Fourth International Consultation On Incontinence (ICI) - Vesicovaginal Fistula In The Developing World Committee Highlights

Main Category: Urology / Nephrology
Article Date: 25 Jul 2008 - 2:00 PDT

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PARIS, FRANCE (UroToday.com) - The increasing attention to vesicovaginal fistulae (VVF) in the developing world continued with the first presentation of the afternoon by Dr. DeRidder. He noted the challenges in this area with respect to presenting levels of evidence and recommendation grades due to a scarcity of randomized controlled trials and high-level evidence. The committee evaluated 149 articles published over the last 5 years, which included only 8 trials, most being observational in nature and Level 3-4 evidence.

The incidence of VVF globally is anywhere from 10,000-50,000 cases, depending on methodology of surveys with a worldwide prevalence of approximately 2 million cases. Dr. DeRidder presented a graph from the 2005 World Health Report that showed maternal mortality as a surrogate risk indicator for VVF. Rates are highest in sub-Saharan Africa and likely reflect common risk factors including poverty, young maternal age and limited access to prenatal care. Dr. DeRidder presented a 2007 study from Nigeria that showed the number of cases surgically corrected dependent on external funding to the surgical clinic.

The etiology of VVF was reviewed including the obstructed labor complex, iatrogenic injuries, cases of abuse/rape and traditional practices such as Gishiri cutting. The obstructed labor complex was highlighted as the primary cause in the developing world and consists of not only VVF but also a high incidence of fetal death, vaginal scarring, complex urologic injuries, secondary infertility, neurological injuries (foot-drop) and pelvic floor injuries, among others. VVF can have devastating consequences for women in the developing world, and Dr. DeRidder highlighted two publications from 2007 that showed a divorce rate of 36%, a fetal death rate of 85%, and frequent maternal loss of self-esteem, depression and suicidal thoughts. Women with VVF are often ostracized from their communities. Dr. DeRidder presented two recent publications showing a 97-100% incidence of mental dysfunction in women with VVF based on the GHQ-28 questionnaire. This dramatically decreased after fistula correction.

Dr. DeRidder next went on to describe the various classification systems for VVF, most of which note the size, location, and status of the urethral closure mechanism. None of the existing classification systems have been shown to be prognostically useful. The 2006 WHO classification describes simple/good prognosis fistulae as those that are single fistulae not involving the closure mechanism, not associated with vaginal stenosis/scarring, without circumferential involvement or ureteral damage, and without prior attempts at repair. All other fistulae would be classified as complicated. A 2008 study of the Goh classification system showed good inter- and intra-observer correlation.

The committee evaluated surgical treatment of VVF in the developing world and recommended intervention 3 months after the initial injury. The vaginal approach under spinal anesthesia is preferred, and a single-layer closure is recommended. Catheter drainage should be 10-14 days. The value of a Martius flap was questioned, especially for uncomplicated fistulae. Repair of complex fistulae is associated with significant rates of post-operative urinary incontinence, and risk factors include urethral involvement, fistula size, vaginal scarring and decreased bladder capacity. The principles of correction are the same with an additional recommendation to perform a sling procedure if the urethral length is less than 2.4 cm or if there is a urethral defect greater than 4mm. v With respect to primary prevention, an interesting study from Kerala, India was presented. After hospital based delivery was made mandatory in this southern Indian province, 95% of deliveries were institutional compared with 35% in the rest of the country. This was shown to lead to a dramatic reduction not only in VVF but in overall maternal morbidity.

Dr. DeRidder summarized a number of this committee's recommendations, all of which were Grade C and are outlined in the above text. He identified a number of areas for suggested future research including pre and post-operative measures of bladder and urethral function, studies on surgical techniques, patient reintegration models and other social studies.

Moderated by Christopher Chapple, MD, and Willie Davila, MD, at the Fourth International Consultation on Incontinence (ICI) - July 5 - 8, 2008. Palais des Congres, Paris, France.

Dirk DeRidder, MD, Committee Chair

Written by William Jaffe, MD, a Contributing Editor with UroToday.

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