Determinants of Outcomes and Prognosis Score in Obstetric Vesico-Vaginal Fistula Repair

Abstract

An estimated 2 million women living in countries with limited resources currently have vesico-vaginal, recto-vaginal, or mixed types of fistulae because of the necrosis that occurs with obstructed labor. We evaluated factors readily assessed by the examining practitioner in a consecutive case series of surgical repairs of obstetrical fistulae, for the ability of those factors to stand as a prognostic guide, in a clinical score. Objectives: To identify the predictors of surgical repair outcomes and establish a Score combining these different determinants to facilitate the care of obstetric fistula. Methods: We conducted a multicentric prospective study between 2011 and 2014 in Democratic Republic of the Congo (DRC). Outcomes: We measured 3 months post-surgery in a series of 483 patients with obstetrical fistula repaired by the same surgeon included closure and failure appreciated by dye test. Multivariable generalized estimating equation models were used to generate adjusted odd ratios (OR) and 95% confidence intervals (CIs). The scores ranging from 3 to 14 were established from the outcomes determinants identified. Results: In total, 483 women were enrolled, and 390 cases were at their first surgery and were included in the obstetric fistula (OF) prognosis score and classification. Their mean age was 35 years at the time of the surgery and 25 years at the onset of OF. In 28.6%, the fistula patient was primigravida. Mean duration between onset of the fistula and surgical treatment was 8 years. In 24%, the fistula patients lived separated from their partners. Overall closure rate of the fistulas was 85.7%. Severe vaginal fibrosis (p 0.01), big fistula size (0.01), small distance from fistula to external urethral meatus (0.01) and prior surgery (p 0.48) predicted failed fistula closure. A clinical score ranging from 3 to 14 points is a prognostic score with a range of 1 to 4 for the distance between the fistula and the external meatus and the size, and a scale of 1 to 6 for fibrosis. Conclusions: This study demonstrated that the marked vaginal scarring; large fistula size and distance to urethral meatus are predictors for unsuccessful fistula repair. Due to the lack of a standard classification that is never unanimous among the different surgeons, this prognostic score allows the combination of the different determinants assessing the chances of success and can help the practitioners to orient the patients towards the determined skill scale to take care of the patients.