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The latest obstetric fistula research summarized for you in one place.
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March 2017

 

Fistula Research Update

 

Presented by Texas Children's® Global Women's Education, Research and Care Program
@TCHglobalWERC

Fistula patients in Madagascar.
With the new year, we are introducing a new way to communicate up-to-date research on obstetric fistula. This newsletter is open to researchers, fistula surgeons, medical providers, nurses, social activists and advocates. We hope that it is shared widely and that it will help us all to reach the collective goal of ending fistula.
-Editors Rachel Pope, MD, MPH & Jeffrey Wilkinson, MD  
Baylor College of Medicine 
Texas Children's Global WERC
Prediction of Surgical Outcomes:
 
Several articles have been published in the last few months on predicting surgical outcomes for fistula repair. The following are some highlights: /rp
 
In Female Urology, Urodynamics, Incontinence, and Pelvic Floor Reconstructive Surgery, Loposso et al. publish work from the Democratic Republic of Congo, examining 166 women with an obstetric fistula from 2007-2013. Fistulas were classified according to the Waaldjik schema, and patients were examined 3 months after surgery. The authors found that although 71.7% of patients were completely cured (even if still wearing one security pad daily), 100% of type IIBb, 66.7% of type IIAb, and 41.2% IIAa fistulas failed. Of note, most fistulas in this cohort were juxta-cervical and 50.6% occurred either at the time of a cesarean section, although it is not clear whether the patients had experienced prolonged obstructed labour prior to the C/S. Patients with fibrosis were also found less likely to heal, although the extent of fibrosis is not specified. Urethral fistulas were 73% less likely to result in dryness whereas Martius flap, fibromuscular sling, and urethrobladder suspension as described by Waaldjik were not correlated with success or failure.  Preoperative classification of the fistula, and size of the fistula did not significantly predict outcome of surgery. A larger sample size and a classification for uniform reporting would be useful according to the authors. https://www.ncbi.nlm.nih.gov/pubmed/27496296
 

Commentary:  These authors  report on data for 166 women with obstetric fistula in the Congo.  Two salient take away points are critical from their report:  1.  The failure rate of advanced  stage fistula repairs remains stubbornly high and argues for the pursuit of better operative techniques to address these fistulas.  These techniques need to be validated in prospective cohort studies or preferably in randomized controlled trials.  Advanced repair techniques have progressed minimally in the last 20 years.  2.  This study shows that more women are presenting with obstetric fistula associated with cesarean deliveries; suggesting a trend towards women reaching care and ultimately receiving a cesarean delivery, but unfortunately, too late to save the baby or prevent fistula.  It also speaks to the quality of that care once received. /jw


In Obstetrics and Gynecology, Bengston and colleagues also look for prediction of incontinence after surgery. They prospectively followed 401 women undergoing primary repair in Malawi for four months after surgery. Using a scoring algorithm based on clinical and demographic characteristics, they found a score over 20 indicated a high risk for ongoing incontinence. Age older than 50 years, length of time with a fistula greater than 20 years, previous surgical attempts, an increasing fistula Goh classification type relevant to the urethra, moderate to severe scarring, circumferential fistula, and urethral length being 1.5 cm or less were all highly associated with residual incontinence. The authors suggest using the scoring tool prior to surgery to guide diagnostic purposes and to assist with referring patients to expert-level surgeons. The tool can be found: http://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/AOG/A/AOG_128_5_2016_09_28_BENGTSON_16-1156_SDC1.pdf
https://www.ncbi.nlm.nih.gov/pubmed/27741181
 

Commentary: Applying such a scoring system to junior, mid-level, and expert surgeons could help to risk-stratify patients and improve overall surgical success rates by properly allocating patients to surgeons abilities. It could also help to properly counsel patients prior to surgery. /rp


Beardmore-Gray et al. ask the question of predictability of Goh classification predicting surgical outcome in the developed world where most fistulas are iatrogenic. Published in the International Urogynecology Journal, they present the results of a single surgeon’s 68 cases over the span of eight years. Smaller fistulas (average of 1.4 cm) and younger age were associated with success. Whereas type 1 fistulas resulted in functional continence in 100% patients, type 4 fistulas only resulted in 75% continence. The authors conclude that the Goh classification may predict eventual continence in the developed world but due to more complex etiology of the fistulas compared to obstetric-related fistulas that predominate in low-resource settings, it is not predictive of anatomic closure.
https://www.ncbi.nlm.nih.gov/pubmed/27822888
 
Also in the International Urogynecology Journal, Lorencz et al. hypothesize that primiparous women are more likely to have more distal fistulas, with more extensive scarring and more frequently circumferential. Retrospectively examining the records of 1,856 women in Ethiopia, Sierra Leone, and Uganda, the following variables were analyzed against parity: Goh classification, the type and size of the fistula, and extent of scarring. Separately, ureteric involvement and the fistula being circumferential were analyzed against parity. Primiparous women were more likely to have type 4 fistulas or in general, more distal fistulas and moderate to severe scarring, however, they were equally as likely to have circumferential fistulas and ureteric involvement as multiparas. Whether a cesarean section was done is not indicated. https://www.ncbi.nlm.nih.gov/pubmed/27826639


As always, providing holistic care is important for women with fistulas. The following articles were published on the mental health of women with pelvic floor disorders and obstetric patterns after repair. /rp
 
Krause and colleagues interviewed 125 women with pelvic floor morbidities (prolapse, fistulas, and fourth degree lacerations) in Western Uganda using the General Health Questionnaire-28 to evaluate their mental health.  Compared to a control group, all types of pelvic floor morbidities were associated with scores reflective of a risk of mental health dysfunction. Interestingly, 40% of the controls also scored at risk of mental health dysfunction. More women with fistulas and fourth degree repairs reported suicidal ideation compared to pelvic organ prolapse.
https://www.ncbi.nlm.nih.gov/pubmed/27822885
 
In Tropical Medicine and International Health, Delamou reports on a literature review of obstetric outcomes after fistula closure. Their search led to a final analysis of 16 studies after excluding many others for relevance. Median followup of women was 30 months after surgery. An average of 17.4% became pregnant after repair, though reproductive potential is not noted in all studies. 86.5% of the pregnancies continued until term and two maternal deaths were noted. 5% resulted in a fistula recurrence. Stillbirths, recurrent fistula, and maternal death was found to be associated with vaginal delivery compared to cesarean section. The review comments on the barriers for women to deliver via scheduled cesarean sections after a fistula repair and argues for the need to facilitate transportation and to provide obstetric services for free in order to improve outcomes.
https://www.ncbi.nlm.nih.gov/pubmed/27596732

Commentary: As the ongoing struggle to prevent fistulas continue, the same cause for fistula occurrence continues to affect women without access to high quality obstetric care after fistula repair.  Women who have overcome the barriers to access fistula repair need extra support to prevent fistula recurrence. /rp

Special thanks to Freedom from Fistula Foundation
 http://www.freedomfromfistula.org.uk/  

and One By One www.fightfistula.org
 
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