Genital Fistulas Research Articles

Vesicovaginal Fistulas: Prevalence, Impact, and Management Challenges.

Background and Objectives: Vesicovaginal fistulas (VVFs) are an abnormal communication between the vagina and bladder and the most common type of acquired genital fistulas. This review will address the prevalence, impact, and management challenges of VVFs. Materials and Methods: Epidemiologic studies examining VVFs are considered. In addition, publications addressing the treatment of VVFs are reviewed. Results: VVFs in developing countries are often caused by obstructed labor, while most VVFs in developed countries have iatrogenic causes, such as hysterectomy, radiation therapy, and infection. The reported prevalence of VVFs is approximately 1 in 1000 post-hysterectomy patients and 1 in 1000 deliveries. VVFs affect every aspect of quality of life, including physical, mental, social, and sexual aspects. Prevention of VVFs is essential. Early diagnosis is necessary to reduce morbidity. Nutrition, infection control, and malignancy detection are important considerations during evaluation and treatment. Conservative and surgical treatment options are available; however, these approaches should be customized to the individual patient. The success rate of combined conservative and surgical treatments exceeds 90%. Conclusions: VVFs are considered debilitating and devastating. However, they are preventable and treatable; key factors include the avoidance of prolonged labor, careful performance of gynecologic surgery, and early detection.

A Noble Structure of the Musculoskeletal System in Various Surgeries: The Fascia Lata

Objective: The objective of this work is to list the surgeries using the fascia lata. Background: The fascia lata finds a place in decayed tissues. The indications are getting wider and wider. Method: We used the PubMed database with the following words: fascia lata, ilio-tibial band, fascia lata and surgery, ilio-tibial band and surgery, fascia lata and reconstruction, ilio-tibial band and reconstruction. Results: Fascia lata is used in the reconstruction of anatomical defects. Specifically, it is used in: Hip to supplement abduction- Shoulder in glenohumeral instability, repair of the cap- Hand and fingers to reconstruct tendons- Eyes: for palpebral ptosis and scleritis - Base of the skull to reconstruct defects- Central nervous system: cerebral dura mater and Cerebrospinal Fluid leak- Otorhinolaryngology: thyroplasty, parotid surgery, rhinoplasty, tympanoplasty- Digestive tract- Tendons: Achilles, patellar, fibular, patellar, patellar, bicipital brachial and crural tendons - Ligaments: anterior cruciate ligament reconstruction, inguinal and retinaculum patellar - Perineum and penis reconstruction - Urology: Genital prolapse, fistulas and penile reconstruction - Abdominal incisional hernias - Breast reconstruction - Eschar - Thorax - Encology. Finally, in experimentation, the fascia lata is tested on cadavers, animals and in vitro. Conclusion: Because of the particular properties of fascia lata in reconstruction, it renders an enormous service to surgery. The development of techniques in surgery would allow its use in other indications.

Fistulas as a complication of cervical cancer: the current state of the problem

One of the possible adverse events of cervical cancer arising both as a result of the progression of the disease and as a result of the treatment, leading to a significant decrease in the quality of life, is the development of genital fistulas. This review presents current information on diagnostic approaches, and treatment options for fistulas caused by cervical cancer. The peculiarities of fistulas that have arisen after radiation therapy and surgical treatment are highlighted.

Rare causes of genital fistula in nine African countries: a retrospective review

BackgroundMost genital fistulas result from prolonged, obstructed labor or surgical complications. Other causes include trauma (from accidents, traditional healers, or sexual violence), radiation, carcinoma, infection, unsafe abortion, and congenital malformation.MethodsThis retrospective records review focuses on rare fistula causes among 6,787 women who developed fistula after 1980 and sought treatment between 1994 and 2017 in Tanzania, Uganda, Kenya, Malawi, Zambia, Rwanda, Ethiopia, Somalia, and South Sudan. We compare fistula etiologies across countries and assess associations between rare causes and type of incontinence (urine, feces, or both).ResultsRare fistula accounted for 1.12% (76/6,787) of all fistulas, including traumatic accidents (19/6,787, 0.28%), traumatic sexual violence (15/6,787, 0.22%), traumatic injuries caused by traditional healers (13/6,787, 0.19%), unsafe abortion (10/6,791, 0.15%), radiation (8/6,787, 0.12%), complications of HIV infection (6/6,787, 0.09%), and congenital abnormality (5/6,787, 0.07%). Trauma caused by traditional healers was a particular problem among Somali women.ConclusionFistulas attributable to rare causes illuminate a variety of risks confronting women. Fistula repair training materials should distinguish trauma caused by traditional healers as a distinct fistula etiology. Diverse causes of fistula call for multi-pronged strategies to reduce fistula incidence.

A retrospective review of genital fistula occurrence in nine African countries

BackgroundFemale genital fistulas are abnormal communications that lead to urinary and/or fecal incontinence. This analysis compares the characteristics of women with fistulas to understand how countries differ from one another in the circumstances of genital fistula development.MethodsThis retrospective records review evaluated demographics and circumstances of fistula development for 6,787 women who sought fistula treatment between 1994 and 2017 in Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia, and Ethiopia.ResultsMost women developed fistula during childbirth, whether vaginal (3,234/6,787, 47.6%) or by cesarean section (3,262/6,787, 48.1%). Others had fistulas attributable to gynecological surgery (215/6,787, 3.2%) or rare causes (76/6,787, 1.1%). Somalia, South Sudan, and Ethiopia had comparatively high proportions following vaginal birth and birth at home, where access to care was extremely difficult. Fistulas with live births were most common in Kenya, Malawi, Rwanda, Uganda, Tanzania, and Zambia, indicating more easily accessible care.ConclusionsCharacteristics of women who develop genital fistula point to geographic differences in obstetric care. Access to care remains a clear challenge in South Sudan, Somalia, and Ethiopia. Higher proportions of fistula after cesarean birth and gynecological surgery in Kenya, Malawi, Rwanda, Uganda, Tanzania, and Zambia signal potential progress in obstetric fistula prevention while compelling attention to surgical safety and quality of care.

Platelet-Rich Plasma: A Promising Regenerative Therapy in Gynecological Disorders.

Platelet-rich plasma (PRP) could be understood as a special preparation of plasma in which the concentration of platelet is immensely high. This rationale for plasma use has been in the medical science for many years with plenty of success in various fields where it was inculcated, bringing dramatically favorable and better outcomes in terms of disease management and prognosis. PRP has been widely used in orthopedics from the very beginning, but in the past few years its use has been extended to other fields too, such as obstetrics and gynecology. From the very onset of the introduction of platelet-rich plasma in gynecology, there had been constant research being carried out all around the globe in order to scientifically prove and confirm its exact role in the management of gynecological problems. Regenerative medicine in gynecology was among the first areas where the platelet-rich plasma was implemented and has substantially given great results, which encouraged further extensive research to be carried out in other spectrums of gynecology. The implications of such great struggles ultimately gave way to evidence suggesting the importance of platelet-rich plasma in managing gynecological disorders like Asherman’s syndrome, urinary incontinence, genital fistulas, thin endometrium, etc. This review article collectively summarizes the various use of platelet-rich plasma in gynecology.

A Quantitative Study on Stigma and Statistically Correlated Factors Among Women Living with Genital Fistula in Oromia Region, Ethiopia. Identification of Urgent Corrective Strategies.

BackgroundTwo-to-three million women worldwide live with a genital fistula, with Asian and sub-Saharan African countries including Ethiopia accounting for the greatest percentage. Genital fistula is a devastating health problem due to the stigma associated with constant incontinence and bad-odor. Thus, this study aimed to determine the magnitude of the stigma towards women living with genital fistula in Oromia region, Ethiopia, and to highlight the factors associated with it, identifying potential strategies for corrective interventions.MethodsThis quantitative study was conducted among 422 women living with genital fistula in five fistula treatment centers of Oromia region using a cross-sectional study design from August 30, 2019 to February 28, 2020. Data were collected by face-to-face interview using a structured questionnaire, entered into Epi-data version 4.2, and analyzed by SPSS version 23. Bivariate and multivariable logistic regression analysis was done. P-value <0.05 was used to ascertain statistical significance with an adjusted odds ratio at 95% confidence interval (CI). The results were presented by text and tables.ResultsThe response rate for this study was 100%. The magnitude of perceived high stigma related to genital fistula was 178 (42.2%). The factors associated with it were the respondents’ father’s educational level of being able to write and read compared to unknown fathers’ educational level (AOR=0.09; 95% CI=0.03–0.34), and duration of living with a genital fistula of less than 2 years compared to living with a genital fistula for 5 years or more (AOR=0.52; 95% CI=0.31–0.86).ConclusionThe perceived level of stigma among women living with a genital fistula in Oromia region was significantly high. To reduce the perceived level of stigma and therefore to prevent the severe negative consequences of it, fathers, but also mothers, husbands, family members, and all the persons close to women living with genital fistulas should provide care and psychological support and all the necessary means to strongly encourage them to seek health care quickly, and to make them feel that they are beloved, and that there is hope for a healthy life in their near future.

Evaluation and management of obstetric genital fistulas treated at a pelvic floor centre in Germany

BackgroundObstetric genital fistulas are an uncommon condition in developed countries. We evaluated their causes and management in women treated at a German pelvic floor centre.MethodsWomen who had undergone surgery for obstetric genital fistulas between January 2006 and June 2020 were identified, and their records were reviewed retrospectively.ResultsEleven out of 40 women presented with genitourinary fistulas, and 29 suffered from rectovaginal fistulas. In our cohort, genitourinary fistulas were more common in multiparous women (9/11), and rectovaginal fistulas were more common in primiparous women (24/29). The majority of the genitourinary fistulas were at a high anterior position in the vagina, and all rectovaginal fistulas were at a low posterior position. While all genitourinary fistulas were successfully closed, rectovaginal fistula closure was achieved in 88.65% of cases. Women who suffered from rectovaginal fistulas and were at high risk of recurrence or postoperative functional discomfort and desired another child, we recommended fistula repair in the context of a subsequent delivery. For the first time, pregnancy-related changes in the vaginal wall were used to optimize the success rate of fistula closure.ConclusionsIn developed countries, birth itself can lead to injury-related genital fistulas. As fistula repair lacks evidence-based guidance, management must be tailored to the underlying pathology and the surgeon’s experience. Attention should be directed towards preventive obstetric practice and adequate perinatal and postpartum care. Although vesicovaginal fistulas occur rarely, in case of urinary incontinence after delivery, attention should be paid to the patient, and a vesicovaginal fistula should be ruled out.Trial registration Retrospectively registered, DRKS 00022543, 28.07.2020.

A Case Series of Robot-assisted Rectus Abdominis Flap Harvest for Pelvic Reconstruction: A Single Institution Experience

To analyze outcomes and postoperative complications in patients undergoing robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction. Case series. Academic setting. Pelvic reconstruction surgery patients. The rectus abdominis muscle flap can be used as a flap for pelvic reconstruction, providing a large volume of soft tissue that can be used in the treatment of many comorbid conditions, including genital fistulas, postradiation pelvic exenteration, and abdominoperineal resection defects. Intraperitoneal harvest of the rectus muscle using a robotic approach allows avoidance of laparotomy and subsequent disruption of the anterior rectus sheath, thus preserving the integrity of the abdominal wall. A retrospective analysis of patient demographic and clinical characteristics was performed for all patients who underwent robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction at our institution from October 1, 2016, to October 31, 2018. The postoperative complications analyzed included bowel obstructions, surgical site infections, emergency room visits, and need for readmission. Six patients (4 women and 2 men), with a mean age of 69.2 years (range = 57-79 years) and median follow-up time of 9.2 months (range = 5-12 months), were included. Muscle flap harvest was performed on the right side in 4 patients and on the left in 2 patients. The indications for reconstructive surgery included vesicovaginal fistula, complex pelvic organ prolapse, anterior and posterior exenteration, partial and total vaginectomy, partial vulvectomy, and abdominoperineal resection. Two patients received neoadjuvant chemoradiation. One of the 6 cases was converted to laparotomy; however, this was not owing to the rectus harvest. Three patients experienced no complications after reconstruction; 1 patient reported occasional abdominal pain; 1 patient had intermittent bowel obstruction; and 1 patient developed a pelvic abscess, requiring readmission. All 6 patients achieved satisfactory healing of the pelvic wound after robot-assisted rectus abdominis flap inset. Robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction is a reliable means of defect closure, despite the presence of substantial comorbidities and risk factors in this patient cohort. Patient selection and counseling are crucial to optimize surgical outcomes in this complex population.

Genital fistula: Successes, challenges, and way forward in a facility specialization in fistula management in Bangladesh

Aims: To explore the prevalence, types of genital fistulas as well as their success, challenges, and way forward on genital fistula in Bangladesh.&#x0D; Methods: Between October 2017 and September 2018, Hope Hospital identified a total number of 101 genital fistula cases though a community network system in Cox’s Bazar. For each of the patients, detailed case histories and clinical management reports documented, and the data were interpreted using descriptive analysis.&#x0D; Results: Out of 101 genital fistula cases admitted to the facility, 95.3% (n=96) of cases were obstetric; three cases iatrogenic, and one each traumatic and congenital. The median age of the women was 28 years (range: 18 -73) and the median duration of two years (range: 1 month-53 years). Most of the cases had urinary incontinence (86.1 %, n=85) and 12 and two cases were fecal and mixed type respectively. Vesicovaginal fistula (VVF) repair was performed in most of the cases (78.2%, n=79) while 21.8% (n=22) received recto vaginal fistula (RVF) repair. 90% (n=91) were discharged without complication. The median duration of hospital stay was 16 days (range: 4 -29). The success rate was 86.1% (n=85), and 16 cases advised for repeat surgery. Pre-and post-surgery counselling was provided without rehabilitation or reintegration support.&#x0D; Conclusions: Facility data in a particular geographic location represents high prevalence of obstetric fistula and lacks rehabilitation and social reintegration support. Further study is essential to draw a complete geographical map for genital fistula in Bangladesh.&#x0D; Keywords: genital fistula, management, rehabilitation, Bangladesh

Rectus Abdominis Pedicled Flap: An Innovative Robotic Approach

Video Objective To provide education on the utility of rectus muscle flap during pelvic floor reconstruction and describe in detail a minimally invasive technique to avoid laparotomy. Setting Patients requiring pelvic floor reconstruction at an academic medical center. Interventions The rectus abdominis muscle flap can be used as a workhorse flap for pelvic reconstruction, providing a large volume of well vascularized soft tissue that can be used in treatment of complex pelvic floor reconstruction, including genital fistulas, post-radiation pelvic exenteration and abdominoperineal resection defects. Intraperitoneal harvest of the rectus muscle using a robotic approach allows avoidance of laparotomy and subsequent disruption of the anterior rectus sheath, thus preserving the integrity of the abdominal wall. This educational video demonstrates robotic docking as well as surgical techniques in detail to show the feasibility for robotic-assisted rectus flap harvest and pelvic floor reconstruction. Conclusion Robotic-assisted rectus abdominis flap harvest for pelvic floor reconstruction is a reliable means of defect closure. This novel approach is surgically feasible for the reconstructive surgeon and maintenance of minimally invasive technique allows for significant advantages over the traditional laparotomy approach.

Iatrogenic gynaecologic fistula: Characteristics and outcomes after treatment at a national competence centre in Norway

Introduction: Genital fistula leads to urinary or faecal incontinence and is a feared delivery complication in the developing world. Surgery or radiation is a more frequent cause in industrialized countries. Our gynaecological department has since 1995 prospectively registered treatment-information of genital fistulas, from 2012 as the Norwegian national referral centre.

The prevalence of psychiatric disorders among genitourinary fistula patients: A study in a tertiary care hospital, Bangladesh

Background: Maternal morbidity and mortality are very potential women’s health issues in many developing countries. Many of these are preventable. The World Health Organization estimated that, the prevalence of obstetric fistula at 0.3% of all deliveries. In Asia, over 200 thousand maternal deaths occur in every year. World-wide it is estimated that, there are over 1000000 new cases of fistula are found each year. Information from UNFPA and Engender health indicates that, well over two million women worldwide are suffering from genital tract fistulas. Aim of the study: The aim of this study was to assess the prevalence of psychiatric disorders among genitourinary fistula patients. Methods and Materials: It was a non-interventional, descriptive, cross sectional study conducted on a special group of population suffering from genitourinary fistula. Prior to commencement of study written permission was taken to work in the “National Fistula Centre” from the Department of Gynaecology &amp; Obstetrics, DMCH. This study was conducted at the National Fistula Centre. This center was established in 2003 in DMCH under the supervision of Gynaecology and Obstetrics Department. One hundred and two (102) patients were included in the study as the study population. Non-probability convenient sampling procedure was used. Samples were collected in two days per week. It was decided that, if any patient refuses, next one will be taken into account, but fortunately none refused the interview. By adopting this method, 102 patients were included and the study was conducted during the period from December 2003 to December 2004. Results: In our study, among total 102 participants the prevalence of the study was 85.29% where include psychiatric illness, depression (63.72%) being the commonest illness. Anxiety disorder was 15.68%, minor emotional disorder was 2.94% and somato form disorder was 2.94%. Fifteen patients (14.70%) were found to be free from psychiatric symptoms. Conclusion: One hundred and two patients diagnosed as genitourinary fistula are studied by Self Reporting Questionnaire (SRQ) to find out psychiatric morbidity among them. Psychiatric diagnosis was confirmed by using DSM – IV criteria under the direct supervision of psychiatrist. The findings of this study may help in the treatment procedure of genitourinary fistula.

Anti-TNF therapy for genital fistulas in female patients with Crohn's disease: a nationwide study from the Groupe d'Etude Thérapeutique des Affections Inflammatoires du tube Digestif (GETAID).

Genital fistulas represent a devastating complication of Crohn's disease. Only studies with small sample sizes have evaluated the efficacy of anti-TNF therapy for this complication. To assess the efficacy of anti-TNF therapy for genital fistulas complicating Crohn's disease and to identify predictive factors associated with clinical response at 1 year. Consecutive patients treated with anti-TNF therapy for genital fistulas complicating Crohn's disease from 1999 to 2016 in 19 French centres from the Groupe d'Etude Thérapeutique des Affections Inflammatoires du tube Digestif were included in a retrospective cohort study. Outcome was clinical fistula closure at 1 year. Among the 204 women with genital fistulas who received anti-TNF therapy, 131 were analysed. The first anti-TNF given was infliximab (79%), adalimumab (20%), or certolizumab (1%). At start of anti-TNF therapy, 56% of patients had seton drainage and 53% had concomitant immunosuppressive treatment. A complementary surgery was performed during the first year in 10 patients (8%). At 1 year, 37% of patients had complete clinical fistula closure, 22% had a partial response, and 41% had no response. Among patients without complementary surgery, 34% (41/121) had complete clinical fistula closure. Only complementary surgery was associated with better response on multivariate analysis (adjusted relative risk: 2.02, 95% CI: 1.25-3.26, P = 0.0043). In the anti-TNF era, approximately one-third of patients with genital fistula in Crohn's disease had complete fistula closure at 1 year. Collaboration between surgeons and gastroenterologists appears to be very important to improve the rate of fistula closure.

Vesicovaginal Fistula: Psychosocial problems of VVF in rural areas of Pakistan

Vesicovaginal fistulas (VVF) are the most commonly acquired genital fistulas that are associated with numerous physical, social, psychological and sexual problems in affected individuals. The prevalence of VVF in women is found to be 2 million approximately in Sub-Saharan Africa and South Asia with an increasing number of 50 – 100 thousands cases every year

Gurya cutting and female genital fistulas in Niger: ten cases

Introduction and hypothesisThe objective was to determine the contribution of female genital cutting to genital fistula formation in Niger from the case records of a specialist fistula hospital.MethodsA retrospective review was undertaken of the records of 360 patients seen at the Danja Fistula Center, Danja, Niger, between March 2014 and September 2016. Pertinent clinical and socio-demographic data were abstracted from the cases identified.ResultsA total of 10 fistulas resulting from gurya cutting was obtained: 9 cases of urethral loss and 1 rectovaginal fistula. In none of the cases was genital cutting performed for obstructed labor or as part of ritual coming-of-age ceremonies, but all cutting procedures were considered “therapeutic” within the local cultural context as treatment for dyspareunia, lack of interest in or unwillingness to engage in sexual intercourse, or female behavior that was deemed to be culturally inappropriate by the male spouse, parents, or in-laws. Clinical cure (fistula closed and the patient continent) was obtained in all 10 cases, although 3 women required more than one operation.ConclusionsGurya cutting is an uncommon, but preventable, cause of genital fistulas in Niger. The socio-cultural context which gives rise to gurya cutting is explored in some detail.

Review of Vesicouterine Fistula at the National Obstetric Fistula Centre,\ Abakaliki, Nigeria

Background: Vesicouterine fistula is a rare type of genital fistula. It is a cause of urinary incontinence in our environment. It usually results from caesarean section. The study was undertaken to document our experience in the management of this condition. Methodology: This is a retrospective study carried out at the National Obstetric Fistula Centre, Abakaliki, Nigeria from January 2013 to October 2015. Records of women with vesicouterine fistula were retrieved. Information on age, parity, predisposing factors, aetiology, presentation, diagnosis, management and outcomes of repair were obtained. Data was analyzed using the Statistical Package for Social Sciences (SPSS) version 20. Results: Vesicouterine fistula was seen in 13 out of 619 women constituting 2.1% of all genital fistulas. The mean age of the women was 37.4 ± 9.9 years with 53.5% of them between 30-39 years. Of the 12 women who had term pregnancies, 3 (25%) had no previous caesarean section, 4 (33.3%) had 1 previous caesarean section and 5 (41.7%) had 2 previous caesarean sections making previous caesarean section a predisposing factor in 75% of cases. Fistula occurred following caesarean section in 7 women (53.8%), vaginal delivery in 4 (30.8%), exploratory laparotomy due to uterine rupture in 1 (7.7%) and dilatation and curettage in 1 (7.7%). All 4 women whose fistula followed vaginal delivery had previous caesarean section. All the 13 women presented with menouria. Two (15.4%) had menouria only while11 (84.6%) had menouria with urinary incontinence. In 6 women (46.2%), diagnosis was clinical. Hysterosalpingogram was employed in 1 patient. All the women has surgical repair via the retropubic extraperitoneal approach. Fistula was closed in all 13 women. Conclusion: Vesicouterine fistula is uncommon and usually follows caesarean section. Previous caesarean section is an important predisposing factor. It presents commonly as menouria and urinary incontinence. Outcomes of repair are excellent.

"I am alone and isolated": a qualitative study of experiences of women living with genital fistula in Uganda.

BackgroundGlobally, 2–3 million women are estimated to have a genital fistula, with an annual incidence of 50,000–100,000 women. Affected women remain silent within their communities, and their experiences often go unnoticed. Our objective was to explore the experiences of Ugandan women living with genital fistulas to understand how their lives were affected and how they coped with the condition.MethodsWe conducted 8 focus group discussions (FGDs) with 56 purposively selected women with a genital fistula seeking treatment at Mulago Hospital, Uganda. Data were transcribed and analysed using qualitative content analysis.ResultsWomen with a fistula were living a physically changed and challenging life, living socially deprived and isolated, living psychologically stigmatised and depressed, and living marital and sexual lives that were no longer joyful. The women’s experiences were full of life changes and coping strategies, and they used both problem- and emotion-focused coping strategies to deal with the challenges. They devised ways to reduce the smell of urine to reduce the stigma, rejection and isolation. While trying to cope, the women found themselves alone and isolated. Women either isolated themselves or were isolated by society, including by close relatives and their husbands. Their sex lives were no longer enjoyable, and generally, women felt a loss of their marital and sexual rights.ConclusionWomen with a fistula make adjustments in their lives to cope with the physical, social, psychological and sexual challenges. They use both problem- and emotion-focused coping to minimise their sense of isolation, as well as the rejection and stigma associated with fistula. These findings are essential for counselling patients, families and community members affected by a fistula. In similar contexts, health programmes should go beyond fistula closure and target communities and families to reduce the stigma and isolation faced by women with genital fistula.

Characteristics, management, and outcomes of repair of rectovaginal fistula among 1100 consecutive cases of female genital tract fistula in Ethiopia.

To characterize the incidence, presentation, management, and outcomes of rectovaginal fistula (RVF) in Ethiopia. In a retrospective study, demographic and clinical data were obtained for all women with genital tract fistulas admitted to the Barhirdar Hamlin Fistula Hospital, Ethiopia, for fistula repair surgery between January 2005 and October 2008. Of 1100 cases, 1057 were suitable for analysis. Vesicovaginal fistula (VVF) without RVF was present in 933 (88.3%) cases, combined VVF and RVF in 79 (7.5%), and isolated RVF in 45 (4.3%). Only 4 (0.4%) women had isolated RVFs that could be attributed to prolonged obstructed labor; the remaining 41 RVFs were due to trauma (including sexual trauma), iatrogenic causes, infection, perineal tears, or previous failed repairs. All RVFs were managed with a flap-splitting operative technique, without grafts or diverting colostomies. Overall, 120 (98.4%) of 122 RVFs repaired at the study hospital remained closed at discharge. Combined VVF and RVF was associated with a longer labor (P<0.001), more stillbirths (P=0.028), a larger and lower VVF (P<0.001 for both), and more vaginal scarring than was isolated VVF (P<0.001). An obstetric RVF represents a more severe injury process than does a VVF. RVFs rarely occur without a VVF if due to obstructed labor. However, they can be managed successfully without diverting colostomies or grafts.

Surgery in low‐income countries during crisis: experience at Médecins Sans Frontières facilities in 20 countries between 2008 and 2014

The global burden of trauma and surgical conditions fall disproportionately on lowand middle-income countries (LMICs) [1, 2]. Inopportunely, developing countries are least equipped to provide essential surgical care [3]. As a result, LMICs have a significant burden of unmet surgical needs [4]. When these fragile health systems are disrupted by conflict, a natural disaster or an epidemic the capacity for and quality of surgical care decreases even further [5]. In response, M edecins Sans Fronti eres (MSF) provides surgical humanitarian assistance in countries affected by crisis through one of the five operation centres; one of these is Operations Centre Brussels (OCB). Describing the epidemiology of surgical care at MSFOCB projects improves planning for humanitarian assistance and provides a unique opportunity to examine surgical needs that were otherwise unmet by national healthcare systems [6]. From 2008 through 2014, MSFOCB performed 119 524 operations at 45 projects in 20 countries. The majority of operations were obstetric (range 28–42% of operations by year), general surgical (e.g. hernias, appendicitis; range 15–49%) and unintentional trauma-related (e.g. road traffic crash, burn; range 10– 42%). Violence was also a common cause of surgical need (e.g. land mine or bomb injury, gunshot wound; range 7– 15%) (Table 1). MSF-OCB teams provided safe anaesthesia, often by task sharing, in the face of complex care needs evidenced by low perioperative death rates (i.e. death from time of anaesthesia care to discharge from the recovery ward; 0.2–0.3% of operations). From 2008 through 2014, the orthopaedic care capacity was deliberately improved to meet the needs of conflict-related projects (Figure 1). This was done by developing fracture care guidelines for nonorthopaedists, as well as recruiting expatriate orthopaedic surgeons. More detailed operative epidemiology of these sites has been reported previously [6–8].