Iatrogenic Female Genitourinary Fistula in Uganda: Etiology, Twelve-year trends, and Risk factors among women delivered by cesarean section

Abstract Background: More than 95% of genito-urinary fistulae in low-income countries are due to prolonged neglected obstructed labour. However, with improving obstetric care and variations in medical training, there seems to be an increase in fistulae resulting from surgical errors. Objective : The aim of this study was to describe the magnitude and trend of iatrogenic genitourinary fistula at four fistula surgery sites in Uganda from 2010 to 2021 and also determining the risk factors of iatrogenic genitourinary fistula following Cesarean Section (CS). Methods: A retrospective review of charts for all women who underwent surgery for genitourinary fistula at four regional fistula repair sites in Uganda between 2010 and 2021 was conducted. A fistula was classified as iatrogenic if a participant had any of; ureteric, vesico-cervical, vesico-uterine, or vaginal vault fistula that followed an obstetric or gynecological surgery. Vesico-vaginal and urethro-vaginal fistulae were classified as ischemic irrespective of the mode of delivery. The annual proportions for the obstetric and iatrogenic fistula over the 12-year period were compared. Descriptive analyses and multivariable log binomial regression were performed to determine the independent risk factors. Results: Over the study period, 521 women had surgery for genito-urinary fistula of which, 169 (32.4%) were iatrogenic. Most of the iatrogenic fistulae followed CS (71%). There was a gradual increase in the proportions of iatrogenic fistulae from 8/52 (9.6%) in 2010 to 38/88 (43.2%) in 2020. The risk factors for iatrogenic fistula following CS were; Grand-multiparity (RR = 5.79; 95% CI: 2.18-15.4; P = 0.001), repeat CS (RR = 4.06; 95% CI: 1.77-9.3; P = 0.001), CS performed by an intern doctor (RR = 4.85; 95% CI: 1.52-15.45; P = 0.008) and CS done at a Health Centre IV (RR = 4.55; 95% CI: 1.2-16.67; P = 0.022). Conclusion: The magnitude of iatrogenic genitourinary fistula in Uganda is high and most follow CS. There is an observed rising trend in iatrogenic fistula over time. The risk factors for iatrogenic fistula following CS are grandmultiparity, repeat CS, CS performed by intern doctors and CS performed at lower health facilities. There is need for routine in service surgical skills (especially cesarean sections) training for obstetric and gynecological surgery providers.