Genital tract fistula is a tragedy which occurs usually as childbirth trauma. It is a public health challenge in the underdeveloped and developing countries; and it continues to affect the lives of its victims adversely. Genital tract fistula is commonly due to prolonged obstructed labour resulting in pelvic tissue ischaemia and necrosis which leads to obstetric fistula in the developing world [1, 2]. Trauma to the genital tract leads to leakage of urine or faeces or a combination of both with associated extensive tissue damage which may result in urethral involvement, complete urethral loss (UL) and acquired gynaetresia with severe vaginal fibrosis or complete occlusion of the vagina popularly known as ‘Ba Anya’ meaning ‘no road’.
The true incidence of obstetric fistula (OF) is unknown . The estimates suggest that there are about 2 million women in sub-Saharan Africa, Asia, Latin America and Caribbean living with genital tract fistula, with an annual incidence of about 50,000–100,000 new cases [4, 5]. Nigeria accounts for nearly 40% of the global burden of fistula, with about 12,000 new cases occurring every year . Genital tract fistula may be complicated by urethral injury leading to UL. Urethral loss complicates about 5% of obstetric fistulae [7, 8]. Stress incontinence complicates about 10% of obstetric fistulae, and it is mostly associated with injury involving urethral tissue loss or involvement of the sphincter mechanism .
Vesico-vaginal fistula (VVF) with UL is often associated with unsuccessful repair and increased risk of repeated failed attempts at repair of the fistula. Urethral fistula develops through the same mechanism as VVF; that is bladder tissue ischaemia involving the urethra, followed by necrosis and sloughing off. The involvement of the urethra in genital tract fistula is an important parameter and determinant in the diagnosis, classification, prognosis, surgical technique of repair, and outcome of the surgery for the fistula client. The description of complexity in the classification of obstetric fistula involves injury to the urethra including the bladder closure mechanism [10, 11]. Also, the injury could be in the distal edge of the fistula < 1.5–< 2.5 from the external urinary meatus or associated with a residual incontinence .
Vesicourethrovaginal fistula was once described as inoperable because of poor closure rate of the urethral component [13, 14]. Mahfouz described fistulae in which the whole urethra has sloughed off as the most troublesome type of all fistula types . Moir also defined a major variety of obstetric injury which may cause the urethra to slough off leaving little or no urethral tissue .
Urethral reconstruction is a corrective surgery performed for the restoration of the urethra in partial or complete urethral loss. There are three standard approaches to urethral reconstruction; these include the use of anterior bladder flaps, posterior bladder flaps and vaginal wall flaps. The vaginal wall flap approach is considered the best approach, easier and faster technique and quiet amenable to anti-continence surgical procedures . The vaginal flaps technique could be by primary closure, use of bilateral labial pedicle flaps, peninsula flaps and labial island flaps .
The success of a urinary fistula repair is defined based on successful closure and restoration of urinary continence. A fistula may be successfully closed but associated with persistent urinary incontinence following surgery, and this is particularly common with urinary fistula associated with urethral involvement . Following successful closure by urethral reconstruction, the repair may be complicated by stress incontinence, persistent uncontrollable leakage of urine, urinary retention, urethral stenosis and vaginal stenosis [3, 19].
Several factors associated with persistent urinary incontinence despite successful closure have been documented by previous studies; these factors include urethral damage, degree of vaginal mucosal scarring/fibrosis, fistula located at the bladder neck, large fistula, circumferential fistula and bladder capacity [18, 20]. Urethral fistula (type IIA and IIB) and circumferential defect are 10 times more likely associated with residual incontinence .
Urethral reconstruction is technically demanding and requires considerable degree of surgical skills and experience. The aim of this study is to evaluate the proportion of patients with urethral loss among VVF, clinical and fistula characteristics, and outcome of VVF associated with urethral loss/damage/injury managed by the female pelvic medicine and reconstructive surgery unit. We describe the experience with and outcome of urethral reconstruction in women living with obstetric fistula during the study period.