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Research Article
Tebeu’s Pronostic Classifi cation of Obstetric
Fistula According to Anatomopathologic
Variables from the University Teaching
Hospital, Yaounde Cameroon -
Pierre Marie Tebeu1*, Georges Didier Ngassa Meutchi2, Claude Cyrille
Noa Ndoua3, Yvette Nkene Mawamba4, Gregory Halle Ekane5 and
Charles Henry Rochat6
1Ligue d’Initiative et de Recherche Active pour la Santé et l’Education de la Femme (LIRASEF)
2Department of Obstetric Gynecology, High Institute of Medical Technologies, Yaoundé-Cameroon
3Departement of Obstetrics and Gynecology, University Teaching Hospital, Yaounde, Cameroon
4Department of Obstetrics and Gynecology, University Teaching Hospital, Yaoundé, Cameroon
5Departement of Obstetrics and Gynecology, General Hospital, Douala, Cameroon
6Geneva Foundation for Medical Education and Research, Switzerland
*Address for Correspondence: Tebeu Pierre Marie, Obstetric Gynecology service, University
Teaching Hospital, Yaoundé, Cameroon, Tel: ++237 6 77 67 55 33; E-mail:
Submitted: 19 August 2017; Approved: 20 September 2017; Published: 22 September 2017
Cite this article: Tebeu PM, Ngassa Meutchi GD, Noa Ndoua CC, Mawamba YN, Ekane GH, et al.
Tebeu s Prognostic classifi cation of obstetric fi stula according to anatomopathologic variables at
the University Teaching Hospital, Yaounde, Cameroon. Int J Reprod Med Gynecol. 2017;3(1): 029-
033.
Copyright: © 2017 Tebeu PM, et al. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.
International Journal of
Reproductive Medicine & Gynecology
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International Journal of Reproductive Medicine & Gynecology
INTRODUCTION
WHO proposes the successful closure rate for rst repair at 85% in
each facility with the continence achievement among the closed cases
at 90 % [1]. Failure of obstetric stula repair is associated with severe
psychological and social implications [2]. Several experts published
their closed rate of obstetric Vesicovaginal Fistulas (VVF) ranging
from 63 to 100% [3-7]. In spite of closure, residual incontinence
varies from 5 to 30% [8,9]. A report from Kenya showed that among
women regularly seen at postoperative follow-up, 54% were still
leaking [10]. ey found that, this condition was associated with
having had previous failed repairs, and greater stula size (> 2cm).
Similar ndings were reported in Uganda, where unsuccessful
stula closure was signi cantly associated with large stula size
(> 3 cm), circumferential defect and brosis [11]. ey found
that, independent predictors for residual stress incontinence a er
successful stula closure were urethral involvement and previous
unsuccessful stula repair.
In Democratic Republic of Congo, the satisfactory rate in terms
of closure with continence was weak for stula size at 4 cm and above
(65.2% vs. 83.7%) [12]. e same authors reported that the satisfaction
was respectively 87.1%, 67.7% and 37.9% if no brosis, moderate or
severe brosis [12]. An Egyptian study revealed that, previous repair,
long duration of VVF until treatment, surgical approach and the
location of the VVF had a signi cant e ect on surgical outcome [13].
We previously compared 22 patients presenting closure with good
continence to 10 others with failure/incontinence. We found that the
later had stula more likely to be localized at the bladder neck region
(80% vs. 50%); with size more than 5 cm (30% vs. 9%); vaginal scaring
(80% vs. 64%), and brosis (80% vs 55%) [14].
e evidence from previous studies is that stula surgical outcome
is strongly associated anatomical patterns including location, size and
quality of tissue [15,16]. ese anatomical features could be used for
proper prognostic classi cation of VVF. Several classi cations have
been proposed for predicting the surgical di culties. us, Falandry
in 1992, proposed a prognostic classi cation in 3 groups, as group I,
also called simple, group II also called di cult, and group III, also
called complicated considering bladder neck involvement, associated
rectovaginal stula, brosis and previous operation as independent
factors for poor prognosis [8].
e prognostic implications of previous operations have been
supported by several studies, In Ghana, Elkins revealed that the
success rate a er surgery was 85% at rst attempt , 50% at second
attempt and 33% at third one [17]. In a Zambian’s study, the total
satisfaction a er stula repair was respectively 70%, 18% and 11% at
rst, second and third attempts [18]. We recently reported similar
trend in Cameroon [19]. e number of previous operations is
associated with poor surgical outcome, and this could be attributed
to the brosis of the tissue and merging resection formerly used
and that could have increase the stula size. Classi cation proposed
by Falandry was later modi ed by Camey who distinguished three
prognostic classes as simple, complex, and complicated stulas, but
did not specify the role of the brosis as prognostic factor [20].
Many other classi cations have been proposed, like that from
Goh, which consider the site, the size and the brosis but does not
combined those factors to address the prognostic classes [21]. In 1995,
another classi cation proposed by Waaldijk, consider the site, but did
not consider the size and brosis as prognostic factors [22]. In 2007,
WHO proposed this classi cation, but while expressing two groups of
stulas, those of good prognosis/simple and those of bad prognosis/
complicated [1]. WHO classi cation su ers from the impact of the
skill of the surgeon, as what appears simple for one surgeon could be
complicated for another one depending on their competency. WHO
classi cation su ers from the lack of brosis as a prognostic factor,
and also, it considers the previous operation and associated recto-
vaginal stula as independent poor prognostic factors.
Based on the review on available classi cation systems, authors
revealed that, a standardized classi cation system with accepted
ABSTRACT
Introduction: Several studies revealed the prognostic value of the fi stula location, size and the vaginal fi brosis on surgical result.
Objective: We conducted this study in order to evaluate a surgical outcome of Obstetric vesicovaginal fi stula focusing on three
leading prognostic factors combination including size, location and softening of surrounding tissue.
Methods: This was a retrospective case series study from 69 patients at the University Teaching Hospital, Yaounde, Cameroon
involving patients operated from March 2009 to March 2015.
We collected data from registers, patient’s folders and by phone call. We defi ned criteria of good prognosis based on the 3 prognostic
factors (retrotrigonal location, size < 2 cm, soft vagina tissue); minor criteria of poor prognosis (bladder wall other than retrotrigonal, size
between 2-4 cm, vagina less scaring); and major criteria of poor prognosis (Complete circumferential defect, size > 4 cm, major scaring/
stenosis).
The combination of the above variables helped in defi ning prognostic classes as, class-I (3 criteria of good prognosis); class-II (1
minor criteria of bad prognosis); class-III (2 minor criteria of bad prognosis); class-IVA (3 minor criteria of bad prognosis, or 1 major criteria
of poor prognosis), and class-IVB ( at least 2 major criteria of bad prognosis ). Closure with continence rate was assessed at discharge,
and at 3 months after surgery.
Results: Obstetric fi stula frequency was respectively class I (18.8%), class II 53.7%), class III (18.8%) and class IV (8.8%). The
satisfactory result decreased from class I to IV as closure with continence rate were, respectively for class I (92.3%), class II (94.6%),
class III (77%) and class IV (16.7%).
Conclusion: Fistula location, size and softening of surrounding tissue provide a promising prognostic classifi cation of obstetric fi stula
in four entities. While waiting for additional researches this appears as a good fi eld option.
Keywords: Fistula; Prognosis; Classifi cation; Surgery; Result
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International Journal of Reproductive Medicine & Gynecology
terminology is urgently needed while avoiding physiological
terminologies as simple [23]. ese observations called for the
development prognostics classes of VVF depending on morphologic
variables commonly reported as independent prognostic variables
for surgical outcome (so ening of the vagina, localization of stula,
and it size) that could better be reproducible [15,16]. In Niger,
60% cases were the sizes of the stula greater than 4 cm, and 78.4%
presented brous tissue [24]. Authors highlighted the need for
prognostic classi cation and concluded that “A simple, reproducible
and universally accepted scienti c classi cation or staging system for
OF dealing with outcomes rather than anatomic landmarks should
replace the present proposed classi cation systems for prognostic and
ethical purposes”.
As each of the three anatomical prognostic variables is not
always presented as an isolated feature, the challenge in prognostic
classi cation will be to combine all the three variables to de ne the
prognosis classes. If this is done it will help in distribution case among
the teams, better organize competency based training and compared
di erent results from stula units over the world.
OBJECTIVE
We conducted this study intending to de ne a prognostic
classi cation of vesicovaginal stula based on three leading prognostic
factors including site, size and brosis on the daily practice.
METHODS
Type, setting and duration of the survey
is was a retrospective cases series study at the University
Centre Hospital, Yaounde Cameroon focusing on patients operated
from March 03, 2009 to March 03, 2015 (six years).
Population
e study population included obstetric vesico-vaginal stulas.
Patients with stula involving urethra, uterus, and ureter were
excluded.
Variables
We collected data from registers, patient’s folders and by phone call.
Variables of interest included, sociodemographic and reproductive
health characteristics (name and rst name, age, nationality,
profession, residence, marital status, education, occupation, religion),
pregnancy and delivery (antenatal care, duration of labor, place of
childbirth, mode of delivery, neonatal status). Past medical features
of the patients (laparotomy, dystocia, Caesarean, hysterectomy,
instrumental delivery, smelling as urine or stools, vulva dermatitis,
urines leaking, presence of stools on the vulva, speculum examination
ndings. Surgical outcome related information’s were also collected
as presence or absence of leaking).
STATISTICAL ANALYSIS
Data were collected using a pre-established individual
questionnaire, introduced in a Microso le Excel 2010, then to
transfer to EPI-7.1. For classi cation purpose, we de ned criteria
of good prognosis based on the 3 prognostic factors (retrotrigonal
location, size < 2 cm, so vagina tissue); minor criteria of poor
prognosis (Wall other than retrotrigonal, 2-4 cm, vagina less brotic);
and major criteria of poor prognosis (Complete circumferential defect,
size > 4 cm, major brosis/stenosis). e combination of the above
variables helped in de ning prognostic classes as, class-I (3 criteria of
good prognosis); class-II (1 minor criteria of bad prognosis); class-III
(2 minor criteria of bad prognosis); class-IVA (3 minor criteria of bad
prognosis, or 1 major criteria of poor prognosis), and class-IVB (at
least 2 major criteria of bad prognosis). Closure with continence rate
was assessed at discharge, and at 3 months a er surgery.
RESULTS
e mean age of patients was 29 (SD: 9.03) years. Many patients
were teenagers at surgery (26%), with primary educational level
(55.1%), single (65.2) and housewives (81.2%) (Table I). Fistula was
mostly trigonal (46.4%) and juxtacervical (20.3%). Many stulas had
small size less than 2 cm (67%), without vaginal brotic tissue (Table
2). Considering the frequency, obstetric stula were respectively
class I (18.8%), class II 53.7%), class III (18.8%) and class IV (8.8%)
(Table 2). ree months follow up a er surgery, revealed similar
outcome among patients reported as Class I and II. Satisfactory result
decreased with the severity of stula class from I to IV. Closure with
continence rate was, respectively for class I (92.3%), class II (94.6%),
class III (77%) and class IV (16.7%) (Table 3).
DISCUSSION
We found that, many patients were teenagers at surgery (26%).
Teenage condition is found in a wide range in obstetric stula
Table 1: Socio-demographic characteristics of fi stula patients.
Characteristics
Overall fi stulas
N = 69
n%
Age mean (SD) 29 (SD: 9.03)
Age (classes) (Years)
15-19 18 26.0
20-34 41 59.5
35-45 10 14.5
Educational level
Primary 38 55.1
Secondary 28 40.6
High 3 4.3
Marital status
Married 21 30.4
Single 45 65.3
Widow 3 4.3
Occupation
Civil servant 2 2.9
Private sector 3 4.3
Housewife 56 81.2
Student 8 11.6
Ethnic group
Bantou 40 58.0
Semi-bantou 24 34.8
Sudanese 5 7.2
Residency
Urban 30 43.5
Rural 39 56.5
Religion
Muslim 5 7.2
Christian 63 91.3
Animist 1 1.5
N: Study population, % percentage many patients were teenagers at surgery,
with primary educational level, single and housewives.
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patients ranging from 8.9 to 86 % [25-27]. e increase obstetrical
risk in teenagers can be explained by anatomic immaturity. ere
is a need to struggle against teenager’s pregnancies in Cameroon.
Patients had primary educational level (55.1%). Poor educational
level among the obstetric stula patients had been reported in several
studies as ranging from 78 to 96% [28,29]. is can be due to the fact
that many of the teenagers could not continue their education due to
the medical and social condition.
Most of the patients were single (65.2%); this is high compared
to 38% of patients previously reported as single at the time of surgery
in the northern Cameroon [26]. is can also be the fact that, in the
northern Cameroon, many women will still be in the compound, but
without real contact with the husband and are wrongly considered
as married. However among 11 divorced patients, (n = 10) having
divorced a er the occurrence of the stula. Almost all of our patients
did not have an occupation (81.2%). Women with obstetric stula are
o en solitary [30]. In the Far North Cameroon, 15% of patients were
thinking about suicide as solution to their condition. Higher gure
(38%) was reported in Ethiopia [31].
Fistula had moderate/severe brosis in 18%, lower than 64.9%
reported in Uganda [11]. We found stula with a size of more than
4 cm only in 18.4%; similar to 18% reported `in Uganda, lower than
25.3% reported in Niger for size of more than 3 cm [11,32]. Moderate
to severe at 70.4% brosis was reported in Nigeria [33]. Fibrosis
associated with stula was similar to the report from DRC, where
20.5% of stula was associated with vaginal brosis during surgical
treatment [34].
We found that many stulas were located at the trigon (46.4%)
and at the juxtacervical area (20.3%). In a previous study in Far North
Cameroon, we found that stula was located on the bladder wall
(15.6%), on the trigon (28.1%), on the bladder neck (31.3) and on the
urethra (25.0%) [14].
Obstetric stulas were mostly class-II with respectively class-I
(18.8%), class-II 53.7%), class-III (18.8%) and class-IV (8.8%). is
observation was in agreement with the report from Falandry who
suggested a prognostic classi cation in three entities including
respectively group-I (37.6%), group-II (41.7%) and group-III (20.7%)
[8] and by Goh [21].
e stula grouped as class I-II (72.5%) suggests that, if this
classi cation is used, it will be rational to gathering class-I / class-II in
basic training and class-III / class-IV as advanced training.
We reported the result initially at discharge, but nally at 3
months. ree months follow up a er surgery, revealed similar
outcome among patients reported as Class I and II. In overall,
satisfactory results decreased with the severity of class from I to IV.
Close with continence rate were, respectively for class I (92.3%), class
II (94.6%), class III (77%) and class IV (16.7%).
ere is a great discrepancy for the time of result report; some
are still presenting their results at discharge, as this was recently
published from Ethiopia, with closure and continence of 84.5% at
discharge [35]. Among our patients, ve of class III-IV who had
closure with continence at discharge didn’t at 3 months meaning the
results should not be concluded before 3 months.
Decreasing satisfaction with the increasing in stula prognosis
class is in agreement with nding by Falandry who organized VVF in
three groups (simple, di cult and complicated) and reported a result
of 96.92% for group-I, 76.16% for group-II and 16.6% for group-
III [8]. But this classi cation from Falandry had the weakness of
misconsideration of some prognostic variables. Results as presented
in the present study were at 3 months for a set of patient, therefore
the repeated surgery was not considered and the censured result was
the combination of closure and continence. Some studies present the
result of obstetric VVF repair including repeating operations for the
same patient [8]. Other studies present the result only as successful
closure without taking into consideration the continence status [36].
Classi cation de ned and highlighted by eld result, can be
considered in the training programs by organizing surgical trainees
in 2 groups of competency Based Training. Yet, consider basic
training (class I and II), and advanced training (class III and IV).
is classi cation could also be possible used while distributing the
surgical task among the sta .
CONCLUSIONS
We have de ned a prognostic classi cation system for
vesicovaginal stula in four classes. We found that, the surgical
outcome diminish gradually with the prognostic class. is
classi cation must be used while organizing training sessions and
while allocating the task among the surgical team.
Table 2: Anatomic characteristics of the fi stula.
Characteristics Overall fi stulas
N = 69
n%
Location
Uretro-vaginal 0 0.0
Cervico-vaginal 10 14.5
Trigono-vaginal 32 46.4
Retro trigonal 13 18.8
Juxtacervical 14 20.3
Size
< 2Cm 46 67.0
2-4 Cm 16 23.0
> 4 Cm 7 10.0
Surrounding tissue
Soft 56 81.0
Moderate Fibrosis 11 16.0
Severe fi brosis 2 3.0
Prognostic class
Class I 13 18.8
Class II 37 53.7
Class III 13 18.8
Class IV 6 8.7
N: Study population, % percentage
Fistula were mostly trigonal and juxtacervical. Many fi stulas had small size less
than 2 cm without vaginal fi brotic tissue.
Table 3: Obstetric fi stula outcome for each prognostic class.
Close and
continent
Class I
N = 13(%)
Class II
N = 37(%)
Class III
N = 13(%)
Class IV
N = 6(%)
At discharge
Yes 12(92.3) 35(94.6) 12(92.3) 4(66.7)
No 1(7.7) 2(5.4) 1(7.7) 2(33.3)
At 3 months
Yes 12(92.3) 35(94.6) 10(77.0) 1(16.7)
No 1(7.7) 2(5.4) 3(23.0) 5(83.3)
N: Study population, % percentage
In overall, satisfactory results after surgery decreased with the severity of class
from I to IV.
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ACKNOWLEDGMENTS
We wish to thank the sta of the Department of Obstetrics
and Gynecology at the University Teaching Hospital, Yaounde,
Cameroon.
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