Identifying Patients With Vesicovaginal Fistula at High Risk of Urinary Incontinence After Surgery

Abstract

Objective To develop a risk score to identify women with vesicovaginal fistula at high risk of residual urinary incontinence after surgical repair. Methods We conducted a prospective cohort study among 401 women undergoing their first vesicovaginal fistula repair at a referral fistula repair center in Lilongwe, Malawi, between September 2011 and December 2014, who returned for follow-up within 120 days of surgery. We used logistic regression to develop a risk score to identify women with high likelihood of residual urinary incontinence, defined as incontinence grade 2-5 within 120 days of vesicovaginal fistula repair, based on preoperative clinical and demographic characteristics (age, number of years with fistula, HIV status, body mass index, previous repair surgery at an outside facility, revised Goh Classification, Goh vesicovaginal fistula size, circumferential fistula, vaginal scaring, bladder size, and urethral length). The sensitivity, specificity, positive and negative predictive values of the risk score at each cut-point were assessed. Results Overall, 11 (3%) women had unsuccessful fistula closure. Of those with successful fistula closure (n=372), 85 (23%) experienced residual incontinence. A risk score cut-point of 20 had sensitivity 82% (95% CI 72%, 89%) and specificity 63% (95% CI 57%, 69%) to potentially identify women with residual incontinence. In our population, the positive predictive value for a risk score cut-point of _20 or higher was 43% (95% CI 36%, 51%) and the negative predictive value was 91% (95% CI 86%, 94%). Forty-eight percent of our study population had a risk score ≥20 and therefore, would have been identified for further intervention. Conclusions A risk score 20 or higher was associated with an increased likelihood of residual incontinence, with satisfactory sensitivity and specificity. If validated in alternative settings, the risk score could be used to refer women with high likelihood of postoperative incontinence to more experienced surgeons.

Systematic review of shorter versus longer duration of bladder catheterization after surgical repair of urinary obstetric fistula

“…Many countries in Africa and Asia offer surgical treatment for women with obstetric fistula, and several studies from these settings report success rates and factors that influence FRB and other clinically important outcomes. 10,[19][20][21][22][23][24][25][26] Although those studies provide useful information, most were limited by their retrospective, nonrandomized, or uncontrolled designs.…”

Autologous rectus fascia sling for post-vesicovaginal fistula repair stress incontinence: case series from a Nigerian experience

“…Residual urinary incontinence following vesicovaginal fistula (VVF) closure constitutes a dilemma for both the patient and attending surgeon [1]. Residual urinary incontinence complicates VVF repair when it involves the sphincteric region of the bladder/bladder neck, large and severe vaginal fibrosis [2][3][4][5]. The repair of VVF that involved the bladder neck with or without its sphincter sometimes leads to obliteration of the angulation of the bladder neck and subsequent leakage of urine.…”

Re: Use of a postoperative pad test to identify continence status in women after obstetric vesicovaginal fistula repair: a prospective cohort study

“…A range of factors that affect the risk of residual incontinence was evaluated in a separate analysis published by our group. 4 We acknowledge that the outcome of continence grade at follow-up is not objective. Quality of life measurements have been utilized alongside 1-hour pad tests in a recent study evaluating continence of women in the years after VVF repair (currently being analysed), as we recognize that the same amount of urinary leakage may be accepted differently among women.…”

“…Ultimately, whatever our personal choices would be, it is the prerogative of the woman to decide her future, and she must then be supported positively no matter what decision she decides to make. 4 Occasionally this will lead to maternal mortality but it is not for the attending doctor to make value judgments about an individual woman's own decisions. Working in highly collaborative multi-disciplinary teams helps to ensure that the management of these challenging cases is in line with best international standards, and the psychological burden to the individual of managing such cases is reduced by being shared.…”