Obstetric fistula repair failure and its associated factors among women who underwent repair in sub-Saharan Africa. A systematic review and meta-analysis.

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.

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.

Incidence and Treatment Outcomes of Rectovaginal Fistula After Rectal Cancer Resection.

OBJECTIVES: Rectovaginal fistulas (RVFs) are an uncommon and disturbing complication with limited success in treatment. This study was aimed at determining the incidence of RVFs after rectal resections in the era of neoadjuvant radiation therapy and the outcomes of their treatment. METHODS: This was a retrospective study of female patients who underwent sphincter-preserving total mesorectal excision for rectal cancer and developed RVF. RESULTS: Four hundred eighty-eight patients underwent rectal resections between January 2013 and December 2019, and 9 developed RVF (1.8%). Average time to presentation was 280 days (range, 6-540 days). The median time to onset for those presenting prior to stoma reversal was 90 days, whereas the duration between stoma reversal and RVF detection in those presenting after stoma closures was 115 days. Success rates of fecal diversion and local procedures for treatment of RVF were 20% (2/10 procedures) and 40% (2/5 procedures), respectively. Redo coloanal anastomosis was performed for 2 patients with successful outcome. An average of 2.1 procedures were performed per patient (19/9) with a per-procedure success rate of 31.6% (6/19 procedures) and a per-patient success rate of 66.7% (6/9). At median follow-up of 64 months, 50% (3/6) of patients with a healed fistula were free of stoma, and all of them were continent. Four patients were sexually active. CONCLUSIONS: The incidence of RVF after rectal resection is low, but treatment outcomes are disappointing. Diversions and local repairs had high failure rates in our patients where the majority received preoperative radiation therapy. After successful healing, sexual function and continence are acceptable.

Function and disability status among women with fistula using WHODAS2.0: A descriptive study from Rwanda and Democratic Republic of Congo.

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.

Comparison of oncological outcomes and major complications between laparoscopic radical hysterectomy and abdominal radical hysterectomy for stage IB1 cervical cancer with a tumour size less than 2 cm.

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.

Incidence and Risk Factors for Postoperative Complications of Rectovaginal Fistula Repairs, Based on Different Surgical Routes.

OBJECTIVE: To investigate incidence and risk factors for postoperative complications after rectovaginal fistula (RVF) repairs, based on different surgical routes. METHODS: This retrospective cohort study utilized CPT codes to identify RVF repairs performed during 2005 to 2017 from the American College of Surgeons National Surgical Quality Improvement Program database. Demographic/clinical characteristics were compared among different surgical routes. Logistic regression was performed to identify associations. RESULTS: Among 1398 RVF cases, 1391 were included for final analysis: 159 (11.4%) were performed transabdominally (group 1), 253 (18.2%) transperineally (group 2), and 979 (70.4%) transvaginally/transanally (group 3). Group 1 was older compared with groups 2 and 3 (58.72 ± 15.23 years vs 44.11 ± 13.51 years vs 46.23 ± 14.31 years, P < 0.0001). Race/ethnicity was comparable in all groups with non-Hispanic-White most common. Comparably, group 1 had higher preoperative comorbidities: hypertension requiring medication (P < 0.0001), chronic obstructive pulmonary disease (COPD) (P = 0.0347), preoperative infection (P = 0.002), functional dependence (P = 0.0001), and longer time between hospital admission to operation (P < 0.0001). Group 1 also had longer operating time (P < 0.0001); more American Society of Anesthesiologist ≥ 3 classification (P < 0.0001); and more likely inpatient status (P < 0.0001). The overall incidence of any postoperative complications was 13.2% (25.2%, group 1 vs 15.8%, group 2 vs 10.6%, group 3; P < 0.0001). The most common postoperative complications included unplanned readmission, postoperative superficial surgical site infection, and reoperation. The incidence of severe postoperative complications was 7.9% (17%, group 1 vs 7.1%, group 2 vs 6.6%, group 3, P < 0.0001): group 1 had highest rates of pulmonary embolism (P = 0.0004), deep venous thrombosis (P = 0.0453), bleeding requiring transfusion (P < 0.0001), stroke (P = 0.0207), unplanned reintubation (P = 0.0052), and death (P = 0.0004). Group 1 also had highest rates of minor postoperative complications like urinary tract infection (P = 0.0151), superficial surgical site infection (P = 0.0189), and pneumonia (P = 0.0103). In addition, group 1 had the greatest postoperative length of stay (P < 0.0001). In multivariate analysis, age (P = 0.0096), inpatient status at the time of surgery (P = 0.0004), and operating time >2 to 3 hours (P = 0.0023) were significant predictors of postoperative complications within 30 days after surgery. CONCLUSIONS: The overall incidence of complications after RVF repairs+/-concomitant procedures was 13.2%. The overall incidence of severe complications was 7.9%. The abdominal approach had more postoperative complications but it was not an independent predictor of postoperative complications after RVF repair.

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.

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.

[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.

The mobile surgical outreach program for management of patients with genital fistula in the Democratic Republic of Congo.

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.

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.

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.

Prevesical peritoneum interposition to prevent risk of rectovaginal fistula after en bloc colorectal resection with hysterectomy for endometriosis: Results of a pilot study.

OBJECTIVE: To evaluate the risk of rectovaginal fistula after en bloc hysterectomy and colorectal resection (H-CR) for endometriosis using prevesical peritoneum interposition. STUDY DESIGN: A retrospective study conducted at Tenon University Hospital, expert center in endometriosis, from June 2016 to June 2018. Patients undergoing H-CR with prevesical peritoneum interposition without protective defunctioning stoma were included. RESULTS: Of the 160 patients who underwent surgery with colorectal resection for endometriosis during the study period, 27 had H-CR (15 with segmental and 12 with discoïd colorectal resection) and were included. The median age (range) was 45 years (41-47.5). Eight patients (13 %) were nulliparous. All procedures were performed by laparoscopy. Parametrial resection was performed in 14 cases (52 %). Associated bowel procedures were ileocecal resection (n = 5) and appendectomy (n = 2). Median follow-up (range) was 14.6 months (10.5-20.2). Nine (33.3 %) patients experienced intra- or postoperative complications including one grade I, four grade II, two grade IIIA and two grade IIIB complications (Clavien-Dindo classification). Seven patients (26 %) experienced postoperative voiding dysfunction. One suspicion of rectovaginal fistula associated with pelvic abscess was diagnosed 4 weeks after surgery but not confirmed during a second operation. CONCLUSION: Despite the small sample size, the present pilot study supports the practice of prevesical peritoneum interposition to limit the risk of rectovaginal fistula in patients who undergo H-CR for deep endometriosis.

Experiences of Rectovaginal Fistula in Anorectal Malformation.

BACKGROUND: Rectovaginal fistulas (RVFs) are very rare malformations in females with anorectal malformations (ARMs). Here, we share the clinical features of RVF and report the long-term outcomes. METHODS: RVF patients were classified using a retrospective analysis of ARM patients who underwent operations at Seoul National University Hospital between January 1999 and May 2017. The Krickenbeck continence scoring system was used to evaluate bowel function 5 and 10 years after surgery. RESULTS: Of the total 460 ARM patients, 203 were female, 7 of whom were diagnosed with RVF. The median age and weight at the time of anorectoplasty were 292 days (range, 140-617) and 8.2 kg (range, 5.5-12), respectively. Six patients had associated anomalies and three patients underwent redo-anorectoplasty. Voluntary bowel movements were observed in 6 out of 7 patients at 5 and 10 years of age. Soiling was observed in all patients at the age of five years and in 6 out of 7 patients at the age of ten years. Constipation was observed in 6 out of 7 patients at both five and ten years of age. CONCLUSIONS: An RVF is a very rare malformation, accounting for 1.5% of total ARMs and 3.4% of ARMs in females. Long-term counseling, education, and guidance are needed for effective management of patients' bowel movements. TYPE OF STUDY: Prognosis study LEVEL OF EVIDENCE: Level IV.

"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.

Is there a relationship between female genital mutilation/cutting and fistula? A statistical analysis using cross-sectional data from Demographic and Health Surveys in 10 sub-Saharan Africa countries.

OBJECTIVES: Literature on associations between female genital mutilation/cutting (FGM/C) and fistula points to a common belief that FGM/C predisposes women to developing fistula. This study explores this association using nationally representative survey data. DESIGN: A secondary statistical analysis of cross-sectional data from Demographic and Health Surveys was conducted to explore the association between FGM/C and fistula. SETTING: Sub-Saharan Africa. PARTICIPANTS: Women aged 15-49 years in Burkina Faso (n=17 087), Chad (n=17 719), Côte d'Ivoire (n=10 060), Ethiopia (n=14 070), Guinea (n=9142), Kenya (n=31 079), Mali (n=10 424), Nigeria (n=33 385), Senegal (n=15 688) and Sierra Leone (n=16 658). MAIN OUTCOME MEASURES: Fistula symptoms. RESULTS: Multivariate logit modelling using pooled data from 10 countries showed that the odds of reporting fistula symptoms were 1.5 times (CI 1.06 to 2.21) higher for women whose genitals were cut and sewn closed than those who had undergone other types of FGM/C. Women who attended antenatal care (ANC) (adjusted odds ratio (AOR) 0.51, CI 0.36 to 0.71) and those who lived in urban areas (AOR 0.62, CI 0.44 to 0.89) were less likely to report fistula symptoms than those who did not attend ANC or lived in rural areas. CONCLUSIONS: Severe forms of FGM/C (infibulation) may predispose women to fistula. Contextual and socioeconomic factors may increase the likelihood of fistula. Multisectoral interventions that concurrently address harmful traditional practices such as FGM/C and other contextual factors that drive the occurrence of fistula are warranted. Promotion of ANC utilisation could be a starting point in the prevention of fistulas.

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.

Update on the Natural Course of Fistulizing Perianal Crohn's Disease in a Population-Based Cohort.

BACKGROUND: This study sought to re-estimate the cumulative incidence of perianal or rectovaginal fistulas and the associated proctectomy rate in the prebiologic era vs the biologic era using a population-based cohort of Crohn's disease (CD) patients. METHODS: The medical records of 414 residents of Olmsted County, Minnesota, who were diagnosed with CD between 1970 and 2010 were reviewed. The cumulative incidence of perianal or rectovaginal fistulas from time of CD diagnosis and the cumulative rate of proctectomy from date of first perianal or rectovaginal fistula diagnosis were estimated using the Kaplan-Meier method. RESULTS: Eighty-five patients (20.5%) diagnosed with CD between 1970 and 2010 had at least 1 perianal or rectovaginal fistula episode between January 1, 1970, and June 30, 2016. The cumulative incidence of perianal or rectovaginal fistulas was 18% after 10 years, 23% after 20 years, and 24% after 30-40 years from CD diagnosis. The cumulative incidence of perianal or rectovaginal fistulas was significantly lower in patients diagnosed in 1998 or after than in patients diagnosed before 1998 (P = 0.03, log-rank). Among 85 patients developing perianal or rectovaginal fistulas, 16 patients (18.8%) underwent proctectomy for the treatment of perianal or rectovaginal fistulas during follow-up. CONCLUSIONS: In a population-based inception cohort of CD, one-fifth of patients were diagnosed with at least 1 perianal or rectovaginal fistula. The cumulative probability of perianal or rectovaginal fistulizing disease has decreased over time.

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.

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.