Causative factors, social and surgical outcomes of vesicovaginal fistulas treated via an abdominal transvesical approach: A single-center experience.

OBJECTIVE: To study the demographics, and surgical and social outcomes of patients with fistula repair performed at our hospital. METHODS: This cross-sectional study included 120 patients with fistula repair performed between 2014 and 2019 in the Urology Department of Lady Reading Hospital, Peshawar using an open transvesical repair method without omental interposition. Data were collected on patients' demographics, and social and surgical outcomes. Fistula severity was assessed using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). RESULTS: About 80 (66.6%) fistulas were iatrogenic and 40 (33.3%) were ischemic, with 36 (90%) due to obstructed labor. The median age of patients was 36 years (29-40 years). The majority of the patients were multiparous and premenopausal (99; 82.5%). Fifty (56.5%) of the iatrogenic fistulas were due to non-obstetric hysterectomy, and 20 (25%) were due to cesarean hysterectomy. Women had the fistulas for 4-49 weeks before seeking treatment with an average ICIQ score of 18. In all, 73 (73%) of the fistula caused by delivery had involved stillbirths, 4 (3.96%) were early neonatal deaths, and nearly 25 (21%) of patients were divorced. About 114 (95%) of patients were completely cured on discharge. CONCLUSION: Vesicovaginal fistula is a devastating condition, with a rising trend in iatrogenic fistulas in low-income countries. In the hands of experienced surgeons, trans-abdominal repair without omental interposition shows a high success rate.

Ruptured uterus: Frequency, risk factors and feto-maternal outcome: Current scenario in a low-resource setup.

INTRODUCTION: Pakistan is among the countries with the highest maternal death rates. Obstetric hemorrhage accounts for 41% of these deaths. Uterine rupture is a grave obstetric emergency with high maternal and neonatal morbidity and mortality. It is important to identify its frequency and associated risk factors to formulate programs for its prevention and management. This study aimed to assess the frequency, associated risk factors, fetomaternal outcomes, and management of women with the ruptured uterus at our hospital. MATERIAL AND METHODS: It was a retrospective study of 206 women to review data collected from cases of uterine rupture managed at the WCTH Bannu, Pakistan from October 2016 to October 2018. A structured proforma was designed and used to extract data from operating theatre registers and the hospital medical records. In our hospital, there is a strong system of maintaining all information of the patients related to demographics, obstetric information, operative notes, and postoperative course during their hospital stay in the patient's charts. Detailed information on operative procedures is further maintained in the operation theater register and all these registers are checked in the weekly statistical meetings to ensure proper documentation. Data was entered and analyzed in SPSS package version 21 (IBM Corp.; Armonk, NY, USA). Frequency and percentages were calculated for the categorical variables. For inferential statistics, chi-square or Fischer exact tests were used. A p-value of < 0.05 was considered statistically significant. RESULTS: The overall incidence of the ruptured uterus was 1.71%. The important etiological factors were grand multiparity 62 (35.2%), obstructed/neglected labour 58 (32.9%), injudicious use of Oxytocin 56 (31.8%) and prostaglandins 26 (14.7%), previous cesarean section 35 (19.8%) and previous pelvic surgery (0.5%). Hysterectomy was done in 80.6% of cases, 34 (19.2%) patients underwent uterine repair and 4.5% had bladder repair. The mortality rate was 21%, mainly due to irreversible shock or disseminated intravascular coagulation. Perinatal mortality was 91.4%. Duration of surgery more than two hours and presentation to the hospital at night time was significantly associated with poor maternal outcome (p = 0.00). CONCLUSION: Uterine rupture is a preventable obstetric emergency associated with high fetomaternal morbidity and mortality. The main causes were grand multigravidity, obstructed labour, previous C-sections and injudicious use of oxytocin and prostaglandins. Women with prolonged surgery and admission at night time had a poor maternal outcome.