Discussion:
Main Findings: This retrospective study examines risk factors for
patients who underwent surgical repair of urogenital fistulas at a
Fistula Hospital in Masaka, Uganda. The data demonstrate that the
incidence rate of blood transfusions in our patient population is 6.2%.
Consistent with our hypothesis, there are specific patient
characteristics that predict a need for perioperative blood
transfusions. Specifically, these risk factors include abdominal
approach and timing of fistula repair was borderline.
Strengths and Limitations: Strengths of this study include
well-defined outcomes and their importance given the lack of
availability of blood in many areas of the world. This is the first
study to our knowledge looking at this important outcome. Furthermore,
we include a population that is generalizable to obstetric fistula
populations in the developing world. The surgeries were completed by a
group of well-trained fistula surgeons from both Uganda as well as other
countries who worked collaboratively to care for these women in a
dedicated Fistula Hospital. Limitations include a retrospective nature
of this study and therefore missing data in some cases that prevent us
from looking at other risk factors that may not have been collected at
the time or even known by the patients themselves. Some of these include
other patient comorbidities or history of previous non-fistula surgeries
for example.
Interpretation: Fistulas approached abdominally were
approximately four time more likely to need a blood transfusion compared
to a vaginal approach. This is consistent with existing research
advocating for vaginal approach as the preferred management option for
surgical fistula repairs.7 A vaginal approach is
typically preferred when feasible due to its minimally invasive nature
and association with shorter operative times, decreased blood loss and
shorter length of stays in hospitals.8,9 Previous
studies have demonstrated higher rate of complications associated with
an abdominal approach, including urinary tract infections, sepsis, blood
transfusions, and hospital readmissions.6,7 Results
from our study are consistent with published data advocating for vaginal
approach in regards to risk of perioperative blood transfusion as well.
However, there are circumstances in which an abdominal approach may be
indicated, such as for ureteric involvement, limited vaginal access,
significant associated scarring or failed prior
repairs.7,8,10 Ultimately, approach is largely
determined by patient characteristics, size and location of fistula and
expertise of surgeon. Although an abdominal approach may be unavoidable
at times, our data may help surgeons identify these higher risk patients
in preoperative surgical planning and ensuring availability of resources
such as sufficient blood.
In our study, timing of repair was also identified as a borderline risk
factor with patients who underwent fistula repair before three months
being approximately half as likely to receive a blood transfusion.
Although this was a borderline relationship in our study, the authors
feel it is notable and may require future studies to fully investigate.
Timing of repair is often left to the surgeon’s discretion, based on
evaluation of the tissue quality and maturity of the fistula.
Traditional teaching typically dictates waiting at least three months
after childbirth before surgically repairing a fistula to allow time for
healing and inflammation to subside as well as recovery from central
necrosis, edema, or infection.4,7,11 Additionally,
conservative management for women who present within the first three
months for repair may help the fistula spontaneously
close.4 However, some experts would argue, that it is
reasonable to repair before the 3-month mark so long as the fistula
tract is mature and the tissue appears healthy. Furthermore, studies
have demonstrated earlier closures within 1-2 weeks of injury may have
similar success rates to delayed repairs.8,12,13 Our
results suggest that there may be additional benefits to delayed repair
in regards to decreasing associated risk for perioperative blood
transfusions particularly in low resource settings where blood may not
be readily available.
In our study, timing of repair was also identified as a borderline risk
factor with patients who underwent fistula repair before three months
being approximately half as likely to receive a blood transfusion.
Although this was a borderline relationship in our study, the authors
feel it is notable and may require future studies to fully investigate.
Timing of repair is often left to the surgeon’s discretion, based on
evaluation of the tissue quality and maturity of the fistula.
Traditional teaching typically dictates waiting at least three months
after childbirth before surgically repairing a fistula to allow time for
healing and inflammation to subside as well as recovery from central
necrosis, edema, or infection.4,7,11 Additionally,
conservative management for women who present within the first three
months for repair may help the fistula spontaneously
close.4 However, some experts would argue, that it is
reasonable to repair before the 3-month mark so long as the fistula
tract is mature and the tissue appears healthy. Furthermore, studies
have demonstrated earlier closures within 1-2 weeks of injury may have
similar success rates to delayed repairs.8,12,13 Our
results suggest that there may be additional benefits to delayed repair
in regards to decreasing associated risk for perioperative blood
transfusions particularly in low resource settings where blood may not
be readily available.
Adequately powered prospective case-control studies would provide the
best estimates of risk factors and potentially identify other
characteristics that serve as risk factors for needing a perioperative
blood transfusion, but such trials would require a large sample size. In
the interim, we believe our study represents important evidence for
consideration in guiding surgical practice in low-resource settings.