Study Type – Therapy (retrospective cohort)
Level of Evidence 3a
What's known on the subject? and What does the study add?
Many case series of lower urinary tract fistula have been reported, usually reporting the results from individual surgeons using their preferred techniques. Definitions of cure and the case-mix or complexity of reported cases vary widely, and a wide range of outcome results are reported in the literature, with primary closure rates between 53% and 95%.
Using the Hospital Episode Statistics database we have demonstrated for the first time the pattern of care provided nationally. A large number of surgeons (490) are currently involved in providing this care in a large number of units (138), with individual workloads varying between 1 and 90 procedures in 10 years; only three undertook >3 operations per year. We have demonstrated an overall operative failure rate (re-operation rate) of 12%, and a high rate of urinary diversion (24%). Cure rates varied between 50 and 100% and were higher in units undertaking >3 operations per year.
- • To examine patterns of care among women with urogenital fistula treated in the English National Health Service (NHS) between 2000 and 2009.
- • To assess whether failure of repair was associated with hospital or surgeon workload.
PATIENTS AND METHODS
- • We conducted a retrospective cohort study using data from Hospital Episode Statistics on women undergoing vesicovaginal or urethrovaginal fistula repair between January 2000 and December 2009 in English NHS hospitals.
- • The main outcome measure was the number of fistula repairs and the incidence of re-repair; re-repair rates were stratified by age, NHS trust and consultant team volume.
- • Between 2000 and 2009, 1194 women underwent surgical repair (n= 905) or ileal conduit (n= 289) for urogenital fistula under the care of 490 consultant teams.
- • A total of 281 teams performed only a single index procedure, and only three consultant teams performed a mean of >3 per year.
- • The rate of unsuccessful repair was 11.9% (108/905).
- • The rate of re-operation at NHS trusts who performed over 30 procedures over the 10-year study period was 7.4% compared with 13.2% at those undertaking fewer (P= 0.02).
- • A similar difference in re-operations between consultant teams performing > or <30 procedures did not reach significance (8.4% v 12.7%, P= 0.13).
- • One in nine women required re-operation after surgical repair of a urogenital fistula.
- • Our results lend weight to the argument for a ‘minimum workload’ for fistula management; given the number of fistulae occurring in England currently, this would best be provided by a network of supra-regional centres.