Urology, University of Toronto
Sunnybrook Health Sciences Centre
Vesicovaginal fistula prevalence, repair patterns, and failures: A retrospective population-based analysis
Sarah Neu1,2, Bo Zhang3, Jennifer A. Locke1,2, Refik Saskin3, Sender Herschorn1,2.
1Urology, University of Toronto, Toronto, ON, Canada; 2Urology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; 3ICES, Toronto, ON, Canada
Introduction: In North America vesicovaginal fistula (VVF) are most commonly due to iatrogenic injury and have a significant negative impact on quality of life. Failed surgical repair of VVF can lead to ongoing morbidity. The objective of our study is to determine the change in rate of VVF repair and failures over time, and to determine risk factors for surgical repair failure.
Methods: We completed a population-based, retrospective cohort study including all women in Ontario, Canada, aged 18 and older between 2005-2018. Patients who underwent VVF repair were identified using linked administrative databases and compared to those who required a second VVF repair for primary repair failure. Broken line regression was used to determine changes in the rate of VVF repair over time. Multivariable cox proportional hazard analysis was used to identify risk factors for VVF repair failure.
Results: 814 patients were identified as having undergone VVF repair. Of these patients, 117 required a second surgical repair (14%). Mean age at time of surgery was 52 years (SD 15). The majority of patients had undergone prior gynecological surgery (68%), and 76% were due to iatrogenic injury. Most repairs were performed by urologists (60%) and completed transvaginally (66%). Annual rate of VVF repair significantly decreased by 0.14/100,000 women in each year from 2005-2009, and insignificantly decreased from 2010-2018. No significant change in VVF re-repair rates were found. Predictors of VVF re-repair included iatrogenic injury as etiology of VVF (HR 2.1, 95% CI 1.3-3.9, p=0.009), and having the primary repair done with cystoscopic fulguration (HR 6.1 95% CI 3.1-11.1, p<0.0005,); protective factor was surgeon number of years in practice (21+ years - HR 0.5, 95% CI 0.3-0.9, p=0.02). Surgeons with more than 21 years of experience have half as many patients requiring second VVF repair.
Conclusions: VVF repair rates have decreased over time, however re-repair rates have remained constant over a 13-year time period. Iatrogenic injury as the cause of VVF is twice as likely to result in the need for a re-repair, compared to other etiologies, and repair done with cystoscopic fulguration were 6 times as likely to fail compared to a trans-vaginal or abdominal approach. Surgeon years in practice may protect against the need for a second VVF surgery.
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