Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report.

BACKGROUND: Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define-for the first time-the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally. METHODS AND FINDINGS: The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries-who only made up 21% of the total attendees. CONCLUSIONS: To track global progress towards timely access to quality SAO care, these indicators-at the basic level-should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.

Frequency and management of non-obstetric fistula in the Democratic Republic of Congo: experience from the Fistula Care Plus project.

OBJECTIVE: To describe the frequency, causes and post-repair outcomes of NOF in hospitals supported by the Fistula Care Plus (FC+) project in the Democratic Republic of Congo. METHODS: Retrospective cohort study from 1 January 2015 to 31 December 2017 in three FC + supported fistula repair sites. RESULTS: Of 1984 women treated for female genital fistula between 2015 and 2017 in the three FC + supported hospitals, 384 (19%) were considered to be non-obstetric fistula (NOF) cases. 49.3% were married/in a relationship at the time of treatment vs. 69% before the fistula, P < 0.001. Type III (n = 247; 64.3%) and type I (n = 121; 31.5%) fistulas according to Kees/Waaldijk classification were the most common. The main causes of NOF were medical procedure (n = 305; 79.4%); of these, caesarean section (n = 234; 76.7%) and hysterectomy (n = 54; 17.7%) were the most common. At hospital discharge, the fistula was closed and dry in 353 women (95.7%). CONCLUSION: Non-obstetric fistula, particularly due to iatrogenic causes, was relatively common in the DRC, calling for more prevention that includes improved quality of care in maternal health services.

OBJECTIF: Décrire la fréquence, les causes et les résultats post-réparation de la fistule non obstétricale (FNO) dans les hôpitaux soutenus par le projet Fistula Care Plus (FC+) en République Démocratique du Congo. MÉTHODES: Etude de cohorte rétrospective du 1er janvier 2015 au 31 décembre 2017 dans trois sites de réparation de fistules soutenus par FC+. RÉSULTATS: Sur 1984 femmes traitées pour une fistule génitale féminine entre 2015 et 2017 dans les trois hôpitaux soutenus par FC+, 384 (19%) étaient considérées comme des cas de FNO. 49,3% étaient mariées/en couple au moment du traitement contre 69% avant la fistule, p <0,001. Les fistules de type III (n = 247; 64,3%) et de type I (n = 121; 31,5%) selon la classification de Kees/Waaldijk étaient les plus courantes. Les principales causes de FNO étaient la procédure médicale (n = 305; 79,4%); parmi lesquelles les césariennes (n = 234; 76,7%) et l'hystérectomie (n = 54; 17,7%) étaient les plus courantes. A la sortie de l'hôpital, la fistule était fermée et sèche chez 353 femmes (95,7%). CONCLUSION: La FNO, en particulier due à des causes iatrogènes, était relativement courante en RDC, appelant à plus de prévention qui comprend l'amélioration de la qualité des soins dans les services de santé maternelle.

An International Continence Society (ICS) report on the terminology for female pelvic floor fistulas.

INTRODUCTION: The terminology for female pelvic floor fistulas (PFF) needs to be defined and organized in a clinically based consensus Report. METHODS: This Report combines the input of members of the International Continence Society (ICS) assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give a coding to definitions. An extensive process of 19 rounds of internal and external review was involved to examine each definition, with decision-making by collective opinion (consensus). RESULTS: A terminology report for female PFF, encompassing 416 (188 NEW) separate definitions, has been developed. It is clinically based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in different specialty groups involved in female pelvic floor dysfunction and PFF. Female-specific imaging (ultrasound, radiology, and magnetic resonance imaging) and conservative and surgical PFF managements as well as appropriate figures have been included to supplement and clarify the text. Interval (5-10 years) review is anticipated to keep the document updated and as widely acceptable as possible. CONCLUSION: A consensus-based terminology report for female PFF has been produced to aid clinical practice and research.

Correction to: Global surgery and the World Health Organization: indispensable partners to achieve triple billion goals.

The legend of the Figure currently reads: "A formula for advancing surgical system strengthening and World Health Assembly resolution 68.15 through the World Health Organization's thirteenth General Programme of Work (GPW-13). This graphic depicts the three strategic shifts outlined in GPW-13 and ties them to specific avenues for surgical system strengthening to achieve overarching goals. GPW-13 = Thirteenth General Programme of Work; NSOAPs = National Surgical, Obstetric, and Anesthesia Plans; PHC = primary healthcare; SDG 3 = Sustainable Development Goal 3; UHC = universal health coverage; WHA 68.18 = World Health Assembly resolution 68.15. " The corrected Figure legend should read: A formula for advancing surgical system strengthening and World Health Assembly resolution 68.15 through the World Health Organization's thirteenth General Programme of Work (GPW-13). This graphic depicts the three strategic shifts outlined in GPW-13 and ties them to specific avenues for surgical system strengthening to achieve overarching goals. GPW-13 = Thirteenth General Programme of Work; NSOAPs = National Surgical, Obstetric, and Anesthesia Plans; PHC = primary healthcare; SDG 3 = Sustainable Development Goal 3; UHC = universal health coverage; WHA 68.15 = World Health Assembly resolution 68.15.

Demand and capacity to integrate pelvic organ prolapse and genital fistula services in low-resource settings.

INTRODUCTION AND HYPOTHESIS: There is a need for expanded access to safe surgical care in low- and middle-income countries (LMICs) as illustrated by the report of the 2015 Lancet Commission on Global Surgery. Packages of closely-related surgical procedures may create platforms of capacity that maximize impact in LMIC. Pelvic organ prolapse (POP) and genital fistula care provide an example. Although POP affects many more women in LMICs than fistula, donor support for fistula treatment in LMICs has been underway for decades, whereas treatment for POP is usually limited to hysterectomy-based surgical treatment, occurring with little to no donor support. This capacity-building discrepancy has resulted in POP care that is often non-adherent to international standards and in non-integration of POP and fistula services, despite clear areas of similarity and overlap. The objective of this study was to assess the feasibility and potential value of integrating POP services at fistula centers. METHODS: Fistula repair sites supported by the Fistula Care Plus project were surveyed on current demand for and capacity to provide POP, in addition to perceptions about integrating POP and fistula repair services. RESULTS: Respondents from 26 hospitals in sub-Saharan Africa and South Asia completed the survey. Most fistula centers (92%) reported demand for POP services, but many cannot meet this demand. Responses indicated a wide variation in assessment and grading practices for POP; approaches to lower urinary tract symptom evaluation; and surgical skills with regard to compartment-based POP, and urinary and rectal incontinence. Fistula surgeons identified integration synergies but also potential conflicts. CONCLUSIONS: Integration of genital fistula and POP services may enhance the quality of POP care while increasing the sustainability of fistula care.

Hysteropexy compared to hysterectomy for uterine prolapse surgery: does durability differ?

INTRODUCTION AND HYPOTHESIS: The aim of this study is to assess the impact of hysterectomy on durability of uterine prolapse repair by comparing hysterectomy/uterosacral cuff suspension (VH) to a new vaginal uterosacral hysteropexy (USH). METHODS: A retrospective chart review of uterine prolapse patients after USH or VH with concomitant procedures as indicated was conducted, analyzing Baden-Walker grading of apex, anterior, and posterior compartments (Kaplan-Meier analysis) Baden et al. (Tex Med 64(5):56-58, 1968). RESULTS: A total of 200 charts met criteria. USH women weighed less, were younger, and more constipated with larger rectoceles. Levator parameters did not differ Romanzi et al. (Neurourol Urodyn 18(6):603-612, 1999). Baden-Walker data were entered at recurrence or minimum of 6 months (2.4 months-10 years; median, 1.5 years). All-apex durability was 96.4%, with no difference between hysteropexy and cuff suspension (96.0% vs. 96.8%, p = 0.90), cystocele (86.8% vs. 93.8%, p = 0.31), or rectocele (97.8% vs. 100%, p = 0.16) at 2 years. CONCLUSION: In uterine prolapse patients, technically similar uterosacral hysteropexy durability did not differ from hysterectomy-based cuff suspension nor between cohorts for cystocele or rectocele.

Toward a complete estimate of physical and psychosocial morbidity from prolonged obstructed labour: a modelling study based on clinician survey.

INTRODUCTION: Prolonged obstructed labour often results from lack of access to timely obstetrical care and affects millions of women. Current burden of disease estimates do not include all the physical and psychosocial sequelae from prolonged obstructed labour. This study aimed to estimate the prevalence of the full spectrum of maternal and newborn comorbidities, and create a more comprehensive burden of disease model. METHODS: This is a cross-sectional survey of clinicians and epidemiological modelling of the burden of disease. A survey to estimate prevalence of prolonged obstructed labour comorbidities was developed for prevalence estimates of 27 comorbidities across seven categories associated with prolonged obstructed labour. The survey was electronically distributed to clinicians caring for women who have suffered from prolonged obstructed labour in Asia and Africa. Prevalence estimates of the sequelae were used to calculate years lost to disability for reproductive age women (15 to 49 years) in 54 low- and middle-income countries that report any prevalence of obstetric fistula. RESULTS: Prevalence estimates were obtained from 132 participants. The median prevalence of reported sequelae within each category were: fistula (6.67% to 23.98%), pelvic floor (6.53% to 8.60%), genitourinary (5.74% to 9.57%), musculoskeletal (6.04% to 11.28%), infectious/inflammatory (5.33% to 9.62%), psychological (7.25% to 24.10%), neonatal (13.63% to 66.41%) and social (38.54% to 59.88%). The expanded methodology calculated a burden of morbidity associated with prolonged obstructed labour among women of reproductive age (15 to 49 years old) in 2017 that is 38% more than the previous estimates. CONCLUSIONS: This analysis provides estimates on the prevalence of physical and psychosocial consequences of prolonged obstructed labour. Our study suggests that the burden of disease resulting from prolonged obstructed labour is currently underestimated. Notably, women who suffer from prolonged obstructed labour have a high prevalence of psychosocial sequelae but these are often not included in burden of disease estimates. In addition to preventative and public health measures, high quality surgical and anaesthesia care are urgently needed to prevent prolonged obstructed labour and its sequelae.

Fistula recurrence, pregnancy, and childbirth following successful closure of female genital fistula in Guinea: a longitudinal study.

BACKGROUND: Female genital fistula is a devastating maternal complication of delivery in developing countries. We sought to analyse the incidence and proportion of fistula recurrence, residual urinary incontinence, and pregnancy after successful fistula closure in Guinea, and describe the delivery-associated maternal and child health outcomes. METHODS: We did a longitudinal study in women discharged with a closed fistula from three repair hospitals supported by EngenderHealth in Guinea. We recruited women retrospectively (via medical record review) and prospectively at hospital discharge. We used Kaplan-Meier methods to analyse the cumulative incidence, incidence proportion, and incidence ratio of fistula recurrence, associated outcomes, and pregnancy after successful fistula closure. The primary outcome was recurrence of fistula following discharge from repair hospital in all eligible women who consented to inclusion and could provide follow-up data. FINDINGS: 481 women eligible for analysis were identified retrospectively (from Jan 1, 2012, to Dec 31, 2014; 348 women) or prospectively (Jan 1 to June 20, 2015; 133 women), and followed up until June 30, 2016. Median follow-up was 28·0 months (IQR 14·6-36·6). 73 recurrent fistulas occurred, corresponding to a cumulative incidence of 71 per 1000 person-years (95% CI 56·5-89·3) and an incidence proportion of 18·4% (14·8-22·8). In 447 women who were continent at hospital discharge, we recorded 24 cases of post-repair residual urinary incontinence, equivalent to a cumulative incidence of 23·1 per 1000 person-years (14·0-36·2), and corresponding to 10·3% (5·2-19·6). In 305 women at risk of pregnancy, the cumulative incidence of pregnancy was 106·0 per 1000 person-years, corresponding to 28·4% (22·8-35·0) of these women. Of 50 women who had delivered by the time of follow-up, only nine delivered by elective caesarean section. There were 12 stillbirths, seven delivery-related fistula recurrences, and one maternal death. INTERPRETATION: Recurrence of female genital fistula and adverse pregnancy-related maternal and child health outcomes were frequent in women after fistula repair in Guinea. Interventions are needed to safeguard the health of women after fistula repair. FUNDING: Belgian Development Cooperation (DGD), Institute of Tropical Medicine of Antwerp (ITM), and Maferinyah Training and Research Center in Rural Health (Guinea).

Management of the urethral outlet in patients with severe prolapse.

PURPOSE OF REVIEW: Numbers of women seeking consultation for pelvic floor disorders, a large portion of which will involve pelvic organ prolapse (POP) and lower urinary tract dysfunction, are expected to reach epidemic proportions within the next decade. A full understanding of the complex impact of pelvic organ prolapse on lower urinary tract function is crucial to successful management. RECENT FINDINGS: Recent data lend support to the concept that women with POP, but no associated urethral dysfunction, may be best served by a surgical repair that carefully avoids dissection in the periurethral area. Conversely, preoperative evaluation will often reveal bladder outlet obstruction concomitant with 'hidden', 'potential', or 'occult' stress urinary incontinence when the prolapse is reduced. Many of these women will not have incontinence symptoms in daily life. Paradoxically, the mechanical bladder outlet obstruction may induce detrusor instability with subsequent obstructed/overactive bladder symptom complexes not dissimilar to those of men with prostatic bladder outlet obstruction. Anatomic research shows that the vessels and nerves supplying the urethra are particulary vulnerable to surgical techniques used in pelvic organ prolapse repair. SUMMARY: This mix of obstructed, overactive bladder with hidden stress incontinence increases with degree of POP, and all women with severe prolapse will fair best if evaluated for all three conditions prior to surgical repair.