Obstetric fistulas have a high frequency in low income environments.
Several vesico vaginal fistula support campaigns are organized. During these surgical treatment, some fistulas persist while decreasing in size and others show stress urinary incontinence.
The aim was firstly, to characterize obstetric fistula patient socio-demographically; secondly, to describe the complications associated factors  post fistula surgical treatment .

The study was realised in 5 sites which organised the VVF campaign
The following interest variables were collected:
Sociodemographic  Characteristics : age (year old), matrimonial status (maried, single, widow, divorcee), study level (Not registered at primary school , high school, university), profession, residence zone, distance between the hospital and the residence ; the first pregnance age, the first manstruation periode age, parity, gestity, abortion, the living children number. 
-	Clinical characteristics : VVF  duration, VVF etiology, sexual intercourse with VVF, cure number, VVF classification according to  GOH and Kees Waaldjik ; VVF dimension and location, Cough test and methylene blue test were realized at the end of its stay after  bladder catheter ablation.  
 Confirmation  VVF Test: methylene blue test or three swabs test.
Cough test and methylene blue test were realized at the end of its stay after  bladder catheter ablation.  Another patients global evaluation was realized by the local team in one month then two months post-operatory.

-	Patients evolution : healing or complications (incontinence,  fistula persistence). 



Two classifications were used :  GOH and KEES WAALDIJK classification 
- Kees Waaldijk VVF Classification Type 1 : Distance between  the external  urethral meatus and distal fistula edge >4cm. Fistula which does not involve the closing mechanism. Type II : Fistula which involves the closing mechanism.
         IIA : Distance between  the external  urethral meatus and distal fistula edge between 1-4cm. without atainment  (sub-) total of urethra   II Aa : No circumferential. IIAb : circumferential.
         IIB : Distance between  the external  urethral meatus and distal fistula edge <1cm. With atainment (sub-)total of urethra  IIB a : No circumferential. IIBb : circumferential.
        III : Complex Fistulas. Diverse, eg. ureter-vaginal fistulas or exceptionnal ones.
    Fistulas Dimensions : Small :  inferior  to 2 cm. Medium : 2-3 cm. Large : 4-5 cm.
Extensive : superior to 6 cm. The closing mecanism has the urethra and the bladder. The closing mecanism is measured at 3 cm from external urethral meatus.
- GOH Classification :
Type 1 : Distal edge of fistula  > 3.5 cm from the external 
Urinary meatus.
Type 2 : Distal edge of fistula   > 2.5 à 3.5 cm from the external 
Urinary meatus.
Type 3 :  Distal edge of fistula    1.5- < 2.5 cm from the external
Urinary meatus .
Type 4 :  Distal edge of fistula   < 1.5 cm from the external urinary
meatus.
Fibrosis and other factors :
Size : a : Size < 1.5 cm in the largest diameter. b : Size 1.5 – 3 cm in the largest diameter. c : Size > 3 cm in the largest diameter.
Scar and other factors :
i.None or only mild fibrosis (around fistula and /or vaginal length > 6 cm), normal capacity.
ii. Moderated or  severe fibrosis( and /or reduced vaginal length and /or capacity.
iii. Special considerations, for example post-radiation, ureteric involvement,    circonferential fistula, previous repair.
The operating technic was Doubling closure. For certain complicated cases, a shred of Martius Was used 
All operated patients were classified according to the American Society of Anesthesiology (ASA) I or II.


Statistical analysis
After encoding and data validation, those have been typed with a computer, by using the software EPI Data. After the validity, we have exported the database on SPSS software for Windows version 24.
Qualitative data have been represented in an absolute and relative frequency (%) and quantitative data under the averages form ± standard deviation (AND) ( if it was a normal distribution) and the median (extrems) (if the distribution was not normal). The normal distribution of each quantitative variable has been apreciated by  Kolmogorov-Smirnov test. The Pearson Chi carré test or the Fischer exact have helped to compare the proportions. The Students t-test has served to compare the averages of two groups having normal distributions and the Mann Withney U test has compared the median’s  two groups.
The logistical regression has been used in the answer analysis after treatment (evolution : good or bad), to look for the factors independently associated to the bad  evolution with the odds ratio calculation with trust intervals to estimate the association degree. The p˂ 0/05 (5%) value has been considered as the statistic significance doorstep.

A total of 98 patients with obstetric fistulas were operated on during the campaigns. It shows that age patients with VVF average were 32.1±11.4 years old with the extrems from 16 to 68 years old.  Primary education level and no education level were found more often(71,8 %) .
The patients hospital and residence distance was long in an average ( 195 Km) and in mediane (203.5 Km). The displacement duration to reach the hospital was more than 24 hours to 72.6% of patients. The VVF average duration was 8 years old. Their  BMI was in normal limits (average 19.6 Kg/m2).
Only the stadium 3 and 4 of the GOH classification, of stadium 3 of the Kees Waaldjik classification, the large and extensive VVF dimension, the VVF location  in urethra and  justa urethra were significantly more high to the patients with complication compared to the patients with a good evolution. 
The complications observed at the last evaluation were classified as IIIB according to Clavien Dindo classification.
In univaried analysis, the fact of being maried, bachelor, the stadium 4   according to GOH, the stadium 3 according to Kees Waaldjik, the large dimension, extensive and the uretral VVF location  were the complication associated factors .
Multivaried analysis, after adjustment,  proves that the bride [ (ORa: 2.85; IC95% : 1.48 – 3.26) ; p = 0.024 ], the celibacy [ (ORa: 3.85; IC95% : 2.65 – 5.95) ; p = 0.006 ], the stadium 3 according to Kees Waaldjik classification [ (ORa: 7.38 IC95% : 3.23-12.71) ; p = 0.025 ], the large VVF dimension  [ (ORa: 3.81 IC95% : 2.03-5.16) ; p = 0.046 ], the extensive VVF dimension  [ (ORa: 5.70 IC95% : 3.19-7.87) ; p = 0.033 ]  and the urethra VVF location  [ORa: 5.38; IC95%: 2.22-8.13; p = 0.030] were independently associated to the post surgical complication.

Vesico-vaginal fistulas concern women living far from health centers. Access to health centers lasts around 24 hours. This is what explains the obstetric fistulas physiopathogenesis , especially in  case of mechanical dystocia.
Complex fistulas according to Goh (stage 3 and 4) and Waldjik (stage 3), urethral fistulas are associated with grade III B complications according to Clavien Dindo.
The complication rate is low preventing us from drawing conclusions.

This study demonstrates that vesico-vaginal fistulas are associated with an undeveloped environment characterized by high distance between home and hospital, difficulties in accessing the hospital. In addition, they concern mostly poorly educated women. From the evolution point of view , complex fistulas and large fistulas in size are linked to urine loss   post surgery 
Up-to-date research is helpful in resolving this complications issues.

Loposso M, Hakim L, Ndundu J, Lufuma S, Punga A, De Ridder D. Predictors of Recurrence and Successful Treatment Following Obstetric Fistula Surgery. Urology. 2016 Nov;97:80-85. doi: 10.1016/j.urology.2016.03.079. Epub 2016 Aug 2. PMID: 27496296.
Loposso MN, Ndundu J, De Win G, Ost D, Punga AM, De Ridder D. Obstetric fistula in a district hospital in DR Congo: Fistula still occur despite access to caesarean section. Neurourol Urodyn. 2015 Jun;34(5):434-7. doi: 10.1002/nau.22601. Epub 2014 Apr 7. PMID: 24706479.