Urogenital Fistula :studies on epidemiology and treatment outcomes in high-income and low-and middle-income countries

Abstract

It has long been recognised that urogenital fistulas in low- and middle-income countries are predominantly of obstetric aetiology, whereas those in high-income countries usually follow pelvic surgery. This disparity was confirmed in systematic review (included as paper 1) and in large cohort studies undertaken in Nigeria (paper 2) and the UK (paper 3). Whilst there is no standardisation of outcome measures, the same studies report treatment ‘success’ in approximately 80-90% of cases in low- and middle-income countries (papers 1 & 2) and 95% in high-income countries (papers 1 & 3). It is recognised that obstetric fistula patients commonly suffer debilitating stress urinary incontinence even after successful closure of their fistula (paper 1). Urodynamic investigation in a cohort of fistula patients in UK also showed a high incidence of functional abnormalities (paper 4). Many of these resolved after repair, and most women reported minimal impact on quality of life in the long-term (paper 5). Success rates were found to be lower following second operations than first in cohort studies from Nigeria (paper 2) and UK (paper 3), and in a UK national cohort study (paper 8). This latter study also found idiosyncratic patterns of care, with re-operation rates related to workload, varying between 0% and 50% (paper 8). Evidence is presented to support an increase in risk of iatrogenic (post-hysterectomy) fistulas in high-income countries (papers 6 & 7). There also is a growing perception by colleagues in low- and middle-income countries of an increase in urogenital fistulas that may be, in part, iatrogenic in nature. These trends may reflect supervision and surgical experience accrued in training and workload maintained in independent practice. In both situations, it behoves those responsible for training and workforce planning in healthcare to ensure an appropriately trained and supervised workforce is maintained in the correct working environment.