Obstetric Fistula Training Programme, Uganda


Obstetric Fistula Unit, Kitovu Hospital, Masaka, Uganda

Dr. Mugdha Avinash Kulkarni writes: "I had a wonderful opportunity of visiting Kitovu Hospital, Masaka, Uganda and working with fistula patients through 'Africara Ireland', the charity headed by Professor Eamon O'Dwyer.

"I arrived in Entebbe from my native India, on 3 January 2010 and was driven to Kitovu Mission Hospital. It was 15 years since I first came to this country and it looked as if time had stood still. Nothing seemed to have changed much except for the capital city, Kampala.

"At Kitovu, I was made comfortable in a cosy, well-equipped little house which had a perfect view of the valley, tiny villages and Lake Nabugabo and Lake Victoria in the distance. I was warmly welcomed by Dr. Maura, Dr. Carla, Dr. Brigid and Dr. John Kelly, the master trainer, gynaecologist from Birmingham, UK.

"For me work began the next day, 4 January. Dr. John Kelly had arrived from Birmingham, UK on 28 December 2009 and had already finished 9 surgeries. A few trainees from Virika Hospital, Fort Potal and Masaka Regional Hospital had arrived earlier. All trainees were given an MCQ test on genital fistula at the beginning of the camp, and were reassessed at the end of the camp.

"The daily routine at Kitovu was morning rounds in the VVF ward at 8.15 am with Dr. Kelly, followed by operations the whole day. Three to 4 patients were operated on daily with the trainees taking turns to assist Dr. Kelly. We were 3 gynaecologists among the trainees.

"Dr. Kelly assisted me in one recto-vaginal fistula and one vesico-vaginal fistula surgery in the first week. There would be a 30-minute much-needed lunch break for the whole team together between surgeries.

"New patients kept coming. A big number of patients was collected and brought from Masindi, northwestern Uganda. Every day after the theatre, they were examined and assessed in the assessment room by Dr. Kelly and us, the trainees.

"Dr. Michael Breen (right), master trainer, gynaecologist and fistula surgeon from Ireland, now working in Zambia, arrived on 10 January 2010. The next 2 weeks were very busy.

"The day began with morning rounds in the VVF ward and 1 hour academic teaching sessions by Dr. Breen. The sessions were very informative and interactive. He covered everything including history-taking, examination, pre-operative preparation, post operative care and management of complications in fistula patients.

"For the next 2 weeks, 6 to 8 procedures were performed daily depending on the complexity of the repairs. The trainees took turns in assisting Dr. Kelly and Dr. Breen - both dedicated teachers who patiently assisted trainees in their repairs. I did 8 more repairs under the guidance of Dr. Breen. He made fistula surgery simple to understand and perform by making us follow standard steps and principles.

"Though I had observed and done some fistula surgery in India, there had been no standard teaching in fistula surgery. The repairs done here were far more complex than what I had seen back home. Dr. Kelly was very meticulous in his assessments and in his surgery and was a great inspiration to all of us. The way he dealt with these women was exceptional.

"Dr. Kelly left on 20 January and Dr. Breen on 24 January, as also all the trainees. I was going to be here till 13 February. Most of the patients were now recovering from the surgery. My daily routine would be to take ward rounds of all the patients. Patients who complained of being wet or had other complaints were assessed and necessary steps were taken.

"As advised by Dr. Breen, I did dye tests on all the patients before taking the Foley catheter out. Dr. Maura was always available if I had any difficulty with any patient.

"There are dedicated staff working in the ward. I would also like to mention the efforts of all anesthetists and the theatre staff in making the fistula camp a success. As Dr. Kelly always said, 'It is team work!'

"After Dr. Breen left, a team of 10 counsellers arrived in the hospital, and they were going to be here for 10 weeks. Through them, I learned that the patients were very happy with their recovery. They were overjoyed that they could get back their dignity in society. They longed for simple pleasures like sleeping on a dry bed, wearing clothes they wanted to and be able to go out carefree in public places.

"The cured patients left the hospital in batches, according to the area they belonged to and with the group they had arrived with. On discharge, each patient was given a card, money for transport and counselling regarding care at home and further deliveries. Each patient was given a new dress to begin a new life!

kitovu vvf-5

"One of the problems that we faced during the post-operative period was infection with malaria. Of all the patients operated upon, 21 patients were given anti-malarial treatment for clinical malaria. Of these 7 tested positive for malarial parasites on their blood smears.

"Sadly, one 29 year-old patient who had a VVF repair and was draining urine well developed severe complicated malaria on the 15th post-operative day. After 4 days of diagnosis and clinical improvement with treatment she developed irreversible acute renal shut down. Unfortunately she died before she could undergo dialysis. Her laboratory reports were as follows:

Hb: 8.8 g/dl, TLC: 9,700 cells/cubic mm, DLC: N 57%, L 41 %, E 02%, platelets normal and adequate, 8 malarial parasites/100 WBCs, urine proteins present,
Blood urea: 98.5 mg/dl, Serum creatinine: 2.10 mg/dl, serum sodium: 139.5 mmol/L, serum potassium: 3.6 mmol/L, serum chloride: 35.25 mmol/L.

  • Total number of fistula surgeries performed: 88
  • VVF:70 (Abdominal repairs: 3, vaginal repairs: 63)
  • VVF-RVF: 2; RVF:10; Stress sling: 4; True ureteric: 1
  • Hysterectomy 1
  • Other procedures: urethral dilatation: 1; EUA: 1
  • Total number of surgeries performed by me: 10
  • VVF repairs: 4 (3 cured and dry; 1 is wet and will require further surgery)
  • RVF repairs: 5 (cured)
  • Vaginal hysterectomy: 1 (cured, patient had third degree utero-vaginal prolapse and stress).
  • Total number of surgeries assisted by me: 16 (12 VVF repairs; 1 RVF; 3 colporrhaphies for stress)

Results:

    1. No. of patients with VVF repairs completely dry till date: 55
    2. Patients who have stress: mild: 4; moderate: 1; severe: 1. All these patients were taught pelvic floor exercises and asked to come for follow-up in the camp in August 2010.
    3. Patients who remain a little wet and are able to pass urine and themselves claim to be much better than before operation: 3 (all were repeat surgeries).
    4. Patients who are wet after surgery (not stress): 6 (4 had undergone urethral reconstruction and were also previously operated on; 2 of these patients have colostomies as well. One patient had been previously operated on and had a very small bladder. She had been advised to have a diversion procedure previously and declined. She was advised frequent passage of urine and pelvic floor exercises to control her wetness. One patient had her first repair and will need further surgery). All of them were advised to come for follow-up in August 2010.
    5. One patient was deemed inoperable and is being counseled for possible diversion later.
    6. Of 4 patients who underwent operation for stress, 3 went home dry; 1 patient's sling operation was unsuccessful. She was asked to come back in August 2010.
    7. All the 10 patients with RVF were discharged dry.
    8. One patient who underwent ureteric re-implantation and one patient who underwent vaginal hysterectomy were dry, cured and happy.

"On 8 February, I went out with the Kitovu Mobile Palliative Care Team led by Dr. Carla to visit cancer patients from the neighbouring districts in their homes. She and her team of nurses deliver palliative care to cancer patients in 4 districts around Masaka. It was a unique and enriching experience.

"I sincerely thank Professor O'Dwyer for giving me this opportunity and 'Africara Ireland' for the sponsorship. I could experience healthcare in the underdeveloped world and was introduced to problems of women here. I thank the master trainers Dr. Kelly, Dr. Breen and Dr. Maura for their guidance and lessons and for giving me the opportunity to treat some of these women. I hope to be able to get more such opportunities in the future and contribute to the welfare of mothers and women in Africa."

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