[page 10] [Urogynaecologia 2017; 30:196]

Outcome of using a modifiedsurgical technique for therepair of complex vesicovaginalfistulas in NigeriaAniefiok J. Umoiyoho, Emmanuel C. Inyang-EtohDepartment of Obstetrics andGynecology, University of Uyo, Nigeria

AbstractThe relatively low effectiveness of

available surgical repair techniques forcomplex obstetric fistula has justified theneed for continued exploration of moreeffective repair techniques. Subjects whopresented at a vesicovaginal fistula referralcentre in Nigeria were randomized into thestudy group (modified technique) and thecontrol group (conventional technique).Success rates between the two groups werecompared. The study comprised 29 patientsin each arm of the study. The mean age ofpatients in the study group was 23.9 ± 9.6years and 24.4 ± 2.1 years among patients inthe control group with the vast majority ofthe patients in the both groups being mar-ried, 75.9% and 86.2% respectively. In bothgroups, the majority were secundipara,55.2% in the study group and 44.8% in thecontrol group. The majority (41.4% in thestudy group and 44.8% in the control group)of the patients in both groups had attainedprimary level of education. The mean dura-tion of the fistulas among patients in thestudy population was 1.1 ± 0.3 years withover half (50.0% among patients in thestudy group and 53.5% of patients in thecontrol group) of the patients had their fis-tula for less than one year. A highly statisti-cally significant difference in success ratebetween patients in the study group andpatients in the control group was obtained(p=0.0004). The modified repair techniquepresented by this study has proved to pro-duce superior results when compared to theconventional repair technique in the man-agement of complex obstetric fistulas inNigeria.

IntroductionVesicovaginal fistula (VVF) resulting

from prolonged obstructed labour continueto occur in low resource countries likeNigeria due to socioeconomic deprivationof the populace and inadequacy of materni-ty care services.1,2

Nigeria’s position as the most populouscountry in Africa carries with it the notori-ety of having the largest number of vesico-vaginal fistula patients in the world. With aprevalence of 400,000 to 800,000 womenliving with vesicovaginal fistula and anincidence of 20,000 new cases annually, themagnitude of the menace is not only hugebut carries the potential of escalating overtime.1,3

At present in Nigeria, efforts targeted ateradication of this scourge is not concerted,budgetary provision is abysmal and nevergets to the end-users and dedicated VVFcentres are far apart and poorly equipped.1,4

With the dearth of trained VVF surgeonsand the slow rate of repair, eradication ofthis scourge is not feasible in the nearfuture.4,5 The prospect of eradicating VVF israther gloomy considering the fact thatmeasures have not been put in place to elim-inate the occurrences of new cases.

Vesicovaginal fistula, which is charac-terized by involuntary leakage of urine isdevastating to the health of affected womenwith attendant disruption of their physical,social and mental health as well as theirenvironment.5 The eradication of this men-ace in a country like Nigeria, where it isendemic requires concerted effort withinnovative strategies targeted at all-threelevels of prevention- primary, secondaryand tertiary.6

While government, medical and healthworkers as well as other relevant stakeholders have roles to play in the primaryand secondary levels of prevention of theoccurrence of especially obstetric fistula,the VVF surgeon is primarily preoccupiedwith prevention at level three- successfulfistula repair.

This research was conducted in order toexplore a way of increasing success rate fol-lowing repair of complex vesicovaginal fis-tula in a dedicated vesicovaginal fistularepair centre in Nigeria. The justification ofthis study is the fact that at present, successrate following repair ranges between 75.0 to88.0% in series where patient selectionbased on available level of surgical exper-tise were not performed before repair, andprognosis of vesicovaginal fistula worsenswith repeated failed attempts at repair.4,6-8

We hope that the results of this study wouldmake its contribution to the efforts targetedat reducing the burden of obstetric fistula inthe world.

Materials and MethodsStudy design and study area

This was a case-control study where

patients with complex obstetric fistulaswere matched based on socio-demographiccharacteristics and randomized into thestudy group, where a modified repair tech-nique was used in fistula repair and the con-trol group, where the conventional repairtechnique was used to repair the fistulas atthe Family Health Centre, Akwa IbomState, Nigeria. The Family Health Centre isa dedicated maternal injury health facilitylocated in the Southeast health zone ofNigeria.

The Family Health Centre is a referralcentre for all cases of maternal injuries likeepisiotomy breakdown, perineal laceration,genital prolapse, vesicovaginal fistula andrectovaginal fistula as well as other types ofgenitourinary fistula in Akwa Ibom Stateand the neighbouring states of Abia, CrossRiver, Imo, Rivers and Bayelsa.

The Family Health Centre is located atMbribit Itam in the outskirts of Uyo, the

Urogynaecologia 2017; volume 30:196

Correspondence: Emmanuel C. Inyang-Etoh,P. O. Box 200, Ikot Ekpene, Akwa Ibom State,Nigeria. Tel.: 2348033452822/2347034038318.E-mail: emmacol2000@yahoo.com

Key words: Obstetric fistula; surgical repair;modified technique; success rate; Nigeria.

Acknowledgment: we wish to express ourgratitude to the management and staff, espe-cially the nurses of Family Health Centre,Mbribit Itam for their assistance and supportduring the conduct of this research. We arealso grateful to Dr Anyiekere M. Ekanem foranalysing the data of this work.

Contributions: AJU, study concept and design,surgeries performing, patients’ organizationinto the study groups; ECI-E, literature search,manuscript drafting and revising, data analy-sis, assistance in surgeries performing andpatients’ organization into the study groups.The authors approved the final manuscript tobe published.

Conflict of interest: the authors declare poten-tial no conflict of interest.

Received for publication: 26 February 2017.Revision received: 2 May 2017.Accepted for publication: 1 June 2017.

This work is licensed under a CreativeCommons Attribution NonCommercial 4.0License (CC BY-NC 4.0).

©Copyright A.J. Umoiyoho and E.C. Inyang-Etoh, 2017Licensee PAGEPress, ItalyUrogynaecologia 2017; 30:196doi:10.4081/uij.2017.196

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state capital of Akwa Ibom State, one of the36 states of the federal republic of Nigeria,located in the South-south geopolitical zoneof the country. The states in this catchmentarea all have similar sociocultural and tradi-tional practices with less than 50% of thewomen having attained at least secondarylevel of education.2 In spite of several healthfacilities distributed across the states, only61% of pregnant women obtain antenatalcare, a mere 36% deliver in health facilities,while only 38% deliver under skilled atten-dance.2 The majority of the women, espe-cially those living in rural areas for variousreasons prefer to deliver in traditional birthattendants’ homes and other unlicensedmaternity centres where intrapartum caremay be suboptimal.2

Recruitment and data collectionFollowing approval from the Ethical

Committee of the Family Health Centre, allthe 140 women who presented with differ-ent degrees of obstetric fistula during the 2year period of the study were screenedusing the prognostic scoring system pro-posed by Umoiyoho and Inyang-Etoh.4Sixty complex cases were identified but 58met the inclusion criteria and were recruitedinto the study. Using the prognostic scoringsystem proposed by the Authors as a guideto patient selection for VVF repair based onfistula complexity and available surgicalexpertise,4 patients whose scores were 4 orless were classified as simple cases andexcluded from the study.4 Patients who metthe inclusion criteria were 58 and includedthose who scored 5 and above over 29, butexcluded two patients who had exceptional-ly high risk factors.4 These two patientswere not recruited into the study becausethey had VVF with either involvement ofthe urethra with circumferential defect ortotal urethral loss. The simple cases thatwere excluded from the study were repairedusing the conventional technique, while thepatients with exceptionally high risk factorswere reserved for a visiting multidisci-plinary expert surgical team.

The 58 patients with complex fistulaswho met the inclusion criteria were coun-selled on the nature of the study andinformed that participation was voluntaryand that information obtained shall be han-dled with a high level of confidentiality.They all consented to participate in the study,so informed consent was obtained from eachof them before surgical intervention. Patientsin the study population were categorizedbased on their age, parity, duration of fistulaand fistula characteristics and randomizedinto the study group and control group usinga simple random sampling technique. Thedata generated were analysed using descrip-

tive and inferential statistics. The successrate of repair between the modified repairtechnique and conventional repair techniquewere compared using the Student t-test, a teststatistic was computed and a p-value of 0.05was considered significant. The results arepresented in tabular form and the success rateof repair between the two groups is also pre-sented on a line graph.

Surgical repair techniques

Conventional repair In the control group where the conven-

tional technique of repair of the fistulas wasused, the patients were placed in the exag-gerated lithotomy position under saddleblock regional anaesthesia and routine vul-val and vaginal preparation, as well as drap-ing were performed; the fistula opening inthe anterior vaginal wall was identified. Theedge of the fistula opening was mobilizedand the edge resected through to the urinarybladder wall. The vaginal wall was thenincised longitudinally through the opening.Next, the bladder wall was identified, dis-sected and separated from the vaginal wallfor up to 2cm around the fistula. Anyremaining scar tissue around the fistula wasthen excised. Interrupted stitches wereplaced around the edges of the bladder wallstarting from the 3 o’clock position usingpolyglactin, size 2/0 on an atraumatic nee-dle. These stitches were then tied separatelyinvaginating the mucosa towards the blad-der cavity. A second layer of repair was thenperformed with interrupted sutures ofpolyglactin, size 2/0 across the defect in amanner so as to bury the first layer takingcare not to allow the sutures breach thebladder mucosa. The vaginal wall was thenclosed using interrupted mattress stitches ofpolyglactin, size 2/0 on an atraumatic nee-dle. Haemostasis was attained.

All the repairs were performed by thelead Author, who is a trained VVF surgeonand the postoperative management fol-lowed an established protocol by dedicatednurses who have been trained to proficiencyin the postoperative care of VVF patients.Test for urine leakage was through the con-tinence dye test, which was performed oneach patient on days 7, 10, 12, 14, and 21with aqueous solution of methylene blue.For the purpose of this study, the urethralcatheter was maintained for 21days for con-tinuous bladder drainage. Postoperativereview and certification of cure was per-formed at 6weeks.

Modified repairIn the modified repair technique, the

approach to repair was similar to the con-ventional technique, save for the introduc-

tion of a third layer of repair. The edge ofthe fistula opening was mobilized and theedge resected through to the urinary bladderwall. The vaginal wall was then incised lon-gitudinally through the opening. Next, thebladder wall was identified, dissected andseparated from the vaginal wall for up to2cm around the fistula. Any remaining scartissue around the fistula was then excised.The first layer of repair was taken about0.5-1cm from the fistula edge with inter-rupted stitches, which were placed aroundthe edges of the bladder wall starting fromthe 3 0’clock position using polyglactin,size 2/0 on an atraumatic needle. The stitch-es were then tied invaginating the mucosatowards the bladder cavity. A second layerof repair was then performed with interrupt-ed sutures of polyglactin, size 2/0 across thedefect in a manner so as to bury the firstlayer taking care not to allow the suturesbreach the bladder mucosa. A third layer ofrepair was in addition performed in such away that the adjourning soft tissues weremobilized through a series of figure 8stitches to support the suture line. Thestitches were carefully inserted and left ten-sion-free ensuring that they did not breachthe bladder mucosa. The vaginal wall wasthen closed using interrupted mattressstitches of polyglactin, size 2/0 on an atrau-matic needle. Haemostasis was attained.The postoperative management was accord-ing to established protocol in the centre, andwas the same for all the patents in the studypopulation.

ResultsOut of the 140 patients who presented at

the study centre with various types andcomplexities of obstetric fistulas during thetwo-year period of the study, 58 met theinclusion criteria and were recruited into thestudy population. The study group com-prised patients who had their fistularepaired with a modified technique and thecontrol group who were repaired with theconventional repair technique, each grouphad 29 patients.

Table 1 shows the socio-demographicparameters of patients in the study popula-tion. The mean age of patients in the studygroup was 23.9±9.6 years and 24.4+2.1years among patients in the control group.The modal age group in both groups was26-30 years of age. The vast majority of thepatients in the study group and controlgroup were married, 75.9% and 86.2%respectively. In both groups, the majoritywere secundipara (i.e. para 2), 55.2% in thestudy group and 44.8% in the control group.The majority (41.4% in the study group and

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44.8% in the control group) of the patientsin both groups had attained primary level ofeducation. A vast majority of the patients inboth groups were engaged in the provisionof unskilled labour, 65.5% of patients in thestudy group and 55.2% in the control group.

The duration of the fistula is showed inTable 2. The mean duration of the fistulasamong patients in the study population was1.1±0.3 years with over half (50.0% amongpatients in the study group and 53.5% ofpatients in the control group) of the patientshad their fistula for less than one year. Only3.6% of patients had their fistula for over 2years in both groups. Table 3 and Figure 1show a comparison of the success rate ofobstetric fistula repair in the study groupand control group as the postoperative peri-od progressed from the 7th postoperativeday to the 21st postoperative day. A highlystatistically significant difference(t=5.7735, df= 8, p=0.0004) in success ratebetween patients in the study group andpatients in the control group is shown in theline graph in Figure 1.

DiscussionThe discovery of a vesicovaginal fistula

repair technique that has a one- chance highcure rate for complex cases of vesicovagi-nal fistula is desirable, because failedattempts at repair is of prognostic value inthe successful repair of complex vesicov-aginal fistula. The mean age of patients inthe study and control groups were 23.9+9.6years and 24.4+2.1 years respectively, witha modal age of 26-30 years, comparable toresults from a similar study in southernMalawi, where a mean age of 22.8 yearsand a modal age group of 20-29 years wereobtained.9 Another study in Malawi com-prising a larger proportion of VVF patientsrevealed a modal age group of 20-24 yearswith the vast majority in the 15-29 years agebracket.10 These results are indicative of thefact that vesicovaginal fistula is a problemof young women of reproductive age whosustain this devastating maternal injury intheir prime. The majority (75.9% and86.2% respectively) of patients in the studyand control groups were married, in agree-ment with a similar study in Malawi whereover half (57.0%) of the women in thatseries remained married, even though20.9% of the women in that series weredivorced.9 These findings give credence tothe fact that where VVF repair is performedearly, the duration of the distressing symp-toms is limited and the disruption of thehealth of affected women is minimal; whilesuch women therefore continue to enjoyspousal and family support.1,9,11 This is dif-

ferent from the severe disruption of thesocial wellbeing of affected women, whichoccurs when VVF becomes protracted orsuffers repeated repair failures.9,11

The majority of patients in this studypopulation were para 2 with primary levelof education, confirming the profile of vic-tims of VVF to be women of low educationand parity.6,9,10 The life of women with VVFis often characterized by the triad of illiter-acy, ignorance and poverty, which set thestage for this preventable maternal injurywith its debilitating consequences.11,12 In

many of the studies that focus on vesicov-aginal fistula- associated factors, affectedwomen are usually primiparous with prima-ry level of education or no formal educa-tion.10,11,12 These findings corroborate thefact that vesicovaginal fistula occurs inunfortunate women living in impoverishedsocieties.10,12 The mean duration of the fistu-la in patients in this study was 1.1+0.3years, probably because of increase publicenlightenment and greater awareness inNigeria that vesicovaginal fistula isamenable to surgical repair. A vast majority

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Table 1. Demographic and obstetric parameters of patients in the study.

Parameter Study group Control group Number Percentage (%) Number Percentage (%)

Age groups <15 1 3.5 0 0.0 15-20 5 17.2 6 20.7 21-25 9 31.0 8 27.6 26-30 13 44.8 13 44.8 >30 1 3.5 2 6.9Marital status Single 7 24.1 4 13.8 Married 22 75.9 25 86.2Parity 1 7 24.1 6 20.7 2 16 55.2 13 44.8 3 4 13.8 8 27.6 >4 2 6.9 2 6.9Educational level No formal 9 31.0 8 27.6 Primary 12 41.4 13 44.8 Secondary 5 17.2 6 20.7 Post-secondary 3 10.4 2 6.9Occupation Unemployed 6 20.7 7 24.1 Unskilled 19 65.5 16 55.2 Semiskilled 3 10.3 4 13.8 Skilled/Technical 1 3.5 2 6.9 Total 29 100.0 29 100.0

Table 2. Duration of the fistula among patients in the study.

Duration of fistula Study group Control groupDuration in years Number Percentage (%) Number Percentage (%)

<1 14 50.0 15 53.51-2 13 46.4 12 42.9> 2 2 3.6 2 3.6Total 29 100.0 29 100.0

Table 3. Success rate following repair among patients in the study.

Assessment day Study group Control groupPost-op day No. Success rate (%) No. Success rate (%)

Day 7 22 78.6 17 60.0Day 10 24 85.7 18 64.3Day 12 25 89.3 19 67.9Day 14 26 92.9 20 71.4Day 21 27 96.4 20 71.4

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of Nigerians living in rural communitiesbelieve VVF results from some spiritualaffliction, and that it has no cure.13,14 Theshort duration of the fistula among patientsin this study also explains why the rate ofdivorce and other disruption of the wellbe-ing of affected women were not prominentamong patients in this study.1,11,14 This studyhas demonstrated that the use of thedescribed modified surgical repair tech-nique for the closure of selected complexVVF among patients in this study had a sig-nificantly higher (p= 0.0004) success ratethan the use of the conventional techniqueof repair. This study was born out of a desireto discover a surgical technique that couldgive a one-chance opportunity of cure inselected complex cases of vesicovaginal fis-tula. The described modified repair tech-nique used in this study employs a thirdlayer of repair, which reinforces the sutureline and reduces further the risk of failure.Even though, modified methods of VVFrepair like plastic surgical techniques andMartius flap procedure have been utilizedby different authorities with some success-es,15-17 the reported modified method ofVVF repair is innovative, as literaturesearch did not yield any positive finding.

The quest for a method of VVF repairthat is highly effective in the repair of com-plex VVF is justified, considering the factthat in the management of vesicovaginalfistula, the first opportunity presents thebest chance of successful repair.12,18

Conversely, repeated failed attempts atrepair aggravates the condition and decreas-es the chances of successful repair for anygiven patient.12,18

ConclusionsIn conclusion, VVF remains a problem

of young married illiterate women living inimpoverished communities of developingcountries. The modified surgical repairtechnique presented by this study hasproved to produce superior results whencompared to the conventional repair tech-nique. A recommendation is hereby made toVVF surgeons to embrace the proposedmodified repair technique, experiment withit and report on their experiences. The reli-ability of this proposed technique may passthe test of time and make a difference bymitigating the burden of women living withvesicovaginal fistula in different parts of theworld.

References1. Ijaiya M, Rahman GA, Adewole AAA.

Vesicovaginal fistula: a review ofNigerian experience. West Afr J Med2010;29:293-8.

2. National Population Commission(NPC) Nigeria. National Demographicand Health Survey (NDHS). Finalreport of national statistics, Abuja,Nigeria, 2015. pp 135-9.

3. Adler AJ, Ronsmans C, Calvert C,Filippi V. Estimating the prevalence ofObstetric fistula: a systematic reviewand metaanalysis. BMC PregnancyChildbirth 2013;13:246-53

4. Umoiyoho AJ, Inyang-Etoh EC.Obstetric fistula repair: a guide to

patient selection. Urogynaecologia IntlJ 2011;25:e8.

5. Umoiyoho AJ, Inyang-Etoh EC, AbahGM, et al. Quality of life following suc-cessful repair of vesicovaginal fistula inNigeria. Rural Remote Health J 2011;1-7.

6. Umoiyoho AJ, Inyang-Etoh EC,Etukumana EA. Vesicovaginal fistularepair: Experience with hospital- basedoutreach approach in Nigeria. Glob JHealth Sci 2012;5:40-5.

7. Lassey AT. Simple fistulas: Diagnosisand management in low-resource set-tings - A descriptive report. Intl JGynecol Obstet 2007;99:S47-S50.

8. Shittu OS, Ojengbede OA, Wara LHI. Areview of postoperative care for obstet-ric fistulas in Nigeria. Intl J. GynecolObstet 2007;99:S79-S84.

9. Rijken Y, Chilopora GC. Urogenital andrecto-vaginal fistulas in southernMalawi: A report of 407 patients. Intl JGynecol Obstet 2007;99:S85-S9.

10. Johnson K. Incontinence in Malawi:analysis of a proxy measure of vaginalfistula in a national survey. Intl J.Gynecol Obstet 2007;S122-S9.

11. Gharoro EP, Abedi HO. Vesicovaginalfistula in Benin City, Nigeria. Intl JGynecol Obstet 1999;64:313-4.

12. Umoiyoho AJ, Inyang-Etoh EC.Community misconception about theaetiopathogenesis and treatment of vesi-covaginal fistula in Northern Nigeria.Intl J Med Biomed Res 2012;1:193-8.

13. Ojengbede OA, Morhason-Bello IO,Shittu O. One stage repair of combinedfistulas: Myth or reality? Intl J GynecolObstet 2007;99:S90-S3.

14. Singh V, Sinha RJ, Sankhwar SN, et al.Transvaginal repair of complex andcomplicated vesicovaginal fistula. Intl JGynecol Obstet 2011;114:51-5.

15. Fitzpatrick C, Elkins TE. Plastic surgi-cal techniques in the repair of vesicov-aginal fistulas: A review. IntlUrogynecol J 1993;5:287-95.

16. Homaira R, Khatun S. A study of differ-ent surgical methods used for repair ofvesicovaginal fistulas in Dhaka MedicalCollege Hospital. Med Today 2010;1:12-4.

17. Menacha A, Akhyat M, Gleicher N, etal. The rectus abdominis muscle flap ina combined abdminovaginal repair fordifficult vesicovaginal fistulae: a reportof 3 cases. J Reprod Med 1990;35:565-8.

18. Genadry RR, Creanga AA, RoenneburgML, Wheeless CR. Complex obstetricfistulas. Intl J Gynecol Obstet2007;99:S51-S6.

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Figure 1. Success rate of VVF repair between the study group (modified) and controlgroup (conventional) techniques as plotted on a line graph.

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