Ongoing incontinence after obstetric fistula
Description: Ongoing incontinence after obstetric fistula repair POFRI Workshop Addis Ababa (Summary of 2025 group study) FIGO POFRI- Judith Bulkamid update Keypoints: Be realistic. In the best case scenario and strictly selected patients there is an
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slide1. Ongoing incontinence after obstetric fistula repair ‘POFRI’ Workshop Addis Ababa (Summary of 2025 group study) FIGO<br>
slide2. POFRI- Judith Bulkamid update Keypoints:
Be realistic. In the best case scenario and strictly selected patients there is an 85% success rate for SUI procedures
Bulkamid. 0.3ml x3 (1ml total) done without cystoscope.
25 cases with STRICT selection criteria.
75 dry or better (57% dry, 26% better, 17% wet)
F/u with questionnaire.
No urethra too short.<br>
slide3. POFRI- Sunday PRP update Keypoints:
Has done three cohorts:
No long term follow up
1st five patients- no change
2nd 20 patients, five dry straight away
3rd five patients 3/5 dry straight away.
Perhaps the immediate cure was due to a bulking effect<br>
slide4. POFRI- Igor augmentation continent cystoplasty Keypoints:
A new technique using about 30-40cm ileum to not only augment the bladder, but to make a continent stoma to the umbilicus.
About ¾ of the harvested ileum is used for the augmented bladder and the remainder fashioned a continent, catheterisable tube.
Advantage is that the ureters are left in place.
Has done 14 cases so far and demonstrated the technique during the workshop.
Commented the any diversion is not without complications and should be used as a last resort.<br>
slide5. POFRI- Hillary Mitroffanoff Keypoints:
Has a series of around 600 diversions
Mitroffanoff is a good option, but as always, it is not without complications.
He demonstrated his procedure on quite a challenging case.
Concluded that ‘incurable fistula’ might be an incorrect term as he has many diversion patients now cured of their incontinence and leading productive lives.<br>
slide6. POFRI- Papers Three papers were put into action last year
Updates
Bulkamid
Potential for two papers with slightly different techniques
PRP
progressing
POFRI incidence
Discussion re retrospective and a prospective
Prospective will be better.
Judith offered some help modifying the study design and various centres have offered to take part in the paper.<br>
slide7. POFRI- Other procedures Michael and Larry
Bulkamid study
Has modified the technique, thus is dfferent to Judith’s technique, but good results.
Ennet
Rectus muscle flap at primary repair
26 cases done, 22 followed up to at least six months and excellent results on the worst of all cases (only two wet)
Andrew
Anterior bladder flap urethra
Up to 60% dry but with a two stage procedure, using fascial sling
Igor
Singapore sling to rectus
Fekade
Colonic neovagina- demonstrated the procedure<br>
slide8. POFRI- Where to go from here? Can we recommend anything? Make another flow chart? - three group discussions Group one:
First step to re-establish diagnosis and thoroughly investigate
We’re not at a stage to recommend any procedure, either:
Minimally invasive and conservative
Surgical
Recommends each unit gets:
We should be using standardized and validated tools as part of the assessment.
Be realistic about communicating outcomes to the patients<br>
slide9. POFRI- Where to go from here? Can we recommend anything? Make another flow chart? - three group discussions Group two:
Assuming we’ve got the diagnosis correct then we can have recommendations for the principals of (but not recommending specific procedures):
Sling
Bulking agents
Urethral/ bladder neck reconstruction
Vaginoplasties
Diversion
PRP used in a research setting for POFRI only
No evidence for muscle flaps for POFRI only.<br>
slide10. POFRI- Where to go from here? Can we recommend anything? Make another flow chart? - three group discussions Group three:
No need to reinvent the wheel, there are recommendation frameworks out there.
Need to work on:
Assessments- cystometry
Surgery: Can we specify selection criteria and standardize methods?
We must publish negative results
Be cautious about recommending things without evidence- can’t be seen as ‘experimenting’
Should be careful that what we recommend can be replicable at centres with limited resources.
Must get ethic approval for any research<br>
slide11. POFRI- Where to go from here? Conclusion of the group discussion Through Ix and Dx
We’re probably at the point of writing a discussion paper for the FIGO supplement only and not at the point of developing and FIGO best practice or flow chart.
The discussion paper could include:
Standardizing assessment
Being realistic about outcomes
We are lacking data and evidence but we’re working towards it
Future
ACTION point- FIGO staff will coordinate a discussion paper to be ready for the FIGO supplement<br>
slide12. FIGO working group Future meetings? We have probably got as far as we can with POFRI for the moment, but there are other things to address
Potential need workshop issues to address were suggested by the group.
Flaps
Diversions
POFRI patient characteristics
Conservative management, e.g. physiotherapy post-op
More advanced investigations
Wider co-morbidities of obstetric labour, e.g. management options for of scarred vagina
Role of minimal invasive procedures
ACTION- to be discussed in FIGO office<br>
slide13. Thank you<br>
slide2. POFRI- Judith Bulkamid update Keypoints:
Be realistic. In the best case scenario and strictly selected patients there is an 85% success rate for SUI procedures
Bulkamid. 0.3ml x3 (1ml total) done without cystoscope.
25 cases with STRICT selection criteria.
75 dry or better (57% dry, 26% better, 17% wet)
F/u with questionnaire.
No urethra too short.<br>
slide3. POFRI- Sunday PRP update Keypoints:
Has done three cohorts:
No long term follow up
1st five patients- no change
2nd 20 patients, five dry straight away
3rd five patients 3/5 dry straight away.
Perhaps the immediate cure was due to a bulking effect<br>
slide4. POFRI- Igor augmentation continent cystoplasty Keypoints:
A new technique using about 30-40cm ileum to not only augment the bladder, but to make a continent stoma to the umbilicus.
About ¾ of the harvested ileum is used for the augmented bladder and the remainder fashioned a continent, catheterisable tube.
Advantage is that the ureters are left in place.
Has done 14 cases so far and demonstrated the technique during the workshop.
Commented the any diversion is not without complications and should be used as a last resort.<br>
slide5. POFRI- Hillary Mitroffanoff Keypoints:
Has a series of around 600 diversions
Mitroffanoff is a good option, but as always, it is not without complications.
He demonstrated his procedure on quite a challenging case.
Concluded that ‘incurable fistula’ might be an incorrect term as he has many diversion patients now cured of their incontinence and leading productive lives.<br>
slide6. POFRI- Papers Three papers were put into action last year
Updates
Bulkamid
Potential for two papers with slightly different techniques
PRP
progressing
POFRI incidence
Discussion re retrospective and a prospective
Prospective will be better.
Judith offered some help modifying the study design and various centres have offered to take part in the paper.<br>
slide7. POFRI- Other procedures Michael and Larry
Bulkamid study
Has modified the technique, thus is dfferent to Judith’s technique, but good results.
Ennet
Rectus muscle flap at primary repair
26 cases done, 22 followed up to at least six months and excellent results on the worst of all cases (only two wet)
Andrew
Anterior bladder flap urethra
Up to 60% dry but with a two stage procedure, using fascial sling
Igor
Singapore sling to rectus
Fekade
Colonic neovagina- demonstrated the procedure<br>
slide8. POFRI- Where to go from here? Can we recommend anything? Make another flow chart? - three group discussions Group one:
First step to re-establish diagnosis and thoroughly investigate
We’re not at a stage to recommend any procedure, either:
Minimally invasive and conservative
Surgical
Recommends each unit gets:
We should be using standardized and validated tools as part of the assessment.
Be realistic about communicating outcomes to the patients<br>
slide9. POFRI- Where to go from here? Can we recommend anything? Make another flow chart? - three group discussions Group two:
Assuming we’ve got the diagnosis correct then we can have recommendations for the principals of (but not recommending specific procedures):
Sling
Bulking agents
Urethral/ bladder neck reconstruction
Vaginoplasties
Diversion
PRP used in a research setting for POFRI only
No evidence for muscle flaps for POFRI only.<br>
slide10. POFRI- Where to go from here? Can we recommend anything? Make another flow chart? - three group discussions Group three:
No need to reinvent the wheel, there are recommendation frameworks out there.
Need to work on:
Assessments- cystometry
Surgery: Can we specify selection criteria and standardize methods?
We must publish negative results
Be cautious about recommending things without evidence- can’t be seen as ‘experimenting’
Should be careful that what we recommend can be replicable at centres with limited resources.
Must get ethic approval for any research<br>
slide11. POFRI- Where to go from here? Conclusion of the group discussion Through Ix and Dx
We’re probably at the point of writing a discussion paper for the FIGO supplement only and not at the point of developing and FIGO best practice or flow chart.
The discussion paper could include:
Standardizing assessment
Being realistic about outcomes
We are lacking data and evidence but we’re working towards it
Future
ACTION point- FIGO staff will coordinate a discussion paper to be ready for the FIGO supplement<br>
slide12. FIGO working group Future meetings? We have probably got as far as we can with POFRI for the moment, but there are other things to address
Potential need workshop issues to address were suggested by the group.
Flaps
Diversions
POFRI patient characteristics
Conservative management, e.g. physiotherapy post-op
More advanced investigations
Wider co-morbidities of obstetric labour, e.g. management options for of scarred vagina
Role of minimal invasive procedures
ACTION- to be discussed in FIGO office<br>
slide13. Thank you<br>