Reducing Iatrogenic Female Genitourinary Fistula: Impact of Short-Term Obstetric Training for Lower Cadre Surgeons in...

In Uganda, almost 50% of genitourinary fistulae are iatrogenic, primarily resulting from inadvertent urinary tract injuries during obstetric and gynecologic surgeries. Cesarean sections (CS), often performed by less experienced providers at lower-level facilities, account for 70% of these cases. In 2022, the Essential Training in Operative Obstetrics (ETOO) program was introduced to improve surgical skills among lower cadre surgeons. This study evaluated the program's impact on iatrogenic fistula incidence at a tertiary teaching hospital in southwestern Uganda.

A retrospective review was conducted on women who underwent fistula repair at a tertiary teaching hospital in southwestern Uganda between January 2020 and December 2024. Data from the pre-training period (2020-2021) were compared with post-training data (2022-2024). Fistulae were classified as iatrogenic if caused by surgical error rather than obstructed labor. Anatomical subtypes included ureteric injuries, vault fistulas, and vesico-[utero]/-cervico-vaginal fistulas. The primary outcome was the annual number and proportion of iatrogenic fistula cases.

Among 102 fistula cases post-training, 57 (55.9%) were iatrogenic. Most followed CS (66.7%) and involved ureteric injuries (54.3%). A significant portion (34.8%) originated from private facilities. Following ETOO implementation, annual iatrogenic cases declined from 39 in 2020 to 19 in 2024. A marked drop occurred in late 2022, aligning with program rollout. The trend slope of -5.4 suggests a steady annual decline.

The ETOO program is associated with a notable reduction in iatrogenic fistula incidence. Expansion to private and lower-level facilities is recommended to enhance nationwide surgical safety.