C-H Rochat, MD

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Obstetric Fistula C-H Rochat, MD Geneva Foundation for Medical Education and Research (www.gfmer.ch ) Faculty of Health Sciences Cotonou, Benin Training Course in Sexual and Reproductive Health Research Geneva 2010

Transcript of C-H Rochat, MD

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Obstetric Fistula

C-H Rochat, MD

Geneva Foundation for Medical Education and Research (www.gfmer.ch)

Faculty of Health Sciences Cotonou, Benin

Training Course in Sexual and Reproductive Health ResearchGeneva 2010

http://www.gfmer.ch/
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Definition

Tissue destruction secondary to the prolonged pressure of the head during obstructed labour (ischaemic laesion)

Tissue laceration during instrumental delivery, Caesarean section or Caesarean hysterectomy

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Problem

Abandoned from their families

Co-morbidity– Infections

– Bladder stones

– Infertility

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Prevalence

Estimated : 2 mio women worldwide

Africa, Asia, South America

– Sub-Saharan Africa: 2/1000 deliveries

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Simple fistula

– Non-fibrotic tissue

– Easy to access

Complex fistula

– Fibrotic tissue

– Loss of tissue

– Urethral involvement

– Retracted bladder

– Aberrant tract

– Previous failed surgery

Classification

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Complex VVF

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http://www.gfmer.ch/Video/Extrait_fistules.wmv

http://www.gfmer.ch/Video/Extrait_fistules.wmv
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Surgical tips

Extended Trendelenburg position

Scott retractor

Headlight

Sharp scissors

Suture material

– Post op follow-up

– Cave: obstructed catheter !

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Simple closure

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Martius Flap

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Symmonds / Falandry

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Mayence II

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Stress incontinence

Junction bladder/urethra most often concerned

Closure mechanismus damaged

Residual stress incontinence

Surgical challenge

For experts and motivated surgeons

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http://www.gfmer.ch/Video/Reconstruction_cervico-uretrale.wmv

http://www.gfmer.ch/Video/Reconstruction_cervico-uretrale.wmv
http://www.gfmer.ch/Video/Reconstruction_cervico-uretrale.wmv
http://www.gfmer.ch/Video/Reconstruction_cervico-uretrale.wmv
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African tape

TVT / TVTO

2001 Mopti 6 cases

2005/2006 Tanguieta 8 cases

Preliminary study

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http://www.gfmer.ch/Video/Bandelette.wmv

http://www.gfmer.ch/Video/Bandelette.wmv
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Treatment

Training

Prevention

The model of Tanguieta

Internet Database (GFMER)

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The model of Tanguieta

GFMER, St. Jean de Dieu Hospital and Faculty of Health Sciences, Cotonou

Comprehensive strategy for training health care providers

Treatment and prevention of obstetric fistula

Exported to centres in Guinea (Conakry), Burkina Faso (Fada N’Gourma) and Cameroon (Maroua)

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A new Web-Based Data Entry

System : the GFMER Database

Collection and evaluation of prospective data

Demographic characteristics of fistula patients

Various surgical and clinical procedures for fistula repair

Social reintegration

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Facilitate the development of a standardized fistula classification

Comparative research across surgical centres

Identification of cases requiring expert fistula surgeon

A new Web-Based Data Entry

System : the GFMER Database

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Areas covered by the GFMER

Database

Circumstances leading to the occurrence of fistula

Socioeconomic and preoperative health status

Surgical and other medical treatments received

Postoperative health status and follow-up

../base de donnees fistule 230307/main login multicentric studies.htm
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GFMER Research and Studies

3 critical areas of research in collaboration with WHO/RHR

Prevention:– analysis of underlying sociocultural and

economic factors

– caesarean sections

– labour management techniques

Treatment:– review and assessment of current surgical and

medical procedures

Reintegration:– evaluation of existing reintegration strategies

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Tanguieta personal case series

1996 - 2006

Hospital northern Benin

13 surgical missions since 1993

Since 1996 specific visits for surgical fistula repair

obstetric fistulae

N = 202

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Baseline data n=202

Age y 28.9 (15-63)

Parity n 2.0 (1-11)

Duration y 3.0 (0.1-20)

Previous fistula repair n (%) 72 (35.6)

Lost to follow-up n (%) 23 (11.4)

Tanguieta personal case series

1996 - 2006

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Complications at the time of delivery

– perinatal mortality: 98%

– Ruptured uterus: 10%

Caesarean section rate: 40%

Maternal mortality?

Tanguieta personal case series

1996 - 2006

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Urethral and/or Trigonal

Supra-trigonal

79%

21%

Tanguieta personal case series

1996 - 2006

Localisation VVF

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urethral

trigonal

others

missing data

combined

supratrigonal

4.5 19 22 42.1 9.8 3 %

Tanguieta personal case series

1996 - 2006

Localisation VVF

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Route– Vaginal 76%– Abdominal 18.6%– Combined 5.4%

Martius graft 31.7% Cutaneous graft 11.9%

Urinary diversion 5% Recto-vaginal fistula 4.5%

Tanguieta personal case series

1996 - 2006

Surgical data

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Case series 1996 – 2006Outcome of Vesico-Vaginal Fistula repair

n=179

Success rate 84%

Stress incontinence 21%

Complications :

1 fatal peritonitis

4 reinterventions for secondary suture


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