V1-03: Management of obstetric fistulae in Sub-saharan Africa
VideoIntroductions and Objectives
Obstetric fistulae occur due to the pressure necrosis caused by prolonged labor and insufficient obstetric care. Familial and social isolation are major consequences. The management of obstetric fistulae is complicated and depends on available medical facilities and sociocultural perceptions in the individual setting. We present our experience with the management of obstetric fistulae.
Data of 46 women treated in a fistula clinic in Niger between 2012 and 2013 were reviewed. 18 were primary cases, 28 were treated for recurrent fistula or persistent incontinence after closure. Vesicovaginal (VVF), urethrovaginal (UVF), rectovaginal (RVF), and ureterovaginal (URVF) fistula was present in 19, 10, 2, and 3 women, respectively. One patient had concomitant UVF+RVF. All cases were operated under spinal anesthesia due to poor general anesthesia facilities. After circumferential incision of the fistula tract, the plane between vaginal mucosa and bladder/rectum wall was disected. In the case of trigonal involvement, circumferential incision was carried out 0.5-1 cm more exterior to the fistula tract after catheterization of ureteral orifices under direct vision from the vagina. After generous mobilization, bladder/rectum wall was closed with running 2/0 vicryl sutures. Vaginal wall was closed primarily following check for leakage with intravesical methylene blue instillation. Urethral catheteter was kept for 2-3 weeks.
Mean patient age was 27.5 (16-47) years. A total of 53 procedures were performed on 46 women. Fistula diameter ranged from 1 to 7 cm. in VVF and the trigon was involved in 5 of them. Two women with large VVF associated with total bladder neck and urethral loss could not be repaired. Bladder neck and mid/distal urethra was involved in 7 and 4 patients with UVF, respectively. In 5 of these women, bladder neck/urethral continuity was interrupted (circumferential fistula). Ureteroneocystostomy with a psoas hitch was required in 3 patients with URVF. Six women received vaginal flap urethroplasty due to postoperative short urethra and stress urinary incontinence. Seven received a mid-urethral sling and four received sacrocolpopexy due to advanced postoperative pelvic organ prolapse. The closure was successful in 83% of primary cases and in 61% women operated for recurrent fistula.
The management of obstetric fistulae is demanding. Transvaginal approach provides successful closure in most cases. However, the surgeon should be prepared to perform additional procedures for persistent/recurrent incontinence even after a successful initial closure.