Remote mentorship as a novel training method in urogenital fistula surgery

Bugeja R1, Brown K1, Harding C1, Greenwell T2

Research Type

Clinical

Abstract Category

Female Lower Urinary Tract Symptoms (LUTS) / Voiding Dysfunction

Abstract 194
Urogynaecology 3 - Lower Urinary Tract Symptoms
Scientific Podium Short Oral Session 9
Wednesday 4th September 2019
14:52 - 15:00
Hall H2
Fistulas Surgery Female
1.Newcastle upon Tyne Hospitals, 2.University College of London Hospitals
Presenter
R

Roberta Bugeja

Links

Abstract

Hypothesis / aims of study
The surgical treatment of urogenital fistula requires specialist skills, and as a result these procedures are usually concentrated in a relatively small number of hospitals. The establishment of a fistula service can therefore be challenging especially in units without prior experience of treating fistulas. The aim of this study was to report initial results for a newly-established surgical team from an existing fistula centre who had limited prior experience of this type of surgery. As in-house training was unavailable, a novel programme of remote mentorship from another existing high-volume fistula centre was developed. The establishment of a new fistula service using this training technique is reported.
Study design, materials and methods
The surgical team consisted of a urologist and a urogynaecologist operating jointly (both of whom had limited previous experience of urogenital fistula surgery). A training programme was designed involving mentorship from another high-volume urogenital fistula service comprising multiple observations of fistula surgery and familiarisation of surgical technique, direct hands on training sessions and ongoing remote support including case review and outcome recording.

A retrospective study was conducted to examine preliminary outcomes. This included the initial 23 urogenital fistula patients comprising 15 vesico-vaginal fistulas (VVF), 5 urethro-vaginal fistulas (UVF) and 3 colo-vaginal fistulas (CVF). The surgical history, diagnostic investigations, procedure notes and post-operative follow-up were reviewed. Outcome was based on anatomical closure and patient reported symptom resolution.
Results
In total, there were 20 surgical repairs (16 VVF, 3 UVF, 1 CVF) on 17 patients.

Table 1: Characteristics n=17  (Figure 1 - Attached below)

Of the 20 procedures, 15 were repaired using a vaginal approach (75%) and 5 were repaired using an abdominal approach (25%). 80% had Martius graft interposition.

Post-operative follow-up was via cystourethrogram or CT urogram and face-to-face symptom review. Anatomical closure was achieved in 88% of patients. 2 patients had a persistent fistula, 1 of these was a neobladder-vaginal fistula. 

A vaginal approach achieved closure in 8 out of 10 VVFs (80%), and 2 patients with UVF. 3 VVFs were a re-do procedure. Anatomical closure was successfully achieved in 2 of these 3 patients following a second procedure. Abdominal approach achieved anatomical closure in all 5 (100%) patients; 3 VVF, 1 UVF, 1 CVF.

On clinical follow-up, symptom resolution was reported in 94%. 1 patient with a persistent fistula on cystourethrogram declined further surgery in view of minimal vaginal urinary leakage following the repair.
Interpretation of results
Despite the varied aetiology of the fistulas, anatomical closure was successful in 88% of the patients. This is comparable to published results from other high-volume fistula centres. Despite not achieving anatomical closure, 1 patient reported acceptable symptom resolution. Therefore 94% of the patients had successful symptom resolution following surgery.
Concluding message
This study suggests that an alternative to the traditional in-house training, remote mentorship can be utilized with good effect. The establishment of a new fistula service can be safely and effectively delivered using this approach. Surgical outcome was comparable to published results from established high volume units. A key factor to ensure success is a close working relationship with the mentoring unit including the ongoing facility for case discussion and maintenance of a collaborative relationship between mentor and mentees.
Figure 1 Results: Table 1 - Characteristics
References
  1. Ockrim, J., Greenwell, T., Foley, C., Wood, D. and Shah, P. (2009). A tertiary experience of vesico-vaginal and urethro-vaginal fistula repair: factors predicting success. BJU International, 103(8), pp.1122-1126
  2. Hilton, P. (2011). Urogenital fistula in the UK: a personal case series managed over 25 years. BJU International, 110(1), pp.102-110
Disclosures
<span class="text-strong">Funding</span> None <span class="text-strong">Clinical Trial</span> No <span class="text-strong">Subjects</span> None