When yet another team sets off from the Department of Obstetrics, Gynecology and Reproductive Science for some remote location in Africa or Central America, its thoughts are on how to provide the superior standard of care, considered to be the routine at home, to women in drastically resource poor settings. Upon returning, what our teams often realize is that the tremendous expertise they develop in these countries is the very thing that makes them the experts in their own fields at home. Fistula repair is the perfect example of this.
“Obstetric fistula is a tremendous problem in sub-Saharan Africa,” says Charles Ascher-Walsh MD, Assistant Professor, Director of Gynecology and Urogynecology, Department of Obstetrics, Gynecology and Reproductive Science. “In many countries there is very little maternal health care and, as a result, maternal mortality rates top 1% in some of these countries. These rates are unfathomable in the United States.” If a woman is lucky enough to survive childbirth, the rates of developing some type of post-partum fistula vary between 2 to 5 per thousand births. This equates to between 50,000 and 100,000 new cases of vesico-vaginal fistula in West Africa alone every year. These women, constantly drenched in their own urine, become social outcasts and live a life of physical and social misery. This problem, however, often has a surgical cure that can reinstitute these women into society.
Mount Sinai has been involved in over 1,000 cases of vesico-vaginal and recto-vaginal fistula repair in West Africa. It is in part due to this experience abroad that Mount Sinai is a primary referral center for vesico-vaginal and recto-vaginal fistula repair in the United States. We recently had a complicated case of a woman who presented with a vesicouterine fistula that resulted from a ruptured uterus in labor. The uterus was adherred to the bladder and pubic symphysis making a vaginal approach exceedingly difficult and was deep in the pelvis in dense scar tissue making traditional laparoscopy equally challenging. Using the DaVinci robotic system and a new stem cell matrix that promotes cellular growth, we were able to achieve a successful closure of the bladder and uterus, without requiring a hysterectomy and with only an over-night hospital stay.
With the knowledge that fistula repair success rates drop from approximately 90% in the best hands for primary repairs to lower than 40% for the third repair, it is no longer acceptable for the inexperienced to attempt these repairs.
Charles J. Ascher-Walsh, MD, is the Director of the Gynecology and Urogynecology Division at the Department of Obstetrics, Gynecology and Reproductive Science