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Obstetric fistula surgery in Uganda

This is one of the stories from the September 2012 issue of International News. Michael Bishop describes obstetric fistula surgery services in Uganda.

Use the table below to access other stories in this issue.

Editorial In their own words: 12 stories of vesicovaginal fistulae
The problem of obstetric fistula: a personal view Provision of fistula services and programmes
Update on the FIGO/RCOG and partners competency-based fistula training manual The problem of continuing urinary incontinence after obestetric vesicovaginal surgery
Creating a balanced narrative about women living with fistulae Moving beyond incontinence
Vesicovaginal fistulae in Nepal Vesicovaginal fistula repairs at Aberdeen Women’s Centre in Sierra Leone
Vesicovaginal fistulae in Bangladesh Vesicovaginal fistula repairs in Tanzania
transportMYpatient: overcoming the barrier of transport costs Journal club

 

Fistula surgery is undertaken in different settings with some centralisation in the Obstetric and Gynaecology Department in the Mulago Teaching Hospital associated with Makerere University in the capital, Kampala. This unit, led by Dr J Baraguene, also regularly treats patients in outreach centres and is supported in a twinning arrangement with an Egyptian hospital. However, visiting surgeons from Europe, the USA and other African countries perform the majority of fistula surgery in Uganda according to the ‘camp’ model. Individual experts have made highly significant contributions, particularly to teaching, by regular visits over many years to particular hospitals (Tom Raassen to Mulago; Brian Hancock to Kamuli, Lira and Kitovu). Little or no fistula surgery is undertaken as part of the regular daily workload in government hospitals outside of the capital. EngenderHealth and the United Nations Population Fund generously provide much of the financial support, by covering hospital charges and travel and accommodation expenses. However, many other non-governmental organisations whose activities are largely unknown to each other, who act independently without central coordination, also contribute.

The author has experience of working in the past seven years in camps organised by the 3M’s Catholic Mission Hospital in Kitovu near Masaka in South West Uganda. Approximately 250 operations are performed annually in four sessions of two to three weeks run by eight surgeons. Much work is involved in broadcasting an imminent camp, procuring and registering patients, and organising the coincident visits of the surgical staff and nursing and medical trainees. Nursing staff must be seconded and protected operating time arranged with corresponding reduction in the elective surgical and gynaecological admissions, as Kitovu is a busy general hospital. 

Fistula ward at Kitovu Hospital in Uganda

Fistula ward at Kitovu Hospital in Uganda

This has been undertaken efficiently over many years by Sister Maura Lynch and a small dedicated team who for the period of the camp take ‘a fistula sabbatical’. Sister Maura is a general surgeon who for many years undertook fistula surgery after establishing the service in the early 1990s with the legendary John Kelly, who still spends many months of every year operating on women with fistulae in several countries in Africa and South Asia.

The problem of accommodating 50 or more patients has been solved by provision of a purpose-built ward, with 30 beds and a dedicated operating theatre with two tables working in parallel. Benefactors in Southern Ireland and the UK have generously sponsored the buildings. After three to four days patients are generally transferred to a convalescent ward where they are self-caring or are assisted by relatives, before catheters are removed after 14 days and appropriate bladder training and pelvic floor exercises are supervised where relevant. Many of the details of the surgical techniques employed and of the postoperative care reflect routines developed at the Fistula Hospital in Addis Ababa that have been refined by Mr Brian Hancock. Much of this is published in his useful and highly recommended training manual, Practical Obstetric Fistula Surgery.1

In other hospitals uretero- and uterovaginal fistulae, usually following delivery of a live fetus, are more prevalent. Invariably this has followed caesarean section and is indicative of an iatrogenic injury rather than one caused by ischaemia from the obstructing fetal head. Visiting specialists will frequently be asked to review and perhaps treat patients with urinary symptoms caused by a variety of both congenital and acquired disorders.

Only a small minority had fistulae suitable for repair by inexperienced trainees, even if closely supervised. Most of the patients with stress incontinence were treated with a retropubic sling constructed from a 4cm segment of rectus sheath inserted with minimal dissection (‘sling-on-a-string’). This represents a personal preference but the technique is in use elsewhere with reasonably well-sustained results. I have also used freely a ‘poor man’s urodynamic test’ with gravity filling during the post-repair dye test to measure approximate functional bladder capacity at 15cm pressure. It is also helpful to determine the threshold volume at which leakage occurs after removal of the catheter. Detrusor compliance is a key parameter in determining recovery of function after fistula repair. Other types of intrinsic perineal muscle slings (pubococcygeus, ischiocavernosus) are used by all the surgeons visiting Kitovu. There is general agreement that urinary diversion using a detubularised sigmoid colonic pouch in continuity with the bowel (Mainz II) is appropriate when multiple attempts at fistula closure or surgery for stress incontinence have failed. This operation should be used earlier in the treatment cycle when it is apparent that primary repair is unlikely to work through extreme tissue loss and very low bladder capacity.

Finally, the results emphasise the difficulty in arranging follow-up for all patients, even by a very well-organised unit. It is unlikely that more than 60% of patients can be seen or contacted three months after discharge and favourable outcomes cannot be assumed in the remainder.

Ideally, in every unit undertaking regular fistula surgery, each surgeon should contribute all work undertaken to a central database. Also a consistent approach should be adopted to treatment and postoperative care. This would be of particular value in the management of incontinence after withdrawal of the catheter, the treatment of genuine stress incontinence and in agreeing the indications for urinary diversion. Unfortunately, in Kitovu documenting results and coordinating the activities of several surgeons has required resources that are as yet unavailable. Issues of handover, working to protocol and detailed audit form the basis of good surgical governance, as well as establishing and enacting research protocols. Increasingly, these are changing the face of training, education, practice and research in all of the surgical specialties in Europe and the USA, and it is unfortunate that these disciplines are generally deficient in the field of obstetric fistula surgery.

Another problem common to many centres of obstetric fistula surgery is that much of it is performed by surgeons near to or beyond their date of retirement. There is a deficiency of young well-motivated surgical and gynaecological specialists who are able to give sufficient time on a regular basis to treat women with fistulae but even more importantly to train local surgeons. Ideally, the work should be done exclusively by indigenous surgeons, but realistically only a minority will be able to undertake the extra commitment in addition to their routine government service work and private practice.

Michael Bishop, Retired consultant urologist

Reference

1. Hancock B, Browning A. Practical Obstetric Fistula Surgery. London: Royal Society of Medicine Press; 2009.