This edition we have interesting articles on a new fistula scoring tool, public health perspectives on preventing fistulas and assisting women to access repair, an exciting celebration of FIGO's fellowship program, a review of slings for residual incontinence, and a comprehensive review of where we stand regarding research in our field. We hope you will enjoy! /rp
Panzi score as a parsimonious indicator of urogenital fistula severity derived from Goh and Waaldijk classifications
Mukwege D, Peters L, Amisi C, Mukwege A, Smith AR, Miller JM
Researchers at the Panzi Hospital in the Democratic Republic of Congo have created a new scoring system to measure severity of urogenital fistula. They combined components of the commonly used Waaldijk and Goh classification systems to develop a more simple, single evidence-based score. Multivariable analysis was applied to 837 urogenital fistula cases to find associations between probability of surgical failure and fistula characteristics based on Goh and Waaldijk categories. A single digit “Panzi score” from 0 (most minor) to 3 (most severe) was then derived by combining scores of three subcomponents: location (<2.5cm vs ≥2.5cm from external urethral orifice), size (> 3cm vs ≤ 3cm), and circumferential defect (yes or no). Women with higher scores, or more severe fistulas, had higher rates of surgical failure. Interestingly, the Goh component of fibrosis severity was not found to be predictive of surgical failure and was therefore not included in the score. The researchers hope that a single, comprehensive Panzi score will allow for better statistical analysis in future studies and help establish a cutoff score for complex fistulas that would require specialized care. Before widespread application of the new scoring system, however, definitive validation of the Panzi score will be needed. /ms
The Panzi score is simple and compelling. Generalizability to other centers and settings and validation as stated are key. Also, rates of failure at a specialized center may underestimate the need for referral from smaller centers because of the score being developed by the successes and failures of more highly skilled surgeons. /jw
“Poverty is the big thing”: exploring financial, transportation, and opportunity costs associated with fistula management and repair in Nigeria and Uganda
Keya KT, Sripad P, Nwala E, Warren CE
This is a qualitative study which was conducted in Uganda and Nigeria to explore financial, transport and opportunity cost barriers on fistula repair and management of women living with a fistula and those providing counseling and fistula repair. The two countries were chosen due to their ability to capture women with fistulas and care provider’s diverse experience of fistula care access, quality, treatment and reintegration. In the two countries, fistula repair services depend on donor funding and repairs are done for free.
The study conducted 107 in-depth interviews with women with fistulas and facilitated 14 focus group discussions with community stakeholders and post-repair clients. Keya et al found that in Uganda and Nigeria families prioritize needs especially food and children’s education over fistula repair because to get a fistula repair they have to sell property, household goods, cattle and crops. Choosing between food and repair delay care which shows that women are affected by the cost of care at home. The study further found that lack of transportation, road conditions, distance to the centre and stigma and rude remarks women receive while in transit due to foul smell from leaking also leads to women not getting surgery.
Despite the fact that fistula repair is free, transport cost is too much for most women for round trips as well as to cover costs for their escorts. After developing a fistula, women face social separation and divorce leading to loss of income as they cannot maintain their small businesses or attend to their farms due to physical limitation. Due to loss of income women borrow money from extended relatives or sell household goods or property to use for transport in order for them to access fistula repair. The authors recommend a quantitative study to estimate exact financial and transport costs women pay and innovative approaches to cover transportation costs for women. /sc
This study encourages programs such as the fistula ambassador program with the Freedom from Fistula Foundation, where former patients find other patients who live close to them and help facilitate their entry in to care. The pathway to cure involves much more than the surgery itself and the financial, emotional and physical costs of getting to a quality treatment center should be factored in to the decisions of any entity planning to provide this care. /jw
Barriers and facilitators to preventive interventions for the development of obstetric fistulas among women in sub-Saharan Africa: a systematic review
Lufumpa E, Doos L, Lindenmeyer A
This paper was a review of studies conducted in sub-Saharan Africa identifying barriers in preventing obstetric fistula. The three-phase delay model was used by the authors to compare 18 eligible studies, including accessibility of care, receiving adequate care and decision to seek care. The most noted barrier to prevention was decision to seek care as there was an overall lack of awareness of the dangers of unsupervised labor. The most noted facilitator was in seeking care, specifically high quality care. However, it was noted that many barriers are not limited to one phase. Barriers like access to care, limitations of finances, education and location of services were found to be interlinked. Facilitators to interventions aimed at prevention of fistula such as increased awareness of maternal and child morbidity, increased involvement of key members of the community and financial support is recommended. The authors conclude that the effectiveness of preventing obstetric fistula requires more research. /wn
Out of the Shadows and 6000 Reasons to Celebrate: An update from FIGO's fistula surgery training initiative
In an effort to tackle the backlog of women needing obstetric fistula repair, FIGO launched a surgical training program for OB/GYN, general surgeons, urologists, and urogynecologists.
With 52 fellows from 19 countries with high burden of women with OF, 40 have reached “standard” level of training, 10 have reached “advanced” level, and two are working towards “expert.” More than 6000 repairs have been done by the fellows, with a success rate of 82%. Through mentorship, training of inter-disciplinary staff, and provision of surgical equipment, this program is proving a success and a major step in the direction of ending fistula. /rp
Lengmang S, Shephard S, Datta A, Lozo S, Kirschner CV
Lengman et al present their findings from a variety of slings used at their center as well as the fascia lata slings currently being used for women still leaking from the urethra despite a closed VVF. Most compelling, are their current sling results. Referred to in the paper as “tight slings,” the authors describe a fascia lata suburethral sling, secured retropubically through the space of Retzius to the suprapubic abdominal fascia. Tension was placed until there was no leakage of dye from the back-filled bladder despite Valsalva. Although about 50% resulted in improved continence, a significant portion of patients were lost to follow-up. They found the slings were more successful in patients with less fibrosis and a shorter interval since VVF repair. The conclude that more research is needed to improve upon procedures to avoid the need for a urinary diversion and to improve patient satisfaction with continence status. /rp
Indeed, additional research in this area is key to solving the problem with the so-called ‘continence gap’ after fistula repair. Slings can be effective, but caution must be exercised when re-entering a scarred retropubic space, as a new fistula can easily be created. Also, based on limited evidence, synthetic slings should probably be avoided. /jw
Research in Obstetric Fistula: Addressing Gaps and Unmet Needs
This is a synopsis of the most up-to-date and relevant research conducted on obstetric fistula and an outline of where we need to focus as a field to improve in evidence-based care. The knowledge gaps in prevention include the lack of accurate prevalence and incidence data, effective public health methods to prevent fistulas, innovative ways to reduce barriers to accessing repair and identification of factors associated with spontaneous fistula closure with a catheter. In the area of surgical repair, the main areas lacking in evidence are in the timing of surgery, choosing a unified classification scheme which lends itself to clinical care, length of time for catheterization and ureteral catheterization for non-simple fistulas, and improvement in complex cases including anti-incontinence procedures and solutions for women who experience sexual dysfunction. Lastly, social reintegration is lacking in determining a safe time to resume intercourse, means for improving reproductive health after repair, and helping women access ongoing care for cesarean delivery after a repair and for those still leaking. /rp
This synopsis helps clarify the gaps in our scientific understanding of obstetric fistula and encourages all of us to redouble our efforts to perform quality research when possible. When performing fistula surgery, we still are largely dealing with expert opinion and consensus to guide technique. The extreme heterogeneity of presentation of women with obstetric fistula and the usual issues with surgical research make prospective randomized trials a challenge. However, we should strive to find ways to develop and complete these trials when possible to ultimately offer our patients the best care possible. /jw