Predictors of outcomes in patients with repeat surgery for obstetric fistula: a retrospective review.

INTRODUCTION AND HYPOTHESIS: Predictors of surgical outcomes in patients with an obstetric fistula who have been operated before should be identified in order to guide surgical strategy and optimize counseling of the patient. METHODS: This retrospective study is aimed at identifying predictors of outcomes for repeat surgery in 346 patients who had been operated on before for an obstetrics fistula at the Fistula Care Center (FCC) in Lilongwe, Malawi. Repeat cases were only undertaken by advanced and expert surgeons. The primary outcome was successful anatomical closure, based on a negative postoperative dye test. The secondary outcomes involved urinary continence, based on a patient-reported questionnaire and an objective 1-h pad weight test. Logistic regression models were used to test the predictors for statistical significance. RESULTS: Successful fistula closure was achieved in 288 (83%) patients and continence was achieved in 185 (64%) patients after the first repeat attempt at the FCC. Lack of urethral involvement (Goh classification: proximity to the urethra) was shown to be a good predictor of the outcomes: fistula closure and subjective and objective continence. CONCLUSIONS: Absence of urethral involvement is an independent predictor for successful outcomes in repeat surgery for obstetric fistulas. Even in the hands of an expert surgeon, the risk of another failure in achieving anatomical closure or subjective or objective continence is between 4 and 5 times higher than when the urethra is not involved.

The Microcirculation of Vaginal Tissue in Women with Obstetric Vesicovaginal Fistula and Short-Term Effects of Surgical Repair on Microvascular Parameters.

OBJECTIVES: The objective of the study was to better understand the extent of the ischemic trauma and the effects of surgical repair on the vaginal microcirculation in patients with obstetric vesicovaginal fistula (VVF). DESIGN: In this observational study, we evaluated the vaginal microvasculature surrounding VVF using handheld vital microscopy (HVM) before, during, and 2 weeks after surgical VVF repair. PARTICIPANTS: Seventeen women undergoing VVF repair were included in this study. SETTING: The study was conducted in the Fistula Care Centre in Lilongwe, Malawi. METHODS: We used HVM with incident dark-field imaging to non-invasively visualize the microvasculature of the vaginal tissue surrounding fistulas. The primary outcome was the presence of microvascular flow. Secondary outcomes included angioarchitecture, fistula closure (postoperative dye test), and urinary continence (pad weight test). RESULTS: Microvascular flow was present before, during, and after surgical repair in, respectively, 83.8%, 83.9%, and 93.4% of obtained image sequences. The angioarchitecture was normal in 75.8% of the image sequences before surgery, 69.4% at fistula closure, and 89.1% two weeks after VVF repair. Fourteen (82.4%) patients had a closed fistula after surgical repair. LIMITATIONS: The study was limited by the lack of a control group and the relatively small sample size. CONCLUSION: Although the vaginal microcirculation in women with VVF is compromised, extensive ischemic damage is not observed in the tissue surrounding fistulas. This suggests significant regenerative capacity of the vaginal vasculature in young women, or less extensive ischemic damage than presumed. Following surgical repair, we observed improvement of microcirculatory flow and angioarchitecture, suggesting that surgery is a good option for patients with obstetric VVF.

Follow-up of obstetric fistula repair using Singapore fasciocutaneous flap and/or gracilis muscle flap.

AIMS: To report on the follow-up of obstetric fistula repair using vascularized surgical flaps, namely the Singapore fasciocutaneous flap, the gracilis muscle flap, or a combination of both. METHODS: This cross-sectional study reports on the follow-up of 60 patients after fistula repair with a vascularized surgical flap at the Fistula Care Center in Lilongwe, Malawi. The primary outcome was fistula closure based on patients' self-reported continence grade. Secondary outcomes were urinary incontinence based on a 1-h pad-weight test, quality of life based on the Incontinence Quality of Life (I-QOL) questionnaire, surgical complications, and the indication for additional surgery after repair. RESULTS: Successful closure was achieved in 62% of cases and full continence was achieved in 12% of cases. Incontinence based on a 1-h pad weight test improved between surgery and follow-up. QOL scores based on the I-QOL were low but patients indicated moderate to great improvement in quality of life. Twenty-two (37%) patients experienced surgical complication, mostly minor wound breakdowns. No major complications were reported. Six (10%) patients were indicated for additional surgery during follow-up. CONCLUSION: The relative safety of the surgical procedures is shown in the findings of this study, including no reports on major complications during follow-up. Vascularized flaps should be considered in complex fistula cases, especially in repeat cases and before considering urinary diversion as a last resort.

Standardization of Laparoscopic Operative Reporting: Improving Gynaecological Surgeon Communication.

OBJECTIVE: No standardization of quality of operative reporting currently exists, and this represents a missed opportunity for communication among health care providers. This study proposed a method to improve operative notes by structuring the findings by six anatomical zones of the pelvis. Objective I was to validate the method of documenting six zones of the pelvis by using intraoperative photography. Objective II was to compare this method with dictations from operative reports created before introducing this method. METHODS: This retrospective cohort study evaluated pre- and post-intervention results of using six zones to guide operative reporting. Reports were collected from participating surgeons and were scored using a validated scoring tool. Each participant was taught to photograph six zones and use the zones in the operative report. Pre- and post-intervention cases were compared using generalized linear mixed models. RESULTS: Scores of study participants using the zones were significantly higher than those without (P <0.0001). Surgeons showed an ability to improve their reporting. The detail illustrated in the cases was qualitatively richer, and the anatomy within the six zones was referenced more frequently. CONCLUSION: Compared with reports without the technique, incorporating the six zones greatly enhances operative reporting and likely would improve communication among care providers. More reliable communication of intraoperative findings has the potential to enhance the value of laparoscopy greatly as a diagnostic tool across gynaecological subspecialties.

Fertility outcomes following obstetric fistula repair: a prospective cohort study.

BACKGROUND: Obstetric fistula (OF) is a maternal morbidity associated with high rates of stillbirth, amenorrhea, and sexual dysfunction. Limited data exists on the reproductive outcomes of women in the years following a fistula repair. The objective of this study is to describe the fertility outcomes and family planning practices in a population of Malawian women 1-4 years after fistula repair. METHODS: Women who had enrolled into a clinical database of OF patients and undergone OF repair between January 1, 2012 and July 31, 2014 were recruited and enrolled to complete a home-based survey of their demographic and reproductive health data 1-4 years after their repair. Pregnancy, amenorrhea, and sexual function were described using frequency analysis, and we compared antimüllerian hormone (AMH) concentrations between women with menses or pregnancy with women with amenorrhea or no pregnancy using Wilcoxon rank sum tests. RESULTS: Of 297 women with a prior OF repair, 148 had reproductive potential and were included in this analysis. Overall 30 women of these women (21%) became pregnant since their fistula repair, with most pregnancies ending with cesarean delivery. Of the 32 women who were amenorrheic at the time of repair, 25 (78.1%) had resumption of menses. Only 11 (8.6%) of sexually active women reported dyspareunia, and among women who were not trying to conceive, 53.1% were currently using a method of family planning. No significant differences were found in AMH concentrations between those who were pregnant or had menses versus those without pregnancy or menses, respectively. CONCLUSIONS: In this long-term follow-up study of women after OF repair, many women were able to achieve a pregnancy with a live birth, have normal menses, be sexually active, and access contraception. These achievements will further assist a population of women whose reintegration and restoration of dignity is closely tied to their ability to achieve their reproductive goals. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02685878 .

Characteristics of Female Sexual Health Programs and Providers in the United States.

BACKGROUND: Female sexual dysfunction is a prevalent condition affecting 12% of women, yet few academic centers in the US have female sexual medicine programs. AIM: To characterize female sexual health programs in the United States, services offered, and training of female sexual health providers. METHODS: We performed an internet search to identify female sexual health programs and clinics in the US. From each programs' website we abstracted the location, clinic setting (academic vs private), training of providers, and whether the clinic provided investigational services (ie, PRP injections, laser/radiofrequency therapy). We categorized clinics as specialized in sexual medicine, specialized with a focus on cancer patients, general, aesthetics-focused, general & aesthetic, or specialized & aesthetic. We used Chi-square and Fisher's exact test to evaluate association between practice setting and provision of investigational therapies with a Bonferroni-adjusted critical P-value of 0.017. OUTCOMES: Our outcomes were the number of clinics in each setting, in each category, and each state, as well as the number of providers by training type. RESULTS: We identified 235 female sexual medicine programs in the United States. Seventeen percent were in the academic setting. Clinics in the non-academic setting were significantly (α = 0.017) more likely to offer PRP injections (0% vs 47%, P < .001), laser/radiofrequency therapy (14% vs 56%, P < .0001), and shockwave therapy (0% vs 14%, P = .011). Among all clinics, 22% provided specialized care, 2% provided care for cancer patients, 29% were more general clinics that advertised female sexual healthcare, 23% were aesthetics-focused, 22% were general practices that provided aesthetics services, and 2% were specialized clinics that offered aesthetics services. 81% of aesthetics-focused clinics advertised PRP injections. Seven states had no clinics and 26 states lacked a clinic specializing in female sexual health. The most frequent providers were OB/Gyns (40%), nurse practitioners (22%), urologists (13%), and physicians assistants (10%). CLINICAL IMPLICATIONS: The geographic distribution of clinics and pervasiveness of clinics offering investigational services for female sexual dysfunction may be a barrier for patients seeking care. LIMITATIONS: As a result of our internet search methodology, we likely did not capture all clinics providing female sexual health services. Further, the accuracy of our data depends on the level of detail provided on each clinics' website. CONCLUSION: Online search identified few clinics providing female sexual healthcare in academic medicine: development of such clinics could benefit patients by improving access to evidence-based care and promoting training of future providers. Elizabeth E. Stanley and Rachel J. Pope, Characteristics of Female Sexual Health Programs and Providers in the United States. Sex Med 2022;10:100524.

Vaginal delivery of vertex-nonvertex twins: a fading skill?

BACKGROUND: Delivery of the second twin is one of the most challenging events for practicing obstetricians. Due to the increased incidence of twin gestations and lack of well-designed clinical trials, evidence-based recommendations are lagging behind clinical demand. OBJECTIVE: The present review examines the practice of second nonvertex twin deliveries. METHODS: A review of the literature was conducted using the term vertex-nonvertex; twin gestation; mode of delivery; and cesarean delivery. RESULTS: There is a lack of evidence supporting the appropriate approach to second nonvertex twin deliveries. Larger studies with increased power are needed to examine the variations regarding gestational period, birth weight, and institutional experience. In the mean time, unless otherwise contraindicated, it is reasonable to attempt vaginal delivery and total breech extraction and proceed to assisted delivery or cesarean delivery if unsuccessful. CONCLUSIONS: Preserving the art of obstetric maneuvering is important as well for twin deliveries. In cases of vertex-nonvertex presentation, vaginal delivery is preferred in certain conditions.

Extended bladder catheterization for women with positive dye tests after obstetric vesicovaginal fistula repair surgery.

OBJECTIVE: To determine the success rate and factors that result in a negative dye test after extended bladder catheterization after surgery for obstetric fistula. METHODS: A retrospective cohort study was carried out on women who underwent obstetric fistula repair in Malawi and had ≥14 days of bladder catherization. Variables such as age, class of fistula, previous repairs, menopausal status, and HIV status were examined for association with successful healing at the end of the catheterization period. RESULTS: Fifty-two patients had a positive dye test after the intended period of catheterization and the catheterization period was extended by 7 days. Of these patients, 29 (55.7%) had a subsequent negative dye test. Older women (mean age 28.4 years) who developed a fistula were more likely to have a negative dye test after extended catheterization, compared to their younger counterparts (mean age 20 years) (P=0.0018). Other variables were not found to be significantly different between the two groups. CONCLUSION: More than half of the patients with a positive dye test had complete closure of the fistula defect after an extension of bladder decompression. It is reasonable to consider an extension of bladder catheterization for 7 days after an initial positive dye test.

Predictors of Urinary Retention After Vesicovaginal Fistula Surgery: A Retrospective Case-Control Study.

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.

Persistent depression after obstetric fistula repair.

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.

Pelvic Ultrasound Findings in Women with Obstetric Fistula: A Cross-Sectional Study of Cases and Controls.

OBJECTIVE: Obstetric fistula (OF) is a morbid condition caused by prolonged obstructed labor. Women with OF experience profound injury and have high rates of infertility and poor obstetric outcomes. We examined endovaginal ultrasound parameters in women with and without OF. DESIGN/SETTING/SAMPLE/METHODS: This cross-sectional study enrolled women evaluated at the Fistula Care Centre in Lilongwe, Malawi. Eligibility criteria included age 18-45, prior pregnancy, and a uterus on ultrasound. Participants underwent endovaginal ultrasound with measurement of cervical dimensions. Comparisons were done using t-tests and Fisher's exact test. Among women with OF, linear regression was used to assess whether fistula stage was associated with cervical length. RESULTS: We enrolled 98 cases and 12 controls. Women with OF had shorter cervical lengths (18.8 mm versus 27.3 mm, p < 0.01), as well as shorter anterior (7.0 mm versus 9.3 mm, p < 0.01) and posterior (9.5 mm versus 11.0 mm, p < 0.04) cervical stroma, compared to controls. CONCLUSION: Women with OF have shorter cervical lengths and anterior and posterior cervical stroma, when compared to women without OF. This may offer a partial explanation for subfertility and poor obstetric outcomes in OF patients. Additional studies to clarify the role of ultrasound in OF patients and prediction of future fertility are warranted.