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.

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.

Sexual Function Before and After Vesicovaginal Fistula Repair.

INTRODUCTION: Women with vesicovaginal fistulas often experience a disruption in their normal lives, including sexual relationships, because of urinary incontinence. AIM: Although surgery repairs the urinary leakage, it is not known how surgery might affect sexual function positively or negatively. METHODS: 119 women were enrolled before surgery and interviewed including a revised Female Sexual Distress Scale (FSDS-R) score and examined for vaginal length, caliber, and pelvic floor strength. MAIN OUTCOME MEASURES: Approximately one third of women return to normal sexual function after repair, although a minority experience de novo dysfunction. RESULTS: 115 women completed follow-up 6 to 12 months after surgery. Approximately one third (35.6%, n = 41) stated that intercourse had returned to the way it was before a fistula. Forty-four women (40%) report sexual problems after the fistula developed; 15% due to incontinence and 23.5% due to pain. Fourteen women (12.2%) stated that they experienced problems with intercourse since surgery; 50% due to incontinence during intercourse and 50% due to pain. Nineteen of the participants (16.5%) scored in the range of dysfunction as assessed by the FSDS-R tool after surgery. Fibrosis did not significantly change and was not found to be associated with sexual function. Vaginal length was found to decrease on average by 5 mm. Of the variables examined, the factors statistically significantly associated with dysfunction included a larger-size fistula as determined by the Goh classification (> 3 cm diameter) and decreased vaginal caliber. FSDS-R scores drastically decreased from before to after surgery and the reason for problems with intercourse changed from leaking urine before surgery to lack of partner and concern for HIV infection. CLINICAL IMPLICATIONS: Women with large fistulas and decreased vaginal calibers are at high risk for sexual dysfunction and should be counseled appropriately preoperatively and offered surgical and medical interventions. STRENGTHS & LIMITATIONS: Physical parameters were combined with qualitative interviews and FSDS-R scores to contextualize sexual health before and after surgery. Limitation is the brief follow-up of 6-12 months after surgery as many women were still abstaining from sexual activity. CONCLUSION: Sexual dysfunction is a complex issue for women with obstetric fistulas; although many women do not continue to experience problems, several need ongoing counseling and treatment. Pope R, Ganesh P, Chalamanda C, et al. Sexual Function Before and After Vesicovaginal Fistula Repair. J Sex Med 2018;15:1125-1132.

Long-term outcomes for women after obstetric fistula repair in Lilongwe, Malawi: a qualitative study.

BACKGROUND: Obstetric fistula affects a woman's life physically, psychosocially, and economically. Although surgery can repair the physical damage of fistula, the devastating consequences that affect a woman's quality of life may persist when she reintegrates into her community. This qualitative study assessed long-term outcomes among women who underwent obstetric fistula repair in Malawi. We explored three domains: overall quality of life before and after repair, fertility and pregnancy outcomes after repair, and understanding of fistula. METHODS: In-depth interviews were conducted in Chichewa with 20 women from seven districts across Central Malawi. All women were interviewed 1 to 2 years after surgical repair for obstetric fistula at the Fistula Care Centre in Lilongwe, Malawi. Interviews were independently coded and analyzed using content analysis. RESULTS: About half of women were married and nine of 20 women reported some degree of urinary incontinence. With the exception of relationship challenges, women's concerns before and after repair were different. Additionally, repair had resolved many of the concerns women had before repair. However, challenges, both directly and indirectly related to fistula, persisted. Improvements in quality of life at the individual level included feelings of freedom, confidence and personal growth, and improved income-earning ability. Interpersonal quality of life improvements included improved relationships with family and friends, reduced stigma, and increased participation with their communities. Nearly half of women desired future pregnancies, but many were uncertain about their ability to bear children and feared additional pregnancies could cause fistula recurrence. Most women were well informed about fistula development but myths about witchcraft and fear of delivery were present. Nearly all women would recommend fistula repair to other women, and many were advocates in their communities. CONCLUSIONS: Nearly all women believed their quality of life had improved at the individual and interpersonal levels since fistula repair, even among women who continued to have urinary incontinence. Contrary to other studies, women reported they were welcomed back by their communities and had limited challenges when reintegrating. Despite the overall improvements in quality of life, many continued to have relationship problems and were concerned about future fertility. These issues need to be further explored in other studies.

A Comparison of Postoperative Surgical Outcomes among Women Undergoing Obstetric Fistula Repair with and without HIV.

BACKGROUND AND OBJECTIVE: Obstetric fistula affects approximately 2 million women worldwide, predominantly in places with a high Human Immunodeficiency Virus (HIV) burden. In Malawi, where thousands of women live with fistulas, HIV prevalence is 11-13%. Although repair is usually successful, surgical outcomes among immunocompromised women are poorly understood. Inconsistent guidelines regarding the Cluster of Differentiation 4 (CD4) threshold necessary for repair make it difficult for surgeons to make informed decisions. This study compares the postoperative outcomes of women undergoing obstetric fistula repair with and without HIV, stratified by CD4 count. METHODS: This is a retrospective case-control study using a database of women who underwent vesicovaginal fistula repair at the Fistula Care Center from 2010-2018. HIV-positive participants, stratified by CD4<350 and CD4>350, were matched to HIV-negative controls by age within 5 years and Goh classification. Controls were matched to cases in a 3:1 ratio. Bivariate analysis and logistic regression were conducted on indicators based on HIV status and CD4 count stratification. Outcomes included dye test results, pad weights, and continence status at 2 weeks post-repair. RESULTS: 54 seropositive women were matched to 135 seronegative women. Of the 54 HIV positive women, 22.2% (n=12) had a CD4 count < 350. We found no statistically significant difference in surgical outcomes between HIV-positive and negative patients. 93.5% of HIV positive and 90% of HIV negative women healed completely. In our sub-analysis of 12 seropositive women with CD4<350, we found a statically significant difference in successful closure, with 25% of women with CD4<350 having a positive dye test indicating incomplete closure, compared to 2.8% of women with CD4>350 (p=0.024). CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: Our analysis confirms previous research indicating that seropositive women with a CD4>350 can safely undergo obstetric fistula repair. Further research is needed to evaluate postoperative outcomes among women with CD4<350.

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.