THE RISK OF VESICO-VAGINAL AND URETHRO-VAGINAL FISTULA AFTER HYSTERECTOMY PERFORMED IN THE ENGLISH NHS: A retrospective cohort study examining patterns of care Paul Hilton 1 & David A Cromwell 2 1 Newcastle upon Tyne Hospitals NHS Foundation Trust; 2 RCOG ORCA and London School of Hygiene & Tropical Medicine.

Background  Obstetric VVF remains a major global public health concern  In UK numbers are small, and ⅔ are related to pelvic surgery  Hysterectomy for benign indications is becoming less common, but lower urinary fistulae are not declining  This study sought to determine :  the rate of lower urinary fistula within 1 year of hysterectomy  whether the rate of fistula related to type of procedure or indication  whether the rate has changed over time

Methods  Used Hospital Episode Statistics database (NHS in England), including ICD-10 for diagnostic & OPCS-4 for procedure coding  Identified women ≥18 having elective hysterectomy for selected indications  Excluded ‘incompatible’ procedure:indication combinations and combinations with <500 cases.  Fistula defined from ICD-10 fistula codes during or within 1 year of the index procedure (hysterectomy)

Rate of fistula by indication & procedure

Results  Unadjusted overall rate for all procedures 1 in 788  TAH for benign reasons 1 in 540  VH for prolapse 1 in 3861  TAH or RH for cervix cancer 1 in 100  Logistic regression showed:  For TAH no difference in rates across benign indications  Lower odds ≥50 year old (aOR 0.61)  Higher odds than (aOR 1.44)

Implications for practice  Association between hysterectomy and lower urinary fistula is well known; exact rates for individual indication:procedure combinations have not been previously defined for English NHS  Does the reduction in hysterectomies affect rates by:  leaving a higher proportion of more complex procedures?  compromising standards of surgical training & experience?