Contemporary Issues in Obstetric Fistula.

We discuss a variety of contemporary issues relating to obstetric fistula. These include definitions of these injuries, the etiologic mechanisms by which fistulas occur, the role of specialist fistula centers in diagnosis and management, the classification of fistulas, and the assessment of surgical outcomes. We also review the growing need for complex reconstructive surgical procedures, follow-up challenges, and the transition to a fistula-free world in which other pathologies (such as pelvic organ prolapse) will be of increasing importance. Finally, we discuss the need to develop responsive systems of maternal health care that treat women with competence, compassion, respect, and fairness.

Gurya cutting and female genital fistulas in Niger: ten cases.

INTRODUCTION AND HYPOTHESIS: The objective was to determine the contribution of female genital cutting to genital fistula formation in Niger from the case records of a specialist fistula hospital. METHODS: A retrospective review was undertaken of the records of 360 patients seen at the Danja Fistula Center, Danja, Niger, between March 2014 and September 2016. Pertinent clinical and socio-demographic data were abstracted from the cases identified. RESULTS: A total of 10 fistulas resulting from gurya cutting was obtained: 9 cases of urethral loss and 1 rectovaginal fistula. In none of the cases was genital cutting performed for obstructed labor or as part of ritual coming-of-age ceremonies, but all cutting procedures were considered "therapeutic" within the local cultural context as treatment for dyspareunia, lack of interest in or unwillingness to engage in sexual intercourse, or female behavior that was deemed to be culturally inappropriate by the male spouse, parents, or in-laws. Clinical cure (fistula closed and the patient continent) was obtained in all 10 cases, although 3 women required more than one operation. CONCLUSIONS: Gurya cutting is an uncommon, but preventable, cause of genital fistulas in Niger. The socio-cultural context which gives rise to gurya cutting is explored in some detail.

Obstetric fistula in Niger: 6-month postoperative follow-up of 384 patients from the Danja Fistula Center.

INTRODUCTION AND HYPOTHESIS: The impoverished West African country of Niger has high rates of obstetric fistula. We report a 6-month postoperative follow-up of 384 patients from the Danja Fistula Center and assess factors associated with operative success or failure. METHODS: The medical records of 384 women who had completed a 6-month follow-up after fistula surgery were reviewed. Cases were categorized as "easy," "of intermediate complexity," or "difficult" based on a preoperative points system. Data were analyzed using simple chi-squared statistics and logistic regression. RESULTS: The patients were predominantly of Hausa ethnicity (73%), married young (average 15.9 years), had teenage first pregnancies (average first delivery 16.9 years), and experienced prolonged labor (average 2.3 days) with poor outcomes (89% stillbirth rate). The average parity was four. Patients commonly developed their fistula during their first delivery (43.5%), but over half sustained a fistula during a subsequent delivery (56.5%). Prior fistula surgery elsewhere (average 1.75 operations) was common. The overall surgical success ("closed and dry") was 54%. When the 134 primary operations were analyzed separately, the overall success rate was 80%. Increasing success was seen with decreasing surgical difficulty: 92% success for "easy" cases, 68% for "intermediate" cases, and 57% success for "difficult" cases. Success decreased with increasing numbers of previous attempts at surgical repair. CONCLUSIONS: These data provide further evidence that clinical outcomes are better when primary fistula repair is performed by expert surgeons in specialist centers with the support of trained fistula nurses.

Abdomen agudo quirúrgico en el anciano

El abdomen agudo quirúrgico suele ser la causa más frecuente de cirugía abdominal de urgencia en el anciano, se asocia con una alta mortalidad a pesar de las tecnologías quirúrgicas modernas. Evaluar la cirugía del abdomen agudo quirúrgico en el anciano. Estudio descriptivo prospectivo que incluye a 102 pacientes de 60 años o más operados en el Hospital Universitario Dr Gustavo Aldereguía Lima de Cienfuegos entre agosto y diciembre del 2002 con el diagnóstico de abdomen agudo quirúrgico. Los datos primarios se obtuvieron de las fichas clínicas de los pacientes y de la observación clínica diaria hasta el egreso. Los pacientes tienen una edad media de 74 años, las causas más frecuentes del síndrome fueron la oclusión intestinal (32,4 porciento), las afecciones de las vías biliares (22,5 porciento), y la apendicitis aguda (21,6 porciento). El síntoma más frecuente fue el dolor abdominal (96,08 porciento), y el signo más frecuente, la taquicardia (80,4 porciento). Se presentaron complicaciones posoperatorias en 47,06 porciento de los pacientes; se observó una mortalidad de 26,5 porciento en relación estadísticamente significativa con la edad, la clasificación ASA, el riesgo quirúrgico, el tiempo de evolución y el tiempo quirúrgico. La peritonitis fibrinopurulenta encabezó las causas directas de muerte. El índice de reintervención fue de 3, 9 porciento(AU)