Urinary fistula represents an underestimated surgical problem that can have a devastating consequence on the patient’s quality of life (QOL) (1). In developed countries, fistula formation commonly results from surgical rather than obstetric causes (2). Surgical repair is considered the standard management (3).

Although previous reports documented the surgical success and post-operative complications of fistula repair and examined urinary and sexual function outcomes, these have not fully assessed the multifaceted impact on the patient’s QOL. In addition, the literature is absent regarding the long-term patient-reported outcomes following fistula repairs. 

This study aims to assess patient-reported functional and quality of life outcomes after fistula repair.

A retrospective analysis of patient records of all female patients who underwent fistula repair in the last ten years was conducted. Patient records included preoperative, intraoperative, and post-operative details from the electronic data software at a single centre. Preoperative data included fistula aetiology, WHO classification, naïve or recurrent cases and the number of previous surgical attempts. Surgical aspects include approach, flap usage and type. Post-operative outcomes included length of hospital stay, complications according to Clavien-Dindo classification, success and recurrence rate. 

Additionally, functional outcomes, quality of life, satisfaction and mental health were assessed using the Urogenital Distress Inventory (UDI-6), International Consultation of Incontinence Questionnaire–Satisfaction (ICIQ-S), and Patient Health Questionnaire 9 (PHQ-9), respectively. We also reviewed sexual function and implemented a modified European Quality of Life 5 Dimensions 5 Level Version (EQ-5D-5L) to assess health-related quality of life. The patients were interviewed in a structured telephone interview using the questionnaires.

Sixty-two patients underwent fistula repair, including 65% (40/62) with a transvaginal and 27% (17/62) with a transabdominal surgical approach. Over 55% of patients required the use of flap,  Martius (34%) and omental (21%). Thirty-two per cent of patients (n=20) had previous failed repairs, while for four patients, this was their third repair attempt, and for two patients, this was their fourth or greater repair surgery. The rate of complications was low (see table 1). The success rate, defined as complete fistula closure without recurrence, was 88% (55/62), and the recurrence rate was 11% (7/62). 

Post-operative functional and quality of life outcomes are detailed in Table 2. Overall, 54 patients (87%) completed the follow-up questionnaires; seven were unavailable to contact, two were deceased, and one declined to participate. The mean follow-up was 62 months  (4 - 120). Bothersome urgency or recurrent SUI were reported in 17% (n=14) and in 9% (n=5) respectively. Persistent voiding dysfunction was observed in 9% of patients (n=5), and 8%(n=4) reported chronic pelvic pain. 
Thirty-five patients (66%) indicated their sex life after surgery was at least the same, and 22 patients (42%) described pain during intercourse. 

The satisfaction rate was high, 80% (n=43) of the patients considered the surgery successful, 72% (n=39) felt better or much better, 89% (n=48) would still have the surgery if they were in the same situation again, and 85% would recommend this surgery. The mean ICIQ-S score was 18.3 out of 23 (SD 5.95).

The mean PHQ-9 score was 4.8. 21% (11/54) with mild to moderate depression and 20% (10/54) patients with moderate-severe symptoms of depression. Additionally, 34 patients (62%) reported experiencing depression before surgery. Of those, 27 (79%) improved after surgical repair.

This study was conducted in a tertiary centre. Therefore, over a third of the patients were referred to have a secondary or further repair. Despite this, the success rate is comparable with that reported in the literature for naïve cases. Moreover, this series is one of the few to report functional outcomes, particularly quality of life, sexual life, and mood-related problems after fistula repair. 
  
Even though more than one-third of the patients were bothered by incontinence, LUTS or pain, more than 80% of them considered the surgery successful, and 89% will have the surgery again. Additionally, a high rate of patients had returned to a normal sexual life after surgery. Fistula correlated with depression, and 79% of our patients improved after surgical repair.

Patient satisfaction rate after fistula repair is high, even though many patients develop de novo incontinence, voiding dysfunction and pain. Sexual function and depression related to fistula improved after surgery.

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Hilton P. Urogenital fistula in the UK: a personal case series managed over 25 years. BJU International 2012;110:102–10. https://doi.org/10.1111/j.1464-410X.2011.10630.x.
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