Leading Experts Discuss Fistula, Safe Surgery and the Way Forward

By: Kayla McGowan, Project Coordinator, Women and Health Initiative, Harvard T.H. Chan School of Public Health. Original post can be found on MHTF Blog

"Mother and Baby at a Post-op Visit to the Fistula Hospital in Arba Minch" © 2010 USAID Ethiopia, used under a Creative Commons Attribution license: https://creativecommons.org/licenses/by/2.0While safe surgical practices can improve maternal health outcomes, surgery can pose its own risks and complications. The Maternal Health Task Force’s Kayla McGowan (KM) had the pleasure of interviewing two leading experts in the field of fistula and safe surgery, Dr. Thomas Raassen (TR) and Carrie Ngongo (CN). They recently conducted a study analyzing nearly 400 ureteric injuries, or injuries to the tube connecting the kidney to the bladder, following obstetric and gynecologic operations in 11 countries in Africa and Asia. Ureteric injuries are one of the most serious complications of pelvic surgery.

KM: What prompted this study?

TR: We have operated on many women…but going over all the data, we came across women who had fistulas which were not caused by the pressure of prolonged or obstructed labor but which were caused by the doctor who was doing an operation. In discussing this with a group of doctors who were preparing a manual for training, it came up that as fistula experts, we all saw quite a number of these cases and we were very interested in finding out the number of patients who had iatrogenic fistulas—fistulas caused by the doctor who is doing an operation. And that led us to write the first article about iatrogenic injuries. Now we are looking at each type of injury separately, starting with ureteric injuries.

CN: Surgery often saves lives, but we need to be aware that there is always a risk of injury during repair of ruptured uterus, cesarean section (c-section) and gynecological hysterectomy—and during fistula repair [itself].  This study allows us to consider the women who developed ureteric injuries during obstetric fistula repair. If a fistula surgeon makes a mistake when operating for obstetric fistula, he or she can cause damage to the ureters.

KM: In your experience, roughly what percent of fistula repair cases are considered iatrogenic, or caused by surgical error?

TR: In our previous study—which assessed nearly 6,000 women undergoing fistula repair—we found that 9.5% of women seeking repair had a fistula we categorized as “definitely iatrogenic” while the cumulative percentage of “definitely” or “probably iatrogenic” was 11%, and the cumulative percentage of “definitely,” “likely” or “probably iatrogenic” was about 13%.

KM: Could you please explain the design and method(s) for your latest study?

CN: This was a retrospective record review looking back at nearly 20 years of data in 11 countries. We assessed how frequently Dr. Raassen and colleagues saw ureteric injury, whether it was on the left or the right side of the body and the causative procedures and outcomes. The paper combines the frequency over nearly two decades and some comments on how to diagnose ureteric problems and address them clinically.

KM: The study found that nearly 68% of ureteric injuries were caused during obstetric operations—including c-section; c-section/hysterectomy; and ruptured uterus repair—while about 18% of these injuries resulted from gynecological hysterectomy. And about 15% were actually caused during surgical repair of obstetric fistula (postrepair group). What are the implications of these findings? Were you surprised by these results?

TR: If you look at well-resourced settings, you will find that the highest percentage [of ureteric injuries] is in the group of gynecological operations (90% or more) and the [number of cases resulting from] c-section or obstetric procedures is much smaller. It is indeed interesting that we see that 68% of cases in the developing world are due to obstetric operations—it is a staggering figure. This means that there is something wrong with obstetric surgery—not only that the training or the conditions in which the doctors work might be insufficient, but it also has to do with the indications for obstetric operations. Are the indications for c-sections always clear? There are alternatives to c-sections, especially when the baby has died [in utero]. These are important figures to mention to the wider public.

KM: You state that “Demographic characteristics show clear differences between women with iatrogenic injuries and those with obstetric fistulas.” Could you expand on this?

CN: One interesting finding was that the women in the postrepair group were much less likely to be living with their husbands. They had an obstetric fistula at first, got repaired for the obstetric fistula and were still leaking because the surgeon who repaired the obstetric fistula gave them a new problem. The demographic data paint a picture of the difficult circumstances faced by many women.

KM: You write that diagnosis and treatment of ureteric injuries is possible in low-resource settings, with success rates greater than 90%. This is encouraging. What are some of your recommendations for diagnosing and treating fistula in these settings?

CN: Diagnosis and treatment are possible even without all the fancy machines [found] in well-resourced settings.

TR: The diagnosis starts with the history-taking of the woman. When you find out that a woman is able to pass urine but has been leaking since she had an operation, you have already found a very important part of your diagnosis. This is something that does not require any machines; it only requires talking to the patient. Secondly, examining the woman is very important.

KM: You identify three contributing factors that complicate obstetric and gynecological surgery: surgeon experience, health facility limitations such as poor lighting or sudden blackout and delay in getting to the hospital. Could you elaborate?

TR: Having a previous abdominal operation was also an influence, but in our setting, it seemed that training and provider setting were more important contributing factors than whether a woman had a previous operation. Another factor is that women often come to the facility late—after already experiencing prolonged obstructed labor [which poses more surgical challenges].

KM: You conclude that ureteric injuries during obstetric and gynecological operations are probably increasing. Why is that? And how can this be addressed?

CN: Our article does not provide evidence for the increasing c-section rate over time, but it is quite likely that as c-sections rates go up, there is greater risk of iatrogenic injuries during c-sections. Anecdotally, fistula surgeons around the world have noticed increases in the rates of iatrogenic fistula corresponding with the global increase in use of c-section.

KM: What is your main message for the maternal health community?

TR: Our main message is that [surgical] training should be better, the conditions under which the doctors work should be better and the indication [for surgery]—which is part of training and teaching—should be clearer.

CN: I would also step back and say that all surgery has risks. We see that one of the risks of c-section is iatrogenic fistula, and it could well be that the risks of undergoing c-section are greater in the developing world. It might be better not to do a c-section if a woman has arrived late to the facility with prolonged, obstructed labor and her baby has died. At that point, a c-section will just introduce risks to the mother without saving the child. The data in our article affirm how risky c-section can be for women in the poorest parts of the world.

Read the full open access paper: Diagnosis and management of 365 ureteric injuries following obstetric and gynecologic surgery in resource-limited settings.

Learn more about how surgery can treat—and cause—fistula.

Read a recent report on c-section safety and quality in low-resource settings.

Access related resources from our partner organization, Fistula Care Plus.

This interview has been edited for length and clarity.

Photo credit: “Mother and Baby at a Post-op Visit to the Fistula Hospital in Arba Minch” © 2010 USAID Ethiopia, used under a Creative Commons Attribution license 2.0