Determinants of postoperative outcomes of female genital fistula repair surgery.

It is estimated that up to 2 million women in resource poor countries are living with a urinary or recto-vaginal fistula (1,2), primarily as a result of prolonged obstructed labor.(3) Despite the growing number of studies examining factors influencing fistula repair outcomes (4–7), there remains limited evidence on which to base clinical practice. More empirical evidence on independent predictors of repair outcomes would serve several purposes. Additional evidence of fistula and patient characteristics independently associated with repair outcomes would strengthen the movement towards developing a standardized fistula classification system by contributing evidence with regard to which characteristics should be included in such a system. Similarly, such information could guide discussions with fistula patients regarding possible outcomes of their repair. Finally, additional evidence regarding predictors of repair outcome would provide useful information to guide clinical practice, including decisions about how and by whom (i.e. the level of skill needed by the surgeon) a given fistula should be repaired. Published evidence to-date fails to demonstrate an independent role of any patient characteristic in predicting repair outcomes(8,9,14,16,20,27). On the other hand, several fistula characteristics, most notably vaginal scarring and urethral involvement, have been found to predict poor prognosis of repair surgery (5,8,9,11,16,17). No published studies have examined the effect of contextual factors on repair outcomes, factors such as surgeon experience or whether the repair was conducted as part of outreach services or in the context of training. Most studies have been conducted at one center in a single country, often by a single surgeon, thereby limiting the ability of these studies to generalize beyond a very specific patient population and setting. Many of the studies had small sample sizes and were of varied quality, and few conducted analyses necessary to assess independent effects of predictors of repair outcomes.(4) Against this background, we conducted a large, multi-country prospective cohort study to evaluate which patient-level (patient and fistula characteristics) and contextual factors predicted fistula repair surgery outcomes. We evaluated the influence of these factors on two outcomes at 3 months after fistula repair surgery: fistula closure and residual incontinence in women after successful fistula closure.