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50: Acceptability of urinary diversion amongst women deemed inoperable for vesicovaginal fistula repair in Rwanda

      Objectives

      Collect patient preferences and feasibility regarding potential performance of urinary diversion surgery in Rwanda for patients with inoperable vesicovaginal fistulas (VVF).

      Materials and Methods

      This observational study utilized questionnaires and interviews to ascertain preferences and opinions about urinary diversion surgeries amongst women with inoperable VVFs. Fistula surgeons with the International Organization for Women and Development, Inc. (IOWD) partnered with local Rwandan physicians at Kibagabaga Hospital in Kigali, Rwanda to conduct interviews during 3 consecutive mission trips from October 2016 to April 2017. After examining all fistula patients, those VVFs deemed inoperable with poor to no chance of successful closure or continence were counseled about their diagnosis and approached for study participation. Women with other causes of urinary incontinence and rectovaginal fistulas were excluded. Participants were interviewed with a Rwandan medical student translator using a combination of text, pictures, and dialogue to explain the 2 urinary diversion surgeries under consideration—ileal conduit and ureterosigmoidostomy. The participants then completed a series of open- and close-ended questions.

      Results

      Written informed consent was obtained for 27 women meeting inclusion criteria. The median age was 37, median number term deliveries 2 (range 1-6), median number living children 0 (range 0-4). Median duration of VVF was 15 years (range 1-40). 25/27 (93%) were willing to undergo one of the urinary diversion procedures. Reasons for desiring urinary diversion included: being dry 12/25 (48%), discomfort/burning from urine leakage 7/25 (28%), social ostracization due to incontinence 4/25 (16%), concerns related to husband/intimacy 1/25 (4%), and fertility concerns 1/25 (4%). The majority of women preferred ureterosigmoidostomy 19/25 (76%) over ileal conduit 6/25 (24%). The preference for ureterosigmoidostomy was due to avoidance of an ostomy bag in 18/19 (95%) women; 1 woman would defer to surgeon recommendation. Amongst the women who preferred ileal conduit, 3/6 (50%) reported they did not want mixing of urine and feces, 2/6 (33%) had concerns about potential fecal incontinence, and 1/6 (17%) had concerns with intestinal worms. Long-term follow-up care after urinary diversion appears feasible with 96% able to go for bloodwork or clinic visits every 3 months including a 1.6 hours (range 10 minutes – 5 hours) median travel time by foot or bus to an outpatient facility. For the 2 women that would decline urinary diversion, one could not accept an ostomy bag or potential fecal incontinence and the other had concerns about another major surgery or additional bag (has colostomy).

      Conclusion

      Almost all (93%) women with inoperable VVF in Rwanda would elect for urinary diversion if the procedure was available, and the majority preferred ureterosigmoidostomy to avoid an ostomy bag. Long-term follow-up care with regular laboratory screening and visits appears feasible. These interviews provided valuable information that IOWD will carefully consider toward development of a urinary diversion program.