May we draw to the attention of your readers our view that the article by Frajzyngier et al. is based on incorrect assumptions. We believe that the whole article is based on incorrect indications for the abdominal repair of obstetric fistula. These are quoted as female genital infibulation, extensive scarring, extensive tissue loss, and trigonal, supratrigonal, intracervical and ureteric involvement. We believe that most obstetric fistula surgeons would agree that simple ureteric fistulae and some intracervical and vesicouterine fistulae are the correct indications for an abdominal repair.
Fistulae with extensive scarring or tissue loss almost always involve the urethra, which may be circumferentially detached from the bladder. They are difficult enough to repair by the vaginal approach, but to attempt to do so abdominally is fraught with hazards, especially considering the conditions in resource-poor countries.
The vaginal route is the route of choice; the only indications for abdominal repair are when the fistula is high and out of sight vaginally. This can usually only be determined by careful vaginal examination under anaesthesia immediately before the commencement of the surgery. A few of the most experienced surgeons claim to repair almost all fistulas vaginally, although we believe that about 5% are much easier to repair abdominally. Easier repairs are more likely to be successful.
In addition to the incorrect indications, some important data are missing. For example, the mode of delivery in the two groups, the number of women with an obstetric fistula and the cause of the fistula in the remaining women. In addition, the number of iatrogenic fistulae is missing, which is important, because this might show that the two groups are not comparable. There is no mention in the Discussion about the fact that, of the 400 women who met the quoted indications for the abdominal route of repair, only 57 were operated on abdominally. The same applies to the 93 women with fibrosis, a met indication, only two of whom had an abdominal repair.
Every obstetric/gynaecology/fistula surgeon should understand why there is an association between women with a parity of more than three and the abdominal route of repair. This is because the higher the parity, the greater the risk of malpresentation/malposition of the baby, which leads to obstructed labour and a possible ruptured uterus, for which a caesarean section needs to be performed. This can cause the high fistula, for which the abdominal route is chosen. However, because the above-mentioned data are missing, it seems as if the two groups are comparable. The two groups are in fact very different and cannot be compared. We believe that this article makes no useful contribution to the management of obstetric fistula.