Fistula Surgeons Research Articles

Surgeons’ perspectives for a future obstetric fistula classification system: exploring the key parameters

Background There is currently no unified classification scheme for accurately describing vesico-vaginal fistulas, thereby limiting communication between surgeons and the ability to compare research. Many factors related to surgical failure or success have not been explored, and surgeons currently do not universally use the same classifications. The objective of this study is to determine which factors are the most important to include in a future obstetric fistula classification scheme. Methods Members of the International Society of Obstetric Fistula Surgeons were surveyed using a non-validated questionnaire to explore their experience and factors they think were most important to include in an updated comprehensive obstetric fistula classification scheme. Based on the surgeons’ response, an average ranking of each determinant of obstetric fistula classification system was computed. Results The most critical factors that surgeons found necessary to include in an updated fistula classification system are the bladder size (88.9%, n=16, rank=8.53), degree of fibrosis of the vagina (83.3%, n=15, rank=8.12), degree of urethral damage (88.9%, n=16, rank=9.34), location of the fistula (100%, n=18, rank=9.22), urethral length (94.4%, n=17, rank=9.06), and whether the fistula is circumferential or not (94.4%, n=17, rank=9.18). The least important factors were how long the patient had had a fistula (11.1%, n=2, rank=2.28) and intraoperative complications (22.2%, n=4, rank=4.59). For most factors important in repair, there was a non-significant correlation between experience level and ratings from 0-10. Scores for urethral length showed a significant correlation between increased surgical experience and higher ratings of importance. Conclusions Three most commonly used classification schemes by Goh, Waaldjik, and the World Health Organization (WHO) only capture some important factors determined by the surveyed surgeons. Given the inconsistency between what experienced and expert surgeons deem to be important determinants for the classification of obstetric fistula and what is currently included in classification systems, we call for constructing a new, validated classification system.

Training and capacity building in obstetric fistula repair: A scoping review.

An ongoing barrier to sustainable obstetric fistula (OF) care is the lack of trained fistula surgeons. Despite a standardized training curriculum, data regarding OF repair training remain limited. To assess the availability of literature on the case numbers or training duration required for OF repair competency and whether these data are stratified by trainee background or repair complexity. A systematic search of MEDLINE, Embase, and OVID Global Health electronic databases and gray literature. All English sources from all years from low- and middle-income and high-income countries were eligible. Identified titles and abstracts were screened and full-text articles were reviewed. Data collection and analysis included a descriptive summary organized by training case numbers, training duration, trainee background, and repair complexity. Of the 405 sources retrieved, 24 were included in the study. The only concrete recommendations were in the International Federation of Gynecology and Obstetrics 2022 Fistula Surgery Training Manual, which proposes 50 to 100 repairs (Level 1), 200 to 300 repairs (Level 2), and trainer discretion for Level 3 competency. More case- or time-based data, particularly if stratified by trainee background and repair complexity, would be useful at the individual, institutional, and policy level for fistula care implementation or expansion.

Validation of an obstetric fistula screening questionnaire: a case\u2013control study with clinical examination

BackgroundObstetric fistula (OF) is a significant cause of maternal morbidity in lower resource settings where women experience obstructed labor without timely access to skilled obstetric care. The true prevalence of OF is unknown; however, it is estimated to affect 2 to 3.5 million women globally. The Demographic and Health Surveys’ (DHS) Fistula Module includes the OF symptom questions most frequently used for prevalence estimates, but these questions have not been validated. The aim of this study is to validate a symptom-based screening questionnaire for OF, including a question in the DHS’ Fistula Module.MethodsWith an international panel of fistula surgeons, we developed and face-validated a screening questionnaire that assessed for symptoms of lower urinary tract fistula (LUTF) and lower gastrointestinal tract fistula (LGTF), as well as urinary and fecal incontinence (UI, FI). We evaluated the discriminative ability of the questionnaire using a case–control study design in a 1:2:2 ratio: cases were parous women with fistula confirmed on examination, controls included parous women without fistula on examination, with and without UI symptoms. All women underwent screening for fistula symptoms and a physical examination, with examiners blinded to screening results.ResultsOf the 367 Rwandan women who completed the questionnaires and underwent clinical examination, 59 women had LUTFs and 34 had LGTFs, 274 women were classified as controls with and without symptoms of UI. All LUTF screening questions performed well, including the DHS fistula question. The combination of two LUTF screening questions had the highest sensitivity (100%; 95% CI 94%, 100%), specificity (96%; 95% CI 93%, 98%), and area under the curve (AUC) (0.98). The combination of a LGTF screening question and FI question demonstrated the highest sensitivity (97%; 95% CI 85%, 100%), specificity (98%; 95% CI 95%, 99%) and AUC (0.98).ConclusionsOur OF screening questionnaire, including the DHS fistula question, demonstrated high sensitivities, specificities, and AUC.

Diagnosis and Management of Intraabdominal Infection: Guidelines by the Chinese Society of Surgical Infection and Intensive Care and the Chinese College of Gastrointestinal Fistula Surgeons

The Chinese guidelines for IAI presented here were developed by a panel that included experts from the fields of surgery, critical care, microbiology, infection control, pharmacology, and evidence-based medicine. All questions were structured in population, intervention, comparison, and outcomes format, and evidence profiles were generated. Recommendations were generated following the principles of the Grading of Recommendations Assessment, Development, and Evaluation system or Best Practice Statement (BPS), when applicable. The final guidelines include 45 graded recommendations and 17 BPSs, including the classification of disease severity, diagnosis, source control, antimicrobial therapy, microbiologic evaluation, nutritional therapy, other supportive therapies, diagnosis and management of specific IAIs, and recognition and management of source control failure. Recommendations on fluid resuscitation and organ support therapy could not be formulated and thus were not included. Accordingly, additional high-quality clinical studies should be performed in the future to address the clinicians' concerns.

Validation of an Obstetric Fistula Screening Questionnaire

Background: Most experts believe that obstetric fistula (OF) remains a significant cause of maternal morbidity in lower resource settings in South Asia and Sub-Saharan Africa; however, the global burden of disease is unknown. We aimed to validate a symptom-based screening questionnaire for OF, including a questionin the Demographic and Health Surveys’ (DHS) Fistula Module. Methods: With an international panel of fistula surgeons, we developed and face-validated a screening questionnaire that assessed for symptoms of lower urinary tract fistula (LUTF) and lower gastrointestinal tract fistula (LGTF), as well as urinary and fecal incontinence (UI, FI). We evaluated the discriminative ability of the questionnaire using a case-control study design in a 1:2:2 ratio: cases were parous women with fistula confirmed on examination, controls included parous women without fistula on examination with and without UI symptoms. All women underwent screening for fistula symptoms and a physical examination, with examiners blinded to screening results. Findings: Of the 367 women who completed the questionnaires and underwent clinical examination, 59 women had LUTFs and 34 had LGTFs, 274 women were classified as controls with and without symptoms of UI. All LUTF screening questions performed well, including the DHS fistula question. The combination of two LUTF screening questions had the highest sensitivity (100%; 95% CI 94%, 100%), specificity (96%; 95% CI 93%, 98%), and AUC (0.98). The combination of a LGTF screening question and FI question demonstrated the highest sensitivity (97%; 95% CI 85%, 100%), specificity (98%; 95% CI 95%, 99%) and AUC (0.98). Interpretation: Our OF screening questionnaire, including the DHS fistula question demonstrated high sensitivities, specificities, and AUCs. Funding Statement: Maren Foundation, Johns Hopkins Center for Global Health Declaration of Interests: None of the authors have disclosures. Ethics Approval Statement: Institutional review board approval was obtained from both Johns Hopkins Medicine (Baltimore, MD, USA) and the National Research Health Committee and the Rwanda National Ethics Committee (Kigali, Rwanda).

Addressing the fistula treatment gap and rising to the 2030 challenge.

Obstetric fistula is a neglected public health and human rights issue. It occurs almost exclusively in low‐resource regions, resulting in permanent urinary and/or fecal incontinence. Although the exact prevalence remains unknown, it starkly outweighs the limited pool of skilled fistula surgeons needed to repair this childbirth injury. Several global movements have, however, enabled the international community to make major strides in recent decades. FIGO's Fistula Surgery Training Initiative, launched in 2012, has made significant gains in building the capacity of local fistula surgeons to steadily close the fistula treatment gap. Training and education are delivered via FIGO and partners’ Global Competency‐based Fistula Surgery Training Manual and tailored toward the needs and skill level of each trainee surgeon (FIGO Fellow). There are currently 62 Fellows from 22 fistula‐affected countries on the training program, who have collectively performed over 10 000 surgical repairs. The initiative also contributes to the UN's Sustainable Development Goals (1, 3, 5, 8, 10, and 17). The UN's ambitious target to end fistula by 2030 will be unobtainable unless sufficient resources are mobilized and affected countries are empowered to develop their own sustainable eradication plans, including access to safe delivery and emergency obstetric services.

A retrospective review to identify criteria for incorporating the Singapore flap and gracilis muscle flap into obstetric fistula repair.

ObjectiveTo identify criteria to guide surgeons regarding indications for use of the Singapore and gracilis muscle flaps in obstetric fistula repair.MethodsThis is a retrospective case series. Obstetric fistula surgeons in Lilongwe, Malawi, have been incorporating plastic surgery techniques with the Singapore and gracilis muscle flaps since collaborating with plastic surgeons in 2016. We describe the surgical outcomes of procedures utilizing each flap individually and those using both.ResultsBetween February 2016 and June 2019, 69 patients received a flap at the time of obstetric fistula repair at the Fistula Care Center in Lilongwe, Malawi. A total of 32 (46.4%) received a Singapore flap, 20 (29.0%) received a gracilis flap, and 17 (24.6%) received both types of flap.ConclusionBased on our outcomes, we note the possible advantage of incorporating the gracilis flap even when it is thought that the Singapore flap is sufficient. However, more data are needed.

A retrospective survey on the duration of leakage and patient perceived bottlenecks to seeking fistula treatment in Uganda

Aims: To assess the duration of leaking urine and patient perceived reasons for delay to seek repair among genitourinary fistula mothers who presented in fistula camps from June-2017 to July-2018 at Mubende and Hoima fistula treatment centers.
 Methods: This was a retrospective study in which qualitative and quantitative data was collected from standardized patient records of patient chats and registers filled by fistula surgeons.
 Results: We had a total of 125 mothers from 19 districts and of age between 16 to 72 years with genital urinary fistula operated. The majority (47.4%) of the clients were 25 years or less, of low parity with 41% (para 1+0) and without formal employment. Only 59.5% of the clients presented within one year from the time they developed the fistula. Perception was that fistulas are only treated during camps; ill health results from difficult labour; and lack of awareness that the bladder can be repaired.
 Conclusions: With the low turn up of mothers seeking repair, there is need to reduce leaking time and lessen suffering of obstetric fistula patients by creating more awareness, promoting routine repairs and continued financial support to care for fistula clients.

Addressing the Shortage of Fistula Surgeons; up date from FIGO’s Training Initiative

The FIGO Fistula Surgery Training Initiative has been developed to build the capacities of fistula surgeons in identified training centres using the Global Competency-Based Fistula Surgery Training Manual. 
 Since the launch of the Training Manual in 2011, the project has evolved, and in the last 4 years, has expanded substantially. Coming from 19 fistula affected countries around the world, there are presently 57 trainee fistula surgeons (‘Fellows’) on the Programme, undergoing training placements in established training centres, as well as receiving coaching visits in their home facilities to progressively build their fistula skills and activities over time.
 While good progress has been made, FIGO recognises and is ready to address the challenges still facing the Programme, and the next exciting phase will include further expansion, with continued admission of Fellows and fistula care teams from selected, high-need countries, while moving towards programmatic consolidation, by further strengthening the skills and activities of Fellows already on the Programme, so that significantly more affected women have access to high quality, life changing fistula treatment.

Evidence based classification/staging system for Obstetric Fistula: Planning and preliminary intervention in Nigeria

Aims: To review the classification systems of obstetric fistula (OF). 
 Methods: A two-day stakeholders’ meeting in Nigeria involving fistula surgeons, nurses, anesthetists, trainee, fistula desk officers at the federal and state government levels and other stakeholders was facilitated by Engender health. The meeting involved presentation of common classifications of obstetric fistula, critical analysis of each classification, group and plenary discussions. Presentation involved a critical analysis of classification parameters, strength and weakness. Three working groups designed classification criteria, prognostic scoring and suggested level of surgical skills needed to manage the patient. Outcome of each group work was presented and discussed in plenary. Each of the classification scenarios were modified by consensus and ratified at subsequent follow up meeting.
 Results: Three new classification systems of the OF were developed, and from these, a consensus classification was also developed in plenary. The initial three classifications developed from group work were similar to each other. Each classification considered size, location, previous repair, scaring, associated morbidity involvement of closing mechanism of the bladder neck, degree of urethral involvement and presence of transection of bladder neck (circumferential defect). The consensus classification, that was adopted, considered classification and prognostic scoring system. The four classification systems will be field tested to generate evidence for reliability and reproducibility.
 Conclusions: We believe a new classification system of obstetric fistula that will provide robust information to the managing team and patient is long overdue. This modest idea is a wake-up call for practitioners to design appropriate tool that is back up with reproducible evidence.

A Survey on the Duration of Leakage and Patient Perceived Bottlenecks to Seeking Fistula Treatment in Uganda

Aims: Uganda still has high fistula burden with 75000-100000 women still living with obstetric fistula and yet new cases are being formed. The ministry of health together with supporting partners established regional treatment centers among which includes Hoima and Mubende regional referral hospitals. This aimed to assess the duration of leaking urine and patient perceived reasons for delay to seek repair among genitourinary fistula mothers who presented in fistula camps at Mubende and Hoima fistula treatment centers.
 Methods: This was a retrospective study in which qualitative and quantitative data was collected from standardized patient records of patient chats and registers filled by fistula surgeons.
 Results : We had a total of 125 mothers from 19 districts and of age between 16 to 72 years with genital urinary fistula operated. The majority (47.4%) of the clients were 25 years or less, of low parity with 41 % (para 1+0) and without formal employment. Only 59.5% of the clients presented within one year from the time they developed the fistula. Among the patient perceived bottlenecks are the perception that fistulas are only treated during camps, lack of money, ill health resulting from difficult labour and lack of awareness that the bladder can be repaired.
 Conclusions: With the low turn up of mothers seeking repair, there is need to reduce leaking time and lessen suffering of obstetric fistula patients by creating more awareness, promoting routine repairs and continued financial support to care for fistula clients.

Out of the shadows and 6000 reasons to celebrate: An update from FIGO's fistula surgery training initiative.

Obstetric fistula is a devastating childbirth injury caused by unrelieved obstructed labor. Obstetric fistula leads to chronic incontinence and, in most cases, significant physical and emotional suffering. The condition continues to blight the lives of 1-2 million women in low-resource settings, with 50000-100000 new cases each year adding to the backlog. A trained, skilled fistula surgeon is essential to repair an obstetric fistula; however, owing to a global shortage of these surgeons, few women are able to receive life-restoring treatment. In 2011, to address the treatment gap, FIGO and partners released the Global Competency-Based Fistula Surgery Training Manual, the first standardized curriculum to train fistula surgeons. To increase the number of fistula surgeons, the FIGO Fistula Surgery Training Initiative was launched in 2012, and FIGO Fellows started to enter the program to train as fistula surgeons. Following a funding boost in 2014, the initiative has grown considerably. With 52 fellows involved and a new Expert Advisory Group in place, the program is achieving major milestones, with a record-breaking number of fistula repairs performed by FIGO Fellows in 2017, bringing the total number of repairs since the start of the project to more than 6000.

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

Introduction and hypothesisThere 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.MethodsFistula 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.ResultsRespondents 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.ConclusionsIntegration of genital fistula and POP services may enhance the quality of POP care while increasing the sustainability of fistula care.

Need for a global obstetric fistula training strategy

Obstetric fistula is a complication of childbirth that often follows obstructed labor and is almost exclusive to low-resource countries. The original Global Burden of Disease Study (GBD 1990 Study) reported an incidence of 8.68 per 100000 and a prevalence of 51.35 per 100 000 for women aged 15–44years in low-resource regions. The most cited global prevalence estimate is 2 million women. Although the global burden of obstetric fistula remains unclear, the number of women suffering from the condition is increasing, while surgical treatment remains limited. There are few experienced fistula surgeons and past surgical training approaches have been inconsistent. The Global Competency-Based Fistula Surgery Training Manual developed by FIGO and partners contains a set curriculum and, to ensure its implementation, a global strategy and training program have been developed. This paper describes key elements of the training program and its implementation. The anticipated impact of the training program is a reduction in global morbidity caused by obstetric fistula.

An update on surgery for vesicovaginal and urethrovaginal fistulae

This review offers a comprehensive summary of the recent publications on the treatment of vesicovaginal fistula. Most reports are related to obstetric fistula in the developing world but in the developed world fistula treatment remains a challenge. The quality of the research in this field is improving. Efforts are being made to improve the classification of fistula as a prognostic tool. Surgical innovations are few in this field. Laparoscopic approaches are reported but only on a very limited amount of patients. The surgical management of fistula remains a two-track item: the gigantic experience on obstetric fistula of fistula surgeons in Africa and Asia and the limited experience of some Western centres with mostly a small series of iatrogenic fistula. Advances are made in both worlds. The previously isolated fistula surgeons are now better organized and they stimulate scientific research in countries with very limited resources. The centres in the developed world explore new surgical approaches such as laparoscopy and minimally invasive treatments.

Obstetric Fistula in Low and Middle Income Countries

Vesicovaginal fistula secondary to obstructed labor continues to be an all-too-common occurrence in underdeveloped nations throughout Africa and Asia. Vesicovaginal fistula remains largely an overlooked problem in developing nations as it affects the most marginalized members of society: young, poor, illiterate women who live in remote areas. The formation of obstetric fistula is a result of complex interactions of social, biologic, and economic influences. The key underlying causes of fistula are the combination of a lack of functional emergency obstetric care, poverty, illiteracy, and low status of women. In order to prevent fistula, some strategies include creation of governmental policy aimed toward reducing maternal mortality/morbidity and increasing availability of skilled obstetric care, as well as attempts to increase awareness about its prevention and treatment among policymakers, service providers, and communities. Whereas prevention will require the widespread development of infrastructure within these developing countries, treatment of fistula is an act which can be done "in the now." Treatment and subsequent reintegration of fistula patients requires a team of specialists including surgeons, nurses, midwives, and social workers, which is largely unavailable in developing countries. However, there is increasing support for training of fistula surgeons through standardized programs as well as establishment of rehabilitation centers in many nations. The eradication of fistula is dependent upon building programs that target both prevention and treatment.

Obstetric fistula‐ a new way forward

Obstetric fistula‐ a new way forward

Classification of female genito-urinary tract fistula: a comprehensive review

The aim of this paper is to review proposed classifications for genito-urinary fistulae. A comprehensive literature review of historical texts, peer review publications, and abstracts was used to compile a listing of the existing genito-urinary fistula classification systems. The absence of an accepted standardized classification for female genito-urinary fistulae has resulted in the proliferation of a number of individually devised categorizations. Fistulae are described by size, location, degree of vaginal scarring, and type (whether it involves the bladder, rectum, intestines, uterus, etc). In addition, most classification systems have not been subjected to outcomes research, making them primarily descriptive in nature. There is a lack of consensus among fistula surgeons in adopting a standardized classification system or systems. Comparative assessment of studies and outcomes is not possible without a standardized classification system. Currently, there is no accepted standardized classification for female genito-urinary fistula.

Classification of female genito‐urinary tract fistula: Inter‐ and intra‐observer correlations

Currently, there is no accepted standardized classification for genital tract fistulae. Many classifications have been proposed previously, mainly based on anatomical locations. This is the first paper on inter- and intra-observer correlations using a recently published classification system based on fixed reference points. To assess intra- and inter-observer reliability of a new classification for genito-urinary fistula. This is a prospective assessment of women with genito-urinary fistula. Women attending the Fistula Clinic in Ethiopia and Liberia were assessed by three fistula surgeons. The women were assessed in the outpatients and the fistulae were staged. In Liberia, where two surgeons were working together, inter-observer reliability was assessed. All women had the fistulae restaged in the operating theatre and intra-observer concordance was assessed. The clinicians were blinded to the outpatient results. A total of 119 women were recruited. All women had intra-observer assessment and had the fistula examined by the same clinician in the outpatients and in the operating theatre. Fifty of these women had inter-observer assessment with two clinicians assessing the same women. The results demonstrated that this classification system had high concordance in intra- and inter-observer reproducibility. The new classification for genito-urinary fistulae utilizing fixed reference points is a useful tool in describing fistulae. This study has shown that this classification produced consistency in description amongst different clinicians and also by the same clinician in a different consultation. This therefore allows more precise communication of clinical findings.

A Code of Ethics for the fistula surgeon

Vesicovaginal fistulas from obstructed labor no longer exist in wealthy industrialized countries. In the impoverished countries of sub-Saharan Africa and south Asia obstetric fistulas continue to be a prevalent clinical problem. As many as 3.5 million women may suffer from this condition and few centers exist that can provide them with competent and compassionate surgical repair of their injuries. As this situation has become more widely known in the industrialized world, increasing numbers of surgeons have begun traveling to poor countries to perform fistula operations. To date, these efforts have been carried out largely by well-intentioned individuals, acting alone. An international community of fistula surgeons who share common goals and values is still in the process of being created. To help facilitate the development of a common ethos and to improve the quality of care afforded to women suffering from obstetric fistulas, we propose a Code of Ethics for fistula surgeons that embraces the fundamental principles of beneficence, non-maleficence, respect for personal autonomy, and a dedication to the pursuit of justice.