A systematic review of the patient burden of Crohn's disease-related rectovaginal and anovaginal fistulas.

BACKGROUND: Crohn's disease (CD)-related rectovaginal fistulas (RVFs) and anovaginal fistulas (AVFs) are rare, debilitating conditions that present a substantial disease and treatment burden for women. This systematic literature review (SLR) assessed the burden of Crohn's-related RVF and AVF, summarizing evidence from observational studies and highlighting knowledge gaps. METHODS: This SLR identified articles in PubMed and Embase that provide data and insight into the patient experience and disease burden of Crohn's-related RVF and AVF. Two trained reviewers used pre-specified eligibility criteria to identify studies for inclusion and evaluate risk of bias using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool for observational studies. RESULTS: Of the 582 records identified, 316 full-text articles were assessed, and 16 studies met a priori eligibility criteria and were included. Few epidemiology studies were identified, with one study estimating the prevalence of RVF to be 2.3% in females with Crohn's disease. Seven of 12 treatment pattern studies reported that patients had or required additional procedures before and/or after the intervention of interest, demonstrating a substantial treatment burden. Seven of 11 studies assessing clinical outcomes reported fistula healing rates between 50 and 75%, with varying estimates based on population and intervention. CONCLUSIONS: This SLR reports the high disease and treatment burden of Crohn's-related RVF and AVF and identifies multiple evidence gaps in this field. The literature lacks robust, generalizable data, and demonstrates a compelling need for substantial, novel research into these rare and debilitating sequelae of CD. Registration The PROSPERO registration number for the protocol for this systematic literature review is CRD42020177732.

Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess the impact of type of surgery for colorectal endometriosis-rectal shaving or discoid resection or segmental colorectal resection-on complications and surgical outcomes. DATA SOURCES: We performed a systematic review of all English- and French-language full-text articles addressing the surgical management of colorectal endometriosis, and compared the postoperative complications according to surgical technique by meta-analysis. The PubMed, Clinical Trials.gov, Cochrane Library, and Web of Science databases were searched for relevant studies published before March 27, 2020. The search strategy used the following Medical Subject Headings terms: ("bowel endometriosis" or "colorectal endometriosis") AND ("surgery for endometriosis" or "conservative management" or "radical management" or "colorectal resection" or "shaving" or "full thickness resection" or "disc excision") AND ("treatment", "outcomes", "long term results" and "complications"). METHODS OF STUDY SELECTION: Two authors conducted the literature search and independently screened abstracts for inclusion, with resolution of any difference by 3 other authors. Studies were included if data on surgical management (shaving, disc excision, and/or segmental resection) were provided and if postoperative outcomes were detailed with at least the number of complications. The risk of bias was assessed according to the Cochrane recommendations. TABULATION, INTEGRATION, AND RESULTS: Of the 168 full-text articles assessed for eligibility, 60 were included in the qualitative synthesis. Seventeen of these were included in the meta-analysis on rectovaginal fistula, 10 on anastomotic leakage, 5 on anastomotic stenosis, and 9 on voiding dysfunction <30 days. The mean complication rate according to shaving, disc excision, and segmental resection were 2.2%, 9.7%, and 9.9%, respectively. Rectal shaving was less associated with rectovaginal fistula than disc excision (odds ratio [OR] = 0.19; 95% confidence interval [CI], 0.10-0.36; p <.001; I2 = 33%) and segmental colorectal resection (OR = 0.26; 95% CI, 0.15-0.44; p <.001; I2 = 0%). No difference was found in the occurrence of rectovaginal fistula between disc excision and segmental colorectal resection (OR = 1.07; 95% CI, 0.70-1.63; p = .76; I2 = 0%). Rectal shaving was less associated with leakage than disc excision (OR = 0.22; 95% CI, 0.06-0.73; p = .01; I2 = 86%). No difference was found in the occurrence of leakage between rectal shaving and segmental colorectal resection (OR = 0.32; 95% CI, 0.10-1.01; p = .05; I2 = 71%) or between disc excision and segmental colorectal resection (OR = 0.32; 95% CI, 0.30-1.58; p = .38; I2 = 0%). Disc excision was less associated with anastomotic stenosis than segmental resection (OR = 0.15; 95% CI, 0.05-0.48; p = .001; I2 = 59%). Disc excision was associated with more voiding dysfunction <30 days than rectal shaving (OR = 12.9; 95% CI, 1.40-119.34; p = .02; I2 = 0%). No difference was found in the occurrence of voiding dysfunction <30 days between segmental resection and rectal shaving (OR = 3.05; 95% CI, 0.55-16.87; p = .20; I2 = 0%) or between segmental colorectal and discoid resections (OR = 0.99; 95% CI, 0.54-1.85; p = .99; I2 = 71%). CONCLUSION: Colorectal surgery for endometriosis exposes patients to a risk of severe complications such as rectovaginal fistula, anastomotic leakage, anastomotic stenosis, and voiding dysfunction. Rectal shaving seems to be less associated with postoperative complications than disc excision and segmental colorectal resection. However, this technique is not suitable for all patients with large bowel infiltration. Compared with segmental colorectal resection, disc excision has several advantages, including shorter operating time, shorter hospital stay, and lower risk of postoperative bowel stenosis.

Delivery mode for prolonged, obstructed labour resulting in obstetric fistula: a retrospective review of 4396 women in East and Central Africa.

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.

A nomogram for predicting rectovaginal fistula after low anterior resection for rectal cancer.

PURPOSE: Rectovaginal fistula (RVF) is a complicated and troublesome complication of low anterior resection (LAR) for rectal cancer. We aimed to investigate the risk factors for post-LAR RVF and develop a predictive nomogram. METHODS: We performed a retrospective analysis of 821 female patients with rectal cancer who underwent LAR between October 2010 and October 2018. Logistic regression was performed to identify risk factors. A nomogram was developed to predict RVF. RESULTS: The incidence of post-LAR RVF was 3.4% (28/821). A multivariate analysis showed that the preoperative serum hemoglobin level (OR 2.449, 95% CI 1.144-5.239), the distance between the tumor and anal verge (OR 4.158, 95% CI 1.392-12.418), surgical procedure (OR 2.369, 95% CI 1.117-5.027), hysterectomy (OR 2.996, 95% CI 1.106-8.833), and bilateral oophorectomy (OR 5.823, 95% CI 1.639-20.689) were significantly associated with the development of RVF. A nomogram was developed, which showed a C-index of 0.824 (95% CI 0.730-0.918) and an adjusted C-index of 0.790. CONCLUSION: This study identified the preoperative serum hemoglobin level, the distance between the tumor and the anal verge, the type of surgical procedure, hysterectomy, and bilateral oophorectomy as predictors of post-LAR RVF. A nomogram was successfully developed. It could aid in the prediction of RVF in patients undergoing LAR.

Perceived Causes of Obstetric Fistula and Predictors of Treatment Seeking among Ugandan Women: Insights from Qualitative Research.

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.

[Epidemiologic, anatomoclinic and therapeutic profil of urogenital and rectovaginal fistula in TOGO]. / Profil épidémiologique, anatomoclinique et thérapeutique des fistules urogénitales et rectovaginales au Togo.

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.

Partial Stapled Hemorrhoidopexy Versus Circumferential Stapled Hemorrhoidopexy for Grade III to IV Prolapsing Hemorrhoids: A Randomized, Noninferiority Trial.

BACKGROUND: Long-term outcomes and efficacy of partial stapled hemorrhoidopexy are not known. OBJECTIVE: The purpose of this study was to compare the long-term clinical efficacy and safety of partial stapled hemorrhoidopexy with circumferential stapled hemorrhoidopexy. DESIGN: This was a parallel group, randomized, noninferiority clinical trial. SETTINGS: The study was conducted at a single academic center. PATIENTS: Patients with grade III/IV hemorrhoids between August 2011 and November 2013 were included. INTERVENTIONS: Three hundred patients were randomly assigned to undergo either partial stapled hemorrhoidopexy (group 1, n = 150) or circumferential stapled hemorrhoidopexy (group 2, n = 150). MAIN OUTCOME MEASURES: The primary outcome was the rate of recurrent prolapse at a median follow-up period of 5 years with a predefined noninferiority margin of 3.75%. Secondary outcomes included incidence and severity of postoperative pain, fecal urgency, anal continence, and the frequency of specific complications, including anorectal stenosis and rectovaginal fistula. RESULTS: The visual analog scores in group 1 were less than those in group 2 (p < 0.001). Fewer patients in group 1 experienced postoperative urgency compared with those in group 2 (p = 0.001). Anal continence significantly worsened after both procedures, but the difference between preoperative and postoperative continence scores was higher for group 2 than for group 1. Postoperative rectal stenosis did not develop in patients in group 1, although it occurred in 8 patients (5%) in group 2 (p = 0.004). The 5-year cumulative recurrence rate between group 1 (9% (95% CI, 4%-13%)) and group 2 (12% (95% CI, 7%-17%)) did not differ significantly (p = 0.137), and the difference was within the noninferiority margin (absolute difference, -3.33% (95% CI, -10.00% to 3.55%)). LIMITATIONS: The study was limited because it was a single-center trial. CONCLUSIONS: Partial stapled hemorrhoidopexy is noninferior to circumferential stapled hemorrhoidopexy for patients with grade III to IV hemorrhoids at a median follow-up period of 5 years. However, partial stapled hemorrhoidopexy was associated with reduced postoperative pain and urgency, better postoperative anal continence, and minimal risk of rectal stenosis. See Video Abstract at http://links.lww.com/DCR/A790.Trial registration (chictr.org) identifier is chiCTR-trc-11001506.

"I feel myself incomplete, and I am inferior to people": experiences of Sudanese women living with obstetric fistula in Khartoum, Sudan.

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.

Obstetric fistula in Niger: 6-month postoperative follow-up of 384 patients from the Danja Fistula Center.

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.

Urinary tract infection among fistula patients admitted at Hamlin fistula hospital, Addis Ababa, Ethiopia.

BACKGROUND: Urinary Tract Infection (UTI) causes a serious health problem and affects millions of people worldwide. Patients with obstetric fistula usually suffer from incontinence of urine and stool, which can predispose them to frequent infections of the urinary tract. Therefore the aim of this study was to determine the etiologic agents, drug resistance pattern of the isolates and associated risk factor for urinary tract infection among fistula patients in Addis Ababa fistula hospital, Ethiopia. METHODS: Across sectional study was conducted from February to May 2015 at Hamlin Fistula Hospital, Addis Ababa, Ethiopia. Socio-demographic characteristics and other UTI related risk factors were collected from study participants using structured questionnaires. The mid-stream urine was collected and cultured on Cysteine lactose electrolyte deficient agar and blood agar. Antimicrobial susceptibility was done by using disc diffusion method and interpreted according to Clinical and Laboratory Standards Institute (CLSI). Data was entered and analyzed by using SPSS version 20. RESULTS: Out of 210 fistula patients investigated 169(80.5%) of the patient were younger than 25 years. Significant bacteriuria was observed in 122/210(58.1%) and 68(55.7%) of the isolates were from symptomatic cases. E.coli 65(53.7%) were the most common bacterial pathogen isolated followed by Proteus spp. 31(25.4%). Statistical Significant difference was observed with history of previous UTI (P = 0.031) and history of catheterization (P = 0.001). Gram negative bacteria isolates showed high level of resistance (>50%) to gentamicin and ciprofloxacin, while all gram positive bacteria isolated were showed low level of resistance (20-40%) to most of antibiotic tested. CONCLUSIONS: The overall prevalence of urinary tract infection among fistula patient is 58.1%. This study showed that the predominant pathogen of UTI were E.coli followed by Proteus spp. It also showed that amoxicillin-clavulanic acid was a drug of choice for urinary tract bacterial pathogens.

Validation of an obstetric fistula screening questionnaire in rural Nepal: a community-based cross-sectional and nested case-control study with clinical examination.

OBJECTIVE: To validate a symptom-based fistula screening questionnaire and estimate obstetric fistula (OF) prevalence in rural Nepal. DESIGN: Cross-sectional and nested case-control study. SETTING: Sarlahi District, Nepal. POPULATION: Parous, reproductive age women. METHODS: The questionnaire assessed symptoms of vesicovaginal and rectovaginal fistula (VVF and RVF, respectively), stress and urge urinary incontinence (SUI and UUI, respectively), fecal incontinence (FI), and included interviewer observations on the smell and presence of urine and/or stool. All women who screened positive for OF and a randomly selected group of women who screened negative for OF were included in a nested case-control study (one case, four normal controls, and four incontinent controls) and underwent confirmatory clinical examinations. MAIN OUTCOME MEASURES: Clinically confirmed OF, and questionnaire sensitivity (Se) and specificity (Sp). RESULTS: Of the 16 893 women who completed cross-sectional screening, 68 were screened-positive cases. Fifty-five (82%) screened-positive cases, 203 screened-negative normal controls, and 203 screened-incontinent controls participated in the case-control study, which confirmed one case of VVF and one case of both VVF and RVF without any false-negative cases. For VVF, the screening tool demonstrated Se 100% (95% CI 34.2-100.0%), Sp 86.9% (95% CI 83.3-89.9%), and estimated VVF prevalence as 12 per 100 000 (95% CI 3-43); for RVF, it demonstrated Se 100% (95% CI 20.7-100.0), Sp 99.8% (95% CI 98.6-100.0), and estimated RVF prevalence as 6 per 100 000 (95% CI 1-34). CONCLUSIONS: The OF screening questionnaire demonstrated high sensitivity and specificity in this low-prevalence setting. TWEETABLE ABSTRACT: Community-based obstetric fistula screening tool validation study, Nepal, n = 16 893: High Se, Sp & feasibility.

A case-control study of the risk factors for obstetric fistula in Tigray, Ethiopia.

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.

Obstetric fistulae in southern Mozambique: incidence, obstetric characteristics and treatment.

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.

Incidence of obstetric fistula in Norway: a population-based prospective cohort study.

INTRODUCTION: Obstetric fistula is a serious complication of childbirth prevalent in developing societies. Less is known about its occurrence in industrialized countries. We aimed to determine incidence and outcome of obstetric fistulas in Norway. MATERIAL AND METHODS: This was a population-based prospective cohort study. Patient characteristics were registered for all treated at the National Treatment Center for Gynecologic Fistulas, Haukeland University Hospital, Bergen. Women with obstetric fistula after delivering in Hordaland County were included when calculating the incidence based on number of deliveries in that county during 1995-2014. RESULTS: Of 280 fistulas, 40 were related to obstetrics (four urogenital and 36 enterogenital), 19 women were from Hordaland County. During this period, 116 389 deliveries were registered, giving an incidence of obstetric fistula of 16.3/100,000 deliveries (95% confidence interval 10.2-25.7/100,000). The urinary fistulas were due to cesarean section, cerclage, and uterine rupture, and all were repaired surgically. The 36 enteral fistulas were all related to vaginal deliveries; nine (25%) were instrumental and 19 (53%) had experienced a perineal tear of grade 3-4. These fistulas were small, with a median diameter of 2 mm. Four healed spontaneously or after enterostomy, and 30 were repaired transvaginally. In all, 37 of 40 obstetric fistulas were confirmed healed at follow up. Two women refrained from surgery, and one was lost to follow up. CONCLUSION: Obstetric fistula does occur in industrialized societies but with a low incidence; fistulas are due to obstetric trauma or surgery rather than prolonged obstructed labor. The outcome of treatment is excellent when women are treated at a competent center.

Factors associated with the failure of obstetric fistula repair in Guinea: implications for practice.

BACKGROUND: The prevention and treatment of obstetric fistula still remains a concern and a challenge in low income countries. The objective of this study was to estimate the overall proportions of failure of fistula closure and incontinence among women undergoing repair for obstetric fistula in Guinea and identify its associated factors. METHODS: This was a retrospective cohort study using data extracted from medical records of fistula repairs between 1 January 2012 and 30 September 2013. The outcome was the failure of fistula closure and incontinence at hospital discharge evaluated by a dye test. A sub-sample of women with vesicovaginal fistula was used to identify the factors associated with these outcomes. RESULTS: Overall, 109 women out of 754 (14.5 %; 95 % CI:11.9-17.0) unsuccessful repaired fistula at discharge and 132 (17.5 %; 95 % CI:14.8-20.2) were not continent. Failure of fistula closure was associated with vaginal delivery (AOR: 1.9; 95 % CI: 1.0-3.6), partially (AOR: 2.0; 95 % CI: 1.1-5.6) or totally damaged urethra (AOR: 5.9; 95 % CI: 2.9-12.3) and surgical repair at Jean Paul II Hospital (AOR: 2.5; 95 % CI: 1.2-4.9). Women who had a partially damaged urethra (AOR: 2.5; 95 % CI: 1.5-4.4) or a totally damaged urethra (AOR: 6.3; 95 % CI: 3.0-13.0) were more likely to experience post-repair urinary incontinence than women who had their urethra intact. CONCLUSION: At programmatic level in Guinea, caution should be paid to the repair of women who present with a damaged urethra and those who delivered vaginally as they carry greater risks of experiencing a failure of fistula closure and incontinence.

Rectovaginal fistula: Twenty years of rectovaginal repair.

AIM: To identify the favorable factors in rectovaginal fistula (RVF) management. METHODS: After Institutional Review Board approval (99-0793B), we retrospectively studied all patients diagnosed, treated and followed up with RVF at Chang Gung Memorial Hospital, Taiwan between January 1990 and December 2009. All female patients with International Classification of Diseases RVF were included. We reviewed demographic data, socioeconomic status, clinical presentation, comorbidities, method of treatment, duration of hospitalization and clinical outcome at 12 months postoperatively. RESULTS: A total of 397 patients were included in the study. Fifty-six patients (14.1%) had conservative treatment and 341 patients (85.9%) underwent surgical intervention. A total of 125 patients underwent simple repair while 216 patients underwent reconstruction. Three hundred and forty-four patients (86.7%) had improved outcome at 12-month follow up. Age (P = 0.003), education level (P = 0.033), ability to pay insurance (P < 0.001), and choice of treatment (P < 0.0001) were identified as significant favorable factors. An etiological factor associated with favorable outcome was RVF from obstetric complication, while that resulting from malignancy had a less favorable outcome. CONCLUSIONS: Age, education level and ability to pay insurance significantly affect 12-month outcome of RVF. Surgery is the preferred option, while medical treatment should be used only for small rectovaginal fistulas or for patients not suitable for surgery and anesthesia. More support and assistance should be offered to those patients with unfavorable factors, such as old age, low education level and inability to afford insurance. All RVF secondary to obstetrical injury had a 100% favorable outcome compared with those secondary to surgery or malignancy. Women with suspected RVF should receive prompt and extensive evaluation to ensure immediate effective management and prevention of further serious complications.

Good clinical outcomes from a 7-year holistic programme of fistula repair in Guinea.

OBJECTIVES: Female genital fistula remains a public health concern in developing countries. From January 2007 to September 2013, the Fistula Care project, managed by EngenderHealth in partnership with the Ministry of Health and supported by USAID, integrated fistula repair services in the maternity wards of general hospitals in Guinea. The objective of this article was to present and discuss the clinical outcomes of 7 years of work involving 2116 women repaired in three hospitals across the country. METHODS: This was a retrospective cohort study using data abstracted from medical records for fistula repairs conducted from 2007 to 2013. The study data were reviewed during the period April to August 2014. RESULTS: The majority of the 2116 women who underwent surgical repair had vesicovaginal fistula (n = 2045, 97%) and 3% had rectovaginal fistula or a combination of both. Overall 1748 (83%) had a closed fistula and were continent of urine immediately after surgery. At discharge, 1795 women (85%) had a closed fistula and 1680 (79%) were dry, meaning they no longer leaked urine and/or faeces. One hundred and fifteen (5%) remained with residual incontinence despite fistula closure. Follow-up at 3 months was completed by 1663 (79%) women of whom 1405 (84.5%) had their fistula closed and 80% were continent. Twenty-one per cent were lost to follow-up. CONCLUSION: Routine programmatic repair for obstetric fistula in low resources settings can yield good outcomes. However, more efforts are needed to address loss to follow-up, sustain the results and prevent the occurrence and/or recurrence of fistula.

Role of protective defunctioning stoma in colorectal resection for endometriosis.

STUDY OBJECTIVE: To evaluate the role of protective defunctioning stoma (PDS) on the occurrence of digestive tract complications after colorectal resection to treat endometriosis. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: All patients undergoing segmental colorectal resection to treat colorectal endometriosis with and without PDS between 2003 and 2011 at Tenon University Hospital, Paris, France. MEASUREMENTS AND MAIN RESULTS: Patients were assessed at 1, 6, and 12 months postoperatively and each year thereafter. Median follow-up was 60 months. Of 198 patients included for analysis, 53 (27%) had PDS. Overall, 15 (7.5%) digestive tract complications occurred: 9 (4.5%) rectovaginal fistulas and 6 (3%) anastomotic leakages. All rectovaginal fistulas occurred in patients with a low colorectal anastomosis (p < .001) and 88% (8 of 9) in patients with a partial colpectomy (p < .001). PDS was associated with a decrease in the number of rectovaginal fistulas in women undergoing partial colpectomy and low colorectal resection from 27% to 15%, without reaching significance (p = .4). No anastomotic leakage occurred in patients with PDS. CONCLUSION: Our results support that PDS can be omitted in patients with mid-colorectal anastomosis without partial colpectomy. In patients requiring partial colpectomy or partial colpectomy plus low colorectal anastomosis, PDS remains questionable.

[Les fistules recto-vaginales d'origine obstétricale: aspects épidémiologiques et approaches thérapeutiques. Etude multicentrique tunisienne]. / Rectovaginal obstetrical fistulas. Therapeutic attitudes. A Multicenter tunisian study.

BACKGROUND: Rectovaginal fistulas are abnormal epithelial-lined connections between the rectum and vagina. The aquired etiology caused by child birth are still frequent in many countries. AIM: to describe epidemiology of obstetrical recto vaginal fistula in our country and discuss therapeutic modalities Materiel and methods: A retrospective multicentric study among 19 hospital departments from February 1982 to January 2007 of obstetrical recto-vaginal fistulas including 41 patients. RESULTS: The median diameter of the fistula was 12 mm. the treatment consist on excision of the fistula and perineal suturing in 34 cases, Advancement flaps was used in four cases, the Musset technique repair in two cases, Gracilis transposition for repair was used in one case. Forty five patients had satisfactory anatomic and functional satisfactory results. One patient had reported dyspareunia. Definitive failure was reported in four cases. CONCLUSION: Our study suggests a regression in obstetrical RVF. However many efforts on institutional, socioeconomic and obstetrical levels have to be done in order to eradicate this pathology. Surgical treatments have good results. However prevention of this complication is the best treatment because a major handicap for women regarding socioeconomic, functional and psychological effects.

Rectal Injury During Penile Inversion Vaginoplasty.

OBJECTIVE: To evaluate the incidence, management, and outcomes of rectal injury (RI) and subsequent rectovaginal fistula (RVF) during gender-affirming vaginoplasty (GAV) at a high-volume transgender surgery center. METHODS: We performed a retrospective review of preoperative, intraoperative and post-operative findings of all patients with RI during GAV from January 2016 to September 2022. Descriptive statistics were calculated using Microsoft Excel. RESULTS: RI occurred in 9 of 1011 primary GAV and colorectal surgery (CRS) consulted in 5 cases, which included sigmoidoscopy with an air leak test in 4 and with temporary bowel diversion in 2. Of the 9, 6 proceeded with full-depth GAV, and 3 were converted to minimal-depth vaginoplasty. Two had bulbospongiosus muscle interposition and none had a concomitant urethral injury. 1/9 patients with RI developed a RVF which occurred in a patient with prior perineal surgery and no intraoperative sigmoidoscopy. Three (50%) with full-depth GAV developed vaginal stenosis postoperatively. CONCLUSIONS: RI during primary GAS in experienced hands is uncommon with an incidence of 0.89% in our series of 1011. Unusual tissue dissection planes were a risk factor. If injuries were identified intraoperatively, repaired with multilayer closure and evaluated by CRS, patients did well without the development of RVF despite completion of full-depth GAV. It is reasonable to complete the full-depth vagina, but patients should be advised of a significant risk of post-operative vaginal stenosis.