•Data on surgical outcomes and complications of radical hysterectomy in low-income countries (LICs) is scant.•Extensive retroperitoneal fibrosis following radical hysterectomy and pelvic ...lymphadenectomy can complicate fistula repair.•Fistula repair following radical hysterectomy can require complex urogenital reconstruction techniques.•Fistula repair following radical hysterectomy can require extensive bowel surgery.
Complications from radical hysterectomy in low-income countries (LICs) are largely unreported in the medical literature. We report on three cases of urinary tract reconstruction performed at the Fistula Care Center (FCC) in Lilongwe, Malawi for iatrogenic fistula following radical hysterectomy. These cases demonstrate the diversity and complexity of reconstruction techniques required and emphasize the need for careful tracking of surgical outcomes of radical hysterectomy.
Obstructed labor leading to a vesicovaginal fistula remains a devastating outcome of childbirth in low-resource countries. Women with an irreparable vesicovaginal fistula may be candidates for a ...urinary diversion, such as the Mainz II modified ureterosigmoidostomy procedure. Previous reviews state that the procedure should be considered in low-resource countries. However, given the limited duration of postoperative follow-up, these studies do not adequately represent the long-term morbidity and mortality that is likely associated with this procedure. We present data that strongly support avoiding the procedure in low-resource countries.
This study aimed to evaluate the postoperative status of the patient (dead, alive, lost to follow-up) and time to death following the Mainz II procedure.
This is a case series including 21 patients who underwent a Mainz II urinary diversion from April 2013 to June 2015 for management of irreparable vesicovaginal fistula at the Fistula Care Centre in Lilongwe, Malawi. Patients were seen postoperatively at 3, 6, 9, and 12 months, followed by every 6 to 12 months thereafter. Descriptive statistics were performed to summarize the data.
During the postoperative period, 8 (38.1%; 8/21) patients died, 5 (23.8%; 5/21) were lost to follow-up, and 8 (38.1%; 8/21) are currently alive and followed up at the Fistula Care Centre. We strongly suspect that 7 of the 8 deaths were related to the procedure given that the patients had illnesses that exacerbated the metabolic consequences of the procedure. The eighth patient died after being attacked by robbers. Unfortunately, the exact cause of death could not be determined for these patients. Given that most of the suspected illnesses would be treatable in an otherwise healthy patient, even in this low-resource setting, we surmised that the metabolic compromise from the Mainz II procedure likely contributed to their untimely death. The average time from procedure to death was 58 months, with the earliest death at 10 months and the most recent at 7 years after the procedure.
The Mainz II procedure is an option for patients with irreparable fistula. However, it should likely not be performed in low-resource countries given the long-term complications that often cannot be adequately addressed in these settings, leading to significant morbidity and mortality.
Obstetric fistula (OF) is a maternal morbidity associated with high rates of stillbirth, amenorrhea, and sexual dysfunction. Limited data exists on the reproductive outcomes of women in the years ...following a fistula repair. The objective of this study is to describe the fertility outcomes and family planning practices in a population of Malawian women 1-4 years after fistula repair.
Women who had enrolled into a clinical database of OF patients and undergone OF repair between January 1, 2012 and July 31, 2014 were recruited and enrolled to complete a home-based survey of their demographic and reproductive health data 1-4 years after their repair. Pregnancy, amenorrhea, and sexual function were described using frequency analysis, and we compared antimüllerian hormone (AMH) concentrations between women with menses or pregnancy with women with amenorrhea or no pregnancy using Wilcoxon rank sum tests.
Of 297 women with a prior OF repair, 148 had reproductive potential and were included in this analysis. Overall 30 women of these women (21%) became pregnant since their fistula repair, with most pregnancies ending with cesarean delivery. Of the 32 women who were amenorrheic at the time of repair, 25 (78.1%) had resumption of menses. Only 11 (8.6%) of sexually active women reported dyspareunia, and among women who were not trying to conceive, 53.1% were currently using a method of family planning. No significant differences were found in AMH concentrations between those who were pregnant or had menses versus those without pregnancy or menses, respectively.
In this long-term follow-up study of women after OF repair, many women were able to achieve a pregnancy with a live birth, have normal menses, be sexually active, and access contraception. These achievements will further assist a population of women whose reintegration and restoration of dignity is closely tied to their ability to achieve their reproductive goals.
ClinicalTrials.gov Identifier: NCT02685878 .
Globally, obstetric fistula is a tragic outcome following obstructed labour. Failure of complex repair and post-operative incontinence are common. We describe an innovative surgical technique ...incorporating the rectus abdominus flap at the time of fistula repair.OBJECTIVEGlobally, obstetric fistula is a tragic outcome following obstructed labour. Failure of complex repair and post-operative incontinence are common. We describe an innovative surgical technique incorporating the rectus abdominus flap at the time of fistula repair.Retrospective case series.DESIGNRetrospective case series.Malawi, Fistula Care Centre.SETTINGMalawi, Fistula Care Centre.Patients were followed for 3 months after discharge to determine continence and healing.METHODSPatients were followed for 3 months after discharge to determine continence and healing.Five of six patients were continent at 3 months and one was lost to follow-up by dry at a one month post-operative phone call. There were no major complications.RESULTSFive of six patients were continent at 3 months and one was lost to follow-up by dry at a one month post-operative phone call. There were no major complications.The rectus abdominus flap may be a useful adjunct to repair of complex obstetric fistula.CONCLUSIONSThe rectus abdominus flap may be a useful adjunct to repair of complex obstetric fistula.
Objective. Obstetric fistula (OF) is a morbid condition caused by prolonged obstructed labor. Women with OF experience profound injury and have high rates of infertility and poor obstetric outcomes. ...We examined endovaginal ultrasound parameters in women with and without OF. Design/Setting/Sample/Methods. This cross-sectional study enrolled women evaluated at the Fistula Care Centre in Lilongwe, Malawi. Eligibility criteria included age 18–45, prior pregnancy, and a uterus on ultrasound. Participants underwent endovaginal ultrasound with measurement of cervical dimensions. Comparisons were done using t-tests and Fisher's exact test. Among women with OF, linear regression was used to assess whether fistula stage was associated with cervical length. Results. We enrolled 98 cases and 12 controls. Women with OF had shorter cervical lengths (18.8 mm versus 27.3 mm, p < 0.01), as well as shorter anterior (7.0 mm versus 9.3 mm, p < 0.01) and posterior (9.5 mm versus 11.0 mm, p < 0.04) cervical stroma, compared to controls. Conclusion. Women with OF have shorter cervical lengths and anterior and posterior cervical stroma, when compared to women without OF. This may offer a partial explanation for subfertility and poor obstetric outcomes in OF patients. Additional studies to clarify the role of ultrasound in OF patients and prediction of future fertility are warranted.
OBJECTIVE:To develop a risk score to identify women with vesicovaginal fistula at high risk of residual urinary incontinence after surgical repair.
METHODS:We conducted a prospective cohort study ...among 401 women undergoing their first vesicovaginal fistula repair at a referral fistula repair center in Lilongwe, Malawi, between September 2011 and December 2014, who returned for follow-up within 120 days of surgery. We used logistic regression to develop a risk score to identify women with a high likelihood of residual urinary incontinence, defined as incontinence grade 2–5 within 120 days of vesicovaginal fistula repair, based on preoperative clinical and demographic characteristics (age, number of years with fistula, human immunodeficiency virus status, body mass index, previous repair surgery at an outside facility, revised Goh classification, Goh vesicovaginal fistula size, circumferential fistula, vaginal scaring, bladder size, and urethral length). The sensitivity, specificity, and positive and negative predictive values of the risk score at each cut point were assessed.
RESULTS:Overall, 11 (3%) women had unsuccessful fistula closure. Of those with successful fistula closure (n=372), 85 (23%) experienced residual incontinence. A risk score cut point of 20 had sensitivity of 82% (95% confidence interval CI 72–89%) and specificity 63% (95% CI 57–69%) to potentially identify women with residual incontinence. In our population, the positive predictive value for a risk score cut point of 20 or higher was 43% (95% CI 36–51%) and the negative predictive value was 91% (95% CI 86–94%). Forty-eight percent of our study population had a risk score 20 or greater and, therefore, would have been identified for further intervention.
CONCLUSION:A risk score of 20 or higher was associated with an increased likelihood of residual incontinence with satisfactory sensitivity and specificity. If validated in alternative settings, the risk score could be used to refer women with a high likelihood of postoperative incontinence to more experienced surgeons.
Objective
We evaluated residual incontinence, depression, and quality of life among Malawian women who had undergone vesicovaginal fistula (VVF) repair 12 or more months previously.
Design
...Prospective cohort study.
Setting
Fistula Care Centre in Lilongwe, Malawi.
Population
Women who had undergone VVF repair in Lilongwe, Malawi at least 12 months prior to enrolment.
Methods
Self‐report of urinary leakage was used to evaluate for residual urinary incontinence; depression was evaluated with the Patient Health Questionnaire‐9; quality of life was evaluated with the King's Health Questionnaire.
Main outcome measures
Prevalence and predictors of residual incontinence, quality of life scores, and prevalence of depression and suicidal ideation.
Results
Fifty‐six women (19.3%) reported residual urinary incontinence. In multivariable analyses, predictors of residual urinary incontinence included: pre‐operative Goh type 3 adjusted risk ratio (aRR) 2.82; 95% confidence interval (CI) 1.61–5.27) or Goh type 4 1.08–2.78), positive postoperative cough stress test (aRR = 2.42; 95% CI 1.24–4.71) and the positive 1‐hour postoperative pad test (aRR = 2.20; 95% CI 1.08–4.48). Women with Goh types 3 and 4 VVF reported lower quality of life scores. Depressive symptoms were reported in 3.5% of women; all reported residual urinary incontinence.
Conclusions
While the majority of women reported improved outcomes in the years following surgical VVF repair, those with residual urinary incontinence had a poorer quality of life. Services are needed to identify and treat this at‐risk group.
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Nearly one in five women reported residual urinary incontinence at follow up, 12 or months after vesicovaginal fistula repair.
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Nearly one in five women reported residual urinary incontinence at follow up, 12 or months after vesicovaginal fistula repair.
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