Obstetric vesico-uterine fistula in nine reference hospitals in the Democratic Republic of the Congo: epidemiological, clinical, and therapeutic aspects

Abstract

Introduction: With global cesarean section rates rising, there's concern about increase in obstetric vesico-uterine fistula (OVUF). Very little is known about this anatomoclinical entity of obstetric fistula in Africa in general and in DRC in particular. Our purpose was to describe the epidemiological, clinical, and therapeutic aspects of OVUF in the Democratic Republic of the Congo (DRC).

Methods: This was a descriptive cross-sectional study. Data were collected from patients who presented with OVUF across seven provinces of the DRC (North Kivu, Haut-Uélé, Kasai Central, Kwilu, Maniema, Nord-Ubangi and Sankuru) from January 2017 to December 2022. Study variables were epidemiological, clinical, and therapeutic features.

Results: Of 1,267 patients presenting with obstetric fistulas, 355 (28.0%) had OVUF. The mean age was 32.9 ± 11.6 years, 80.6% of patients (286/355) lived in rural areas, and the majority had a low level of education (40% no formal education, 30.1% primary school, 28.7% secondary school). In total, 64.8% of patients were primiparous (230/355) and in all (100%) cases, OVUF was caused iatrogenically during cesarean delivery. Majority (76.3%) of patients laboured for one day or less (mean duration 1.0 ± 0.5 days) before giving birth, and the fetus died in 58.3% of cases. In 35.8% of cases, the fistula had lasted more than 10 years (mean age 10.1 ± 10.0 years) before repair. A proportion of 88.2% (n = 313) of OVUF was isolated while 11.3% (n = 40) was associated with a uretero-vaginal fistula. In 82.8% (n = 294) of cases the OVUF was single. The average fistula size was 2.4 ± 1.0 cm (range: 0.5 and 5.5 cm) and 274 (77.2%) fistulas measured between 1.5 and 3 cm, with 14.9% (n = 53) of them larger than 3 cm. Fibrosis was present in 65.1% of cases, cervical involvement was absent in 97.7% and post-operative complications were absent in 94.4%. In all cases, the OVUF was surgically repaired abdominally with a success rate of 97.5% (346/355).

Conclusion: The proportion of OVUF is relatively high in the DRC. Most affected patients were young, under-educated, primiparous women living in rural areas. Cesarean section was the sole identified cause of OVUF which was isolated, single, without fibrosis, in majority of cases. Abdominal repair of OVUF was very effective, with good results in almost all cases. Teaching young doctors working mainly in remote areas how to perform safe cesarean section is needed to reduce incidence of OVUF in DRC.

Keywords: Cesarean section; Democratic Republic of the Congo; Obstetric vesico-uterine fistula.

Fig. 1

Distribution of cases of OVUF among all cases of obstetric fistula recorded in the seven provinces