospital, Kampala. Data were analysed to describe dimensions and commonalities of themes identified under perceived causes and treatment seeking experiences, and their intersection. Perceived obstetric fistula causes included delays in deciding on hospital delivery, lengthy labour, injury caused by the baby, health worker incompetence, and traditional beliefs. Treatment seeking timing varied. Early treatment seeking was facilitated by awareness of treatment availability through referral, the media, community members, and support by partners and children. Barriers to early treatment seeking included inadequate financial and social support, erroneous perceptions about fistula causes and curability, incorrect diagnoses, and delayed or lack of care at health facilities. Our study supports broad educational and awareness activities, facilitation of social and financial support for accessing care, and improving the quality of emergency obstetric care and fistula treatment surgical capacity to reduce women's suffering.

Objective: To describe the frequency, causes and post-repair outcomes of NOF in hospitals supported by the Fistula Care Plus (FC+) project in the Democratic Republic of Congo., Methods: Retrospective cohort study from 1 January 2015 to 31 December 2017 in three FC + supported fistula repair sites., Results: Of 1984 women treated for female genital fistula between 2015 and 2017 in the three FC + supported hospitals, 384 (19%) were considered to be non-obstetric fistula (NOF) cases. 49.3% were married/in a relationship at the time of treatment vs. 69% before the fistula, P < 0.001. Type III (n = 247; 64.3%) and type I (n = 121; 31.5%) fistulas according to Kees/Waaldijk classification were the most common. The main causes of NOF were medical procedure (n = 305; 79.4%); of these, caesarean section (n = 234; 76.7%) and hysterectomy (n = 54; 17.7%) were the most common. At hospital discharge, the fistula was closed and dry in 353 women (95.7%)., Conclusion: Non-obstetric fistula, particularly due to iatrogenic causes, was relatively common in the DRC, calling for more prevention that includes improved quality of care in maternal health services., (© 2020 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.)

Objective: To 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., Design: A prospective cohort study., Setting: Fistula Care Centre in Malawi., Population: Women with an obstetric fistula., Methods: Baseline 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 Measures: Baseline creatinine and renal ultrasound findings., Results: Four 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., Conclusion: In 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 Abstract: Most patients with obstetric fistulas have normal renal function. Preoperative renal ultrasounds should be performed., (© 2020 Royal College of Obstetricians and Gynaecologists.)

Obstetric fistula (OF) remain a source of public health concern and one of the most devastating maternal morbidities afflicting about two million women, mostly in developing countries. It is still prevalent in Nigeria due to the existence of socio-cultural beliefs/practices, socio-economic state and poor health facilities. The country's estimated annual 40,000 pregnancy-related deaths account for about 14% of the global maternal mortality, placing it among the top 10 most dangerous countries in the world for a woman to give birth. However, maternal morbidities including OF account for 20 to 30 times the number of maternal mortalities. This review substantiates why OF is yet to be eliminated in Nigeria as one of the countries with the largest burden of obstetric fistula. There is need for coordinated response to prevent and eliminate this morbidity via political commitment, implementation of evidence-based policy and execution of prevention programs., Competing Interests: The authors declare no competing interests., (© Oladosu Akanbi Ojengbede et al.)

Objective: To evaluate the mode of delivery and stillbirth rates over time among women with obstetric fistula., Design: Retrospective record review., Setting: Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia and Ethiopia., Population: A total of 4396 women presenting with obstetric fistulas for repair who delivered previously in facilities between 1990 and 2014., Methods: Retrospective review of trends and associations between mode of delivery and stillbirth, focusing on caesarean section (CS), assisted vaginal deliveries and spontaneous vaginal deliveries., Main Outcome Measures: Mode of delivery, stillbirth., Results: Out of 4396 women with fistula, 3695 (84.1%) delivered a stillborn baby. Among mothers with fistula giving birth to a stillborn baby, the CS rate (overall 54.8%, 2027/3695) rose from 45% (162/361) in 1990-94 to 64% (331/514) in 2010-14. This increase occurred at the expense of assisted vaginal delivery (overall 18.3%, 676/3695), which declined from 32% (115/361) to 6% (31/514)., Conclusions: In Eastern and Central Africa, CS is increasingly performed on women with obstructed labour whose babies have already died in utero. Contrary to international recommendations, alternatives such as vacuum extraction, forceps and destructive delivery are decreasingly used. Unless uterine rupture is suspected, CS should be avoided in obstructed labour with intrauterine fetal death to avoid complications related to CS scars in subsequent pregnancies. Increasingly, women with obstetric fistula add a history of unnecessary CS to their already grim experiences of prolonged, obstructed labour and stillbirth., Tweetable Abstract: Caesarean section is increasingly performed in African women with stillbirth treated for obstetric fistula., (© 2019 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of 1 Royal College of Obstetricians and Gynaecologists.)

Background: Obstetric fistula is still common in low- and middle-income countries (LMIC) despite the on-going shift to increased facility deliveries in the same settings. The social behavioural circumstances in which fistula, as well as its consequences, still occur are poorly documented, particularly from the perspective of the experiences of women with obstetric fistula. This study sought to describe women's experiences of antenatal, partum and post-partum care in southern Mozambique, and to pinpoint those experiences that are unique to women with fistula in order to understand the care-seeking and care provision circumstances which could have been modified to avoid or mitigate the onset or consequences of fistula., Methods: This study took place in Maputo and Gaza provinces, southern Mozambique, in 2016-2017. Qualitative data were collected through in-depth interviews conducted with 14 women with positive diagnoses of fistula and an equal number of women without fistula. All interviews were audio-recorded and transcribed verbatim prior to thematic analysis using NVivo11., Results: Study participants had all attended antenatal care (ANC) visits and had prepared for a facility birth. Prolonged or obstructed labour, multiple referrals, and delays in receiving secondary and tertiary health care were common among the discourses of women with fistula. The term "fistula" was rarely known among participants, but the condition (referred to as "loss of water" or "illness of spillage") was recognised after being prompted on its signs and symptoms. Women with fistula were invariably aware of the links between fistula and poor birth assistance, in contrast with those without fistula, who blamed the condition on women's physiological and behavioural characteristics., Conclusion: Although women do seek antenatal and peri-partum care in health facilities, deficiencies and delays in birth assistance, referral and life-saving interventions were commonly reported by women with fistula. Furthermore, weaknesses in quality of care, not only in relation to prevention, but also the resolution of the damage, were evident. Quality improvement of birth care is necessary, both at primary and referral level. There is a need to increase awareness and develop guidelines for prevention, early detection and management of obstetric fistula, including early postpartum treatment, availability of fistula repair for complex cases, and rehabilitation, coupled with the promotion of community consciousness of the problem.

Objective: To describe components of the mobile surgical outreach (MSO) program as a model of care delivery for women with genital fistula; present program results; and discuss operational strengths and challenges., Methods: A retrospective observational study of routinely collected health data from women treated via the MSO program (2013-2018). The program was developed at Panzi Hospital in the Democratic Republic of Congo to meet the needs of women with fistula living in remote provinces, where travel is prohibited. It includes healthcare delivery, medico-surgical training, and community sensitization components., Results: The MSO team cared for 1517 women at 41 clinic sites across 18 provinces over the study period. Average age at presentation was 31 years (range, 1-81 years). Most women (n=1359, 89.6%) presented with vesicovaginal fistula. Most surgeries were successful, and few women reported residual incontinence postoperatively. Local teams were receptive and engaged in clinical skills training and public health education efforts., Conclusion: The MSO program addresses the backlog of patients awaiting fistula surgery and provides a template for a national strategic plan to treat and ultimately end fistula in DRC. It offers a patient-centered approach that brings medico-surgical care and psychosocial support to women with fistula in their own communities., (© 2020 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Objective: To analyze trends in iatrogenic urogenital fistula among patients admitted for fistula repair at the Pakistan Institute of Medical Sciences, Islamabad., Methods: In this longitudinal study, all patients who presented for fistula repair between 2006 and 2018 were included in the study. Patient data were collected on age, parity, and type and etiology of fistula, which was classified as ischemic or iatrogenic., Results: Of 634 fistula patients, 371 (58.5%) had iatrogenic fistula, while 263 (41.5%) patients developed ischemic fistula due to obstructed labor. Mean age of patients was 31.6 years. Yearly trends showed an increase in iatrogenic fistula from 43.2% in 2006-2008 to 71.4% in 2017-2018. The major etiological contributor to iatrogenic fistula was hysterectomy (52.5%), followed by cesarean hysterectomy (26.4%), and cesarean delivery (19.9%)., Conclusion: A rising trend in iatrogenic fistula was observed. This emphasizes the need for optimization of surgical approaches and surgical skills. Moreover, gynecologic surgeries should be restricted to authorized gynecologic surgeons., (© 2020 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Background: Obstetric fistula is among the most devastating maternal morbidities that occur as a result of prolonged, obstructed labor. Usually, the child dies in a large number of the cases. Moreover, some of the women become infertile while the majority suffer physical, psychosocial and economic challenges. Approximately 5000 new cases of obstetric fistula occur in Sudan each year. However, their experiences are under documented. Therefore, this study aimed to shed light on their daily lives living with obstetric fistula and how they cope., Methods: Using a qualitative study design, 19 women living with obstetric fistula were interviewed. The study took place in the fistula ward located in Khartoum hospital and the fistula re-integration center in Khartoum, Sudan. Thematic analysis approach was employed. Stigma and coping theories guided the data collection, analysis, and discussion of the findings., Findings: Women in our study suffered a challenging physical life due to leakage of urine. In addition, they encountered all forms of stigmatization. Women used both emotion-focused and problem-focused coping techniques to mitigate the consequences of obstetric fistula., Conclusion: The study findings underscore the importance of obstetric fistula prevention programs and the urgency of repair surgeries to alleviate women's suffering. Community sensitization, rehabilitation and re-integration of women back to their communities are also important strategies on their journey to wholeness.

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., (© 2019 International Federation of Gynecology and Obstetrics.)

Objectives: To report a large series of vesicovaginal fistula, and to assess the incidence of ureteric injury in association with vesicovaginal fistula., Methods: We retrospectively reviewed a prospective database of patients with vesicovaginal fistula referred to our center between 2004 and 2016. Data on patient demographics, fistula etiology, mode of repair, and any associated ureteric injury and its treatment were noted., Results: Overall, 116 patients (median age 49 years, range 23-88 years) were referred for management of vesicovaginal fistula during the study period. Four of these patients (3.4%) had associated ureteric injury, one of whom had bilateral injury. Ureteric obstruction alone was noted in two patients, ureterovaginal fistula alone in one patient, and bilateral ureteric obstruction and ureterovaginal fistula in one patient. All ureteric injuries were managed with simultaneous reimplantation into the bladder at the time of vesicovaginal fistula repair. Five patients had post-radiotherapy vesicovaginal fistula, and the remainder were post-surgical. Three patients with post-radiotherapy vesicovaginal fistula proceeded to primary diversion., Conclusions: Ureteric injury is far less common than previously reported, occurring in <5% of patients presenting with vesicovaginal fistula. It can be successfully managed, and it remains the major indication for abdominal repair of vesicovaginal fistula., (© 2019 The Japanese Urological Association.)

Objective: We evaluated residual incontinence, depression, and quality of life among Malawian women who had undergone vesicovaginal fistula (VVF) repair 12 or more months previously., Design: Prospective cohort study., Setting: Fistula Care Centre in Lilongwe, Malawi., Population: Women who had undergone VVF repair in Lilongwe, Malawi at least 12 months prior to enrolment., Methods: Self-report of urinary leakage was used to evaluate for residual urinary incontinence; depression was evaluated with the Patient Health Questionnaire-9; quality of life was evaluated with the King's Health Questionnaire., Main Outcome Measures: Prevalence and predictors of residual incontinence, quality of life scores, and prevalence of depression and suicidal ideation., Results: Fifty-six women (19.3%) reported residual urinary incontinence. In multivariable analyses, predictors of residual urinary incontinence included: pre-operative Goh type 3 [adjusted risk ratio (aRR) 2.82; 95% confidence interval (CI) 1.61-5.27) or Goh type 4 1.08-2.78), positive postoperative cough stress test (aRR = 2.42; 95% CI 1.24-4.71) and the positive 1-hour postoperative pad test (aRR = 2.20; 95% CI 1.08-4.48). Women with Goh types 3 and 4 VVF reported lower quality of life scores. Depressive symptoms were reported in 3.5% of women; all reported residual urinary incontinence., Conclusions: While the majority of women reported improved outcomes in the years following surgical VVF repair, those with residual urinary incontinence had a poorer quality of life. Services are needed to identify and treat this at-risk group., Tweetable Abstract: Nearly one in five women reported residual urinary incontinence at follow up, 12 or months after vesicovaginal fistula repair., (© 2018 Royal College of Obstetricians and Gynaecologists.)

Genitourinary fistula is a psychophysiosocial distress that results in prolonged labour. Gradually, it has become a public health issue globally with advancing of its incidence day by day. A handsome number of mothers are also suffering in Bangladesh from genitourinary fistula. This study was done to observe the patterns of presentations of genitourinary fistula and their fetal outcome. One hundred sixteen (116) consecutive patients were enrolled in the study by purposive sampling as a diagnosed case of genitourinary fistula presented in Department of Obstetrics & Gynecology of Dhaka Medical College Hospital, Dhaka, Bangladesh from January 2017 to September 2017. It was a prospective observational cross-sectional study. A pre-structured, interview and observation based, peer reviewed data collection sheet was prepared. Data regarding sociodemographic, clinical and Obstetrical profile were recorded. Statistical analysis was done with SPSS version 23. Data were presented as mean and standard deviation, frequency and percentage with range. The mean age of the respondents was 27.27±4.21 (age range: 20-35 years). The mean height of the respondents was 150.26±13.28cm (range: 133-172cm). Among 106 mothers 69(65.1%) and 25(23.6%) were primiparous and multiparous respectively. On the contrary, 5(4.7%) each were grand multiparous and experienced fistula due to non obstetrics complications like malignancy, hysterectomy and radiotherapy. Mothers had 1, 2 and 3 fistulas in 98(92.5%), 6(5.7%) and 2(1.9%) respectively. Among 106 mothers, 99(93.4%) experienced only urinary incontinence whereas 5(4.7%) experienced fecal incontinence. Only 2(1.9%) experienced both urinary and fecal incontinence. Maximum vesicovaginal fistula was due to obstructed labour (65.09%) which was subsequently followed by trauma (14.15%). Vesicovaginal fistula was the commonest type which was subsequently followed by vesicocervical fistula. Among 106 mothers, 73(68.9%) and 25(23.6%) gave birth, still birth and alive babies respectively. On the contrary, 4(3.7%) neonate experienced death in neonatal period whereas 1(0.9%) each twin deliveries resulted in 'one dead and one alive' and 'Twin alive' respectively. In case of only 3(2.8%) mothers 'no information' regarding fetal outcome could be recorded. Prolonged labour is the principal culprit to develop genitourinary fistulas among which VVF is the commonest variety. Still birth is the frequently evident fetal outcome in case of this clinical disaster of pregnancy.

Background: Schistosoma haematobium infection has been documented as an uncommon cause of vesicovaginal fistula (VVF) and can result in impaired wound healing of urogenital tissues. For these reasons, it could potentially be linked to an increased rate of obstetric fistula among women who experience obstructed labor and/or in a higher failure rate of fistula repair. Therefore, the primary objective of our study was to determine the prevalence of S. haematobium infection among women undergoing obstetric VVF repair in Lilongwe, Malawi. Our secondary objectives were to assess if S. haematobium infection could be a risk factor for obstetric fistula development or unsuccessful VVF repair in our patient population., Methods: From July to October 2013, we conducted S. haematobium testing via urine microscopy on 96 patients undergoing obstetric VVF repair surgery at the Fistula Care Centre in Lilongwe, Malawi., Results: The prevalence of S. haematobium infection among women undergoing obstetric VVF repair was 2% (n=2). Both women with S. haematobium had successful VVF repairs., Conclusions: Although S. haematobium has the potential to be a risk factor for obstetric VVF formation or unsuccessful VVF repair, it was uncommon among the women in our clinic with obstetric VVF., (© 2018 The College of Medicine and the Medical Association of Malawi.)

Kitovu Hospital in Masaka, Uganda, is a leading obstetric fistula repair centre in the country with the highest rates of fistula in the world. In this retrospective case review, the regional incidence and causative factors were studied in patients with vesicovaginal fistula (VVF) who were admitted at Kitovu Hospital. Fistula history included severity (ICIQ score), causes and outcomes of VVF were measured. Women suffered with symptoms of VVF for an average of 4.97 years with an average ICIQ severity score of 7.21. Patients travelled an average distance of 153 km and the majority travelled by public transport. Rates of prolonged labour were high. 69% of fistula-causing delivery resulted in stillbirth and 12% resulted in early neonatal death. Following surgery, 94% of patients were dry on discharge. Impact statement What is already known on this subject? Vesicovaginal fistula (VVF) is a severe, life-changing injury. Although largely eradicated from the Western world thanks to modern obstetric practice, VVF is still highly prevalent in developing countries where factors such as young childbearing age and poor access to emergency obstetric care increase the incidence (Wall et al. 2005 ). At the current rate of fistula repair, it is estimated that it would take 400 years to treat those already suffering with fistula, providing that no new cases emerged (Browning and Patel 2004 ). What do the results of this study add? The Ugandan women in this study reiterate tales of foetal loss, social isolation and epic journeys in search of fistula repair, as previously described in the literature. The study offers some hope for prompt help-seeking during labour and after fistulas are developed. It demonstrates the success of fistula repairs at Kitovu Hospital but highlights the paucity of service provision across Uganda. What are the implications of these findings for clinical practice and/or further research? Further epidemiological research is required to quantify the true burden of the disease. Only by raising the profile of VVF in both developing and developed countries, can there be a collaborative effort to make universal change. To embark upon the prevention and cure of the disease it is necessary to continue tackling issues of poverty and gender inequality.

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.

Obstetric fistulas are a major public health problem in poor countries. This study aimed to describe the epidemiological, clinical and therapeutic features of obstetric fistulas in northern Katanga province, Democratic Republic of the Congo. We conducted a descriptive cross-sectional study of 242 patients with obstetric fistula living in northern Katanga province from September 2009 to December 2013. The parameters studied included maternal sociodemographic data, obstetric and neonatal parameters, specific features of the fistula as well as management approach and outcome. Variables were analyzed using Epi Info 7.1 software. Out of 242 patients with obstetric fistula, 229 (95%) patients delivered vaginally and among them 74.6% delivered at home. In 93,4% of cases the new-born died in the perinatal period. The average age of patients was 27.9 ± 10.3 years. One out of six patients had less than 20 years and in general almost 1 out of 2 patients had less than 25 years. Seven out of ten patients had a parity of less than 3 and the average parity was 2.5±2.0. Ninety percent of patients had a low educational level and 95% lived alone. The patients had, on average, a history of fistula of more than 4.7±4.4 years, it was a vesico-vaginal fistula (96%) type 2-3 (37%) and it was repaired using a transvaginal approach (67%). The average failure rate was 14%. Obstetric fistula is a real public health problem in our environment and it deserves further consideration to be eradicated.

Introduction and Hypothesis: We tested the null hypothesis that there were no differences between patients with obstetric fistula and parous controls without fistula., Methods: A unmatched case-control study was carried out comparing 75 women with a history of obstetric fistula with 150 parous controls with no history of fistula. Height and weight were measured for each participant, along with basic socio-demographic and obstetric information. Descriptive statistics were calculated and differences between the groups were analyzed using Student's t test, Mann-Whitney U test where appropriate, and Chi-squared or Fisher's exact test, along with backward stepwise logistic regression analyses to detect predictors of obstetric fistula. Associations with a p value <0.05 were considered significant., Results: Patients with fistulas married earlier and delivered their first pregnancies earlier than controls. They had significantly less education, a higher prevalence of divorce/separation, and lived in more impoverished circumstances than controls. Fistula patients had worse reproductive histories, with greater numbers of stillbirths/abortions and higher rates of assisted vaginal delivery and cesarean section. The final logistic regression model found four significant risk factors for developing an obstetric fistula: age at marriage (OR 1.23), history of assisted vaginal delivery (OR 3.44), lack of adequate antenatal care (OR 4.43), and a labor lasting longer than 1 day (OR 14.84)., Conclusions: Our data indicate that obstetric fistula results from the lack of access to effective obstetrical services when labor is prolonged. Rural poverty and lack of adequate transportation infrastructure are probably important co-factors in inhibiting access to needed care.

Background: Obstetric fistula is one of the most devastating consequences of unmet needs in obstetric services. Systematic reviews suggest that the pooled incidence of fistulae in community-based studies is 0.09 per 1000 recently pregnant women; however, as facility delivery is increasing, for the most part, in Africa, incidence of fistula should decrease. Few population-based studies on fistulae have been undertaken in Sub-Saharan Africa, including Mozambique. This study aimed to estimate the incidence of obstetric fistulae in recently delivered mothers, and to describe the clinical characteristics and care, as well as the outcome, after surgical repair., Methods: We selected women who had delivered up to 12 months before the start of the study (June, 1st 2016). They were part of a cohort of women of reproductive age (12-49 years), recruited from selected clusters in rural areas of Maputo and Gaza provinces, Southern Mozambique, who were participating in an intervention trial (the Community Level Interventions for Pre-eclampsia trial or CLIP trial). Case identification was completed by self-reported constant urine leakage and was confirmed by clinical assessment. Women who had confirmed obstetric fistulae were referred for surgical repair. Data were entered into a REDCap database and analysed using R software., Results: Five women with obstetric fistulae were detected among 4358 interviewed, giving an incidence of 1.1 per 1000 recently pregnant women (95% CI 2.16-0.14). All but one had Caesarean section and all of the babies died. Four were stillborn, and one died very soon after birth. All of the patients identified and reached the primary health facility in reasonable time. Delays occurred in the care: in diagnosis of obstructed labour, and in the decision to refer to the secondary or third-level hospital. All but one of the women were referred to surgical repair and the fistulae successfully closed., Conclusion: This population-based study reports a high incidence of obstetric fistulae in an area with high numbers of facility births. Few first and second delays in reaching care, but many third delays in receiving care, were identified. This raises concerns for quality of care.

Background: Obstetric Fistula is a childbirth injury that disproportionately affects women in sub-Saharan Africa. Although poverty plays an important role in perpetuating obstetric fistula, sociocultural practices has a significant influence on susceptibility to the condition., Aim: This paper aims to explore narratives in the literature on obstetric fistula in the context of Hausa ethno-lingual community of Northern Nigeria and the potential role of nurses and midwives in addressing obstetric fistula., Discussion: Three major cultural practices predispose Hausa women to obstetric fistula: early marriages and early child bearing; unskilled birth attendance and female circumcision and sociocultural constraints to healthcare access for women during childbirth. There is a failure to implement the International rights of the girl child in Nigeria which makes early child marriage persist. The Hausa tradition constrains the decision making power of women for seeking health care during childbirth. In addition, there is a shortage of nurses and midwives to provide healthcare service to women during childbirth., Conclusion: To improve health access for women, there is a need to increase political commitment and budget for health human resource distribution to underserved areas in the Hausa community. There is also a need to advance power and voice of women to resist oppressive traditions and to provide them with empowerment opportunities to improve their social status. The practice of traditional birth attendants can be regulated and the primary health care services strengthened., (Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Objective: To compare outcomes following surgical repair of genital fistula among Nigerian women with or without HIV., Methods: A retrospective review was conducted of all genital fistula repair surgeries performed at Evangel Vesicovaginal Fistula Center in Jos, Nigeria, between January 1, 2004, and April 30, 2014. Patient characteristics, HIV status, genital fistula characteristics, and postoperative outcomes were assessed for between-group variance. The odds ratio (OR) and 95% confidence intervals (CIs) were the primary measures used for determining the association between HIV status and surgical outcomes., Results: Of the 3313 surgeries recorded, 201 (6.1%) were performed among patients with HIV infection. No statistically significant between-group differences were found for patient or fistula characteristics. By contrast, failed vesicovaginal failure (VVF) closure was significantly more common among women infected with HIV than among their HIV-negative counterparts (OR 0.629, 95% CI 0.443-0.894). No between-group differences in failure rates were found for ureterovaginal or rectovaginal fistulas., Conclusion: Determining HIV status before surgery could aid prediction of outcomes among Nigerian women undergoing repair of VVF. Further studies are required to examine factors that might improve outcomes for women with HIV infection., (© 2017 International Federation of Gynecology and Obstetrics.)