Women deemed inoperable inspiring groundbreaking surgeries

Nearly 200,000 women live with obstetric fistula in Nigeria. For each one woman who gets repaired a year, four others develop the condition.  Surgeons dedicated to their repair number less than two dozen across the country.  As if there wasn’t enough trouble with fistula, surgeons are finding women deemed inoperable. Fistula results from prolonged obstructed […]

Nearly 200,000 women live with obstetric fistula in Nigeria. For each one woman who gets repaired a year, four others develop the condition. 

Surgeons dedicated to their repair number less than two dozen across the country. 

As if there wasn’t enough trouble with fistula, surgeons are finding women deemed inoperable.

Fistula results from prolonged obstructed labour. When a baby’s head is trapped in the pelvis too long during labour, the pressure kills the tissue at the point of contact. A hole forms-either between the vagina and bladder (and urine leaks through without control) or between the vagina and the rectum (and faeces leak through). In severe cases, both urine and faeces leak through.

In nine out of 10 cases, the fistula can be closed. In women deemed inoperable, the fistula is considered “so severe that no surgeon, however skilled, can make the patient continent,” explains Dr Oladosu Ojengbede, a professor of obstetrics and gynaecology and renowned fistula surgeon.

But he doesn’t believe in that limitation.

“Irreparable cases do exist but we don’t have figures on that. We need to develop a strategy to manage these cases. We don’t even know how to look for them or assess them.”

Risk factors contributing to women deemed irreparable abound: inadequate assessment before a repair surgery, inability to recognize associated injuries other than the fistula. Then again the fistula may be large, number more than one and result in excessive scarring. In addition, the surgical approach may just be inadequate.

Some surgeons wouldn’t get involved in such a case. Others would suggest surgically diverting a woman’s urine flow. 

But a crop of leading surgeons are charting previously unknown territories to change the fate of women deemed inoperable. They reconstruct urethras and construct vaginas.

“Urinary diversion isn’t something you should just jump into. It reduces quality of life,” says Ojengbede. 

Dr Sa’ad Idris is among fistula surgeons who have moved obstacles. 

A USAID-funded project Fistula Care Plus, run by Engender Health, pooled health workers to repair women living with fistula in Sokoto. One of the cases was so severe, Idris and his team ended up creating a new vagina for the woman.

His next groundbreaking surgery removed confusion about a patient thought to be both male and female. Initial consensus labelled the patient male, but scans and tests showed a rudimentary uterus, said Idris. 

Idris and his team grew out the uterus, set the neck and fallopian tubes in position-and then used part of the patient’s large intestine close to the rectum to create a vagina 8cm long.

Idris still keeps in touch with the patient, said to be married and having a satisfactory sexual relationship with her husband.

“We are really excited about what we are able to do now,” he says.

Surgeons at National Obstetric Fistula Centre, Abakaliki, have also succeeded at urethra reconstruction (known as urethroplasty) to stop incontinence. 

It is becoming routine. “And we are getting good results. We need to move our limitations,” says Dr Sunday Adeoye, chief medical director at the centre.

The growing knowledge is filtering into research papers to go around the health community. At present, it is the stuff of discussion as network of fistula workers meet every year.

“This is a discussion we were not having in 2008. As the discussion continues, it matures,” says Iyeme Efem, country manager for Engender Health, at a meeting in Kaduna of health workers involved in fistula care.

“We need connections to ensure that together we are addressing the holistic person and not just repairing the hole.”

The movement is on to map locations and surgeons where innovative surgeries are possible-and get facilities ready to meet the need.

“Let’s get the facilities to be able to handle these things. Let’s not declare a patient inoperable until we have had a second opinion.”