Five year review of rectovaginal fistulas at Addis Ababa Fistula Hospital Professor Gordon Williams Dr Habtemariam Tekle Mary Venn

Introduction Incidence: 3.3% - 15% Primarily caused by prolonged obstructed labour No standard classification

Objectives To identify Aetiology Patient characteristics Extent of rectovaginal injury Patients requiring a colostomy Outcomes

Methods 5 years retrospective data from 2004 –2009 Operation register & patient cards reviewed Information recorded on a prepared questionnaire

Causes of Rectovaginal Fistula Number (%) Child birth Mean duration of labour 3.8 days 282 (89.5) Post coital 22 (7) Accidents 8 (2.5) Other 3 (1) Total 315 210VD ,26CS, 12DD, 34ID POSTCOITAL = 14 RAPE = 8 ACCIDENTS 8 INCLUDING OX INJURY,FALLACCIDENT,FIGHT, OTHERS: ABORTION,LESION,HERBAL

Characteristics of All Rectovaginal Fistula Type High 111 (35.2%) Mid 90 (28.6%) Low 86 (23.3%) Circumferential 36 (11.4%) Combined 28 (8.9%) REPEAT COUNT(DOUBLE COUNT) = 351 ALL CIRCUMFERENCIAL DUE TO OBSTETRIC CAUSES = 36(97.2% following obstructed labour: 28 VD, 4 CS, 3 ID, 1 accident)

Characteristics of Obstetric Rectovaginal Fistula (N = 282) Primiparous 200 (70.9%) Multiparous 82 (29.1%) Concurrent VVF 240 (85.1%) Position of fistula High 108 (38.3%) Mid 88 (31.2%) Low 58 (20.6%) Combined 28 (9.9%) ALL CIRCUMFERENCIAL DUE TO OBSTETRIC CAUSES = 36(97.2% following obstructed labour: 28 VD, 4 CS, 3 ID, 1 accident)

Characteristics of Post-coital Fistula N = 22 Parity nulliparous 15 Age Mean 24 Type Low 20 (90.9%) 3PRIMI, 4MULTI Age range 8-60 years (NB 60 year old sustained injury aged 12) median and mode 23 years, mean 24.5 years, or 23.3 years excluding patients <16 and >30 years old Position of fistulae; 90.9% low (n=20) 1 mid (4.5%) 1 high (4.5%)

Associated Injuries N = 315 Stricture 6 (2%) Concurrent VVF 244 (77.5%) Concurrent tear 19 (6%) None 46 (14.5%) 6 strictures, all following obstructed labour, all with VVF. All with high fistulae, half circumferential, same half had colostomy. 5 cures at first attempt, remaining pt died of sepsis. Concurrent VVF240 caused by obstructed labour, 1 rape, 3 accidents

Colostomy Colostomy 67 (21%) Colostomy not closed: 6 AAFH: 51 Elsewhere: 16 Needed revision: 2 Time from opening to closure of colostomy: 5 months Colostomy not closed: 6 Lost to follow up: 3 RVF not closed: 2 Patient died: 1 Aetiology: 47 VD (70.1%) 10 CS 2 DD 5 ID 2 post-coital 1 accident Positions: 43 high (64.2%) 5 mid 4 low 8 mid-high 7 mid-low Circumferential: 24 Yes (35.8%) 43 No (64.2%)

Cure & Surgical Technique: First time surgery Single layer closure 9/14 Two layer closure 245/261 Abdominal approach 1/1 End to end anastomosis 16/21 Unspecified 5 Total cure at 1st repair =276

Outcomes Overall closure success 294 (93%) 1st operation 276 (88%) 2nd operation 13 3rd operation 3 4th operation 1 7th operation 1 Breakdown of Operation 1 Sub-optimal Outcomes(n=39) 27 first ops were broken  11 cured at second op, 2 at third, 1 at fourth, 1 at seventh, =15 9 no f/u after first failed op, 1 no f/u after 4x failed attempts, =10 1 never closed after 6 attempts at AAFH, 1 pinhole after three ops 2 first ops repaired BUT pinhole remained after first op 5 first ops abandoned  1 closed at second op, 1 at third, 3 holes remained (not re-attempted) 1 RVF repaired but incontinent, required perineal reconstruction then cured after second op 2 RVF closed but poor sphincter tone, leaking 1 pt died 1 no f/u  

Outcomes of Concurrent VVF in Patients with RVF (N = 240) Closed at 1st attempt 169 (70%) Broken 63 Abandoned 6 Died 1 Concurrent VVF in 240/282 obstetric cases (85.1%) Only 169 VVF closed at first attempt (70.4%) 66 closed and dry 45 closed, mild stress 29 closed, moderate stress 18 closed, severe stress 2 closed, urge incontinence 2 closed, mixed incontinence 7 urine retention, self-catheterisation 63 broken 6 abandoned, 2 other (1 patient died, 1 patient’s ureter could not be re-implanted at initial op, dry following later re-implantation) NB of the 4 non-obstetric VVF, all closed and dry. Total rate of VVF closure at first attempt 70.9%.

Outcomes for Colostomy Patients Cured 1st operation 51 (77%) 2nd operation 8 3rd operation 1 7th operation 1 No Follow up 3 Pin hole remained 1 Could not be repaired 1 Died 1

Conclusions RVF is mainly caused by childbirth and long duration of labour in primiparous Patients who had colostomy had an obstetric cause & were high & circumferential RVF’s Patients with concurrent VVF & RVF had less success Standard classification needed for prediction of outcome Criteria for colostomy have to be settled