The mobile surgical outreach program for management of patients with genital fistula in the Democratic Republic of Congo

To describe components of the mobile surgical outreach (MSO) program as a model of care delivery for women with genital fistula; present program results; and discuss operational strengths and challenges.

A retrospective observational study of routinely collected health data from women treated via the MSO program (2013–2018). The program was developed at Panzi Hospital in the Democratic Republic of Congo to meet the needs of women with fistula living in remote provinces, where travel is prohibited. It includes healthcare delivery, medico‐surgical training, and community sensitization components.

The MSO team cared for 1517 women at 41 clinic sites across 18 provinces over the study period. Average age at presentation was 31 years (range, 1–81 years). Most women (n=1359, 89.6%) presented with vesicovaginal fistula. Most surgeries were successful, and few women reported residual incontinence postoperatively. Local teams were receptive and engaged in clinical skills training and public health education efforts.

The MSO program addresses the backlog of patients awaiting fistula surgery and provides a template for a national strategic plan to treat and ultimately end fistula in DRC. It offers a patient‐centered approach that brings medico‐surgical care and psychosocial support to women with fistula in their own communities.

Demand and capacity to integrate pelvic organ prolapse and genital fistula services in low-resource settings.

There is a need for expanded access to safe surgical care in low- and middle-income countries (LMICs) as illustrated by the report of the 2015 Lancet Commission on Global Surgery. Packages of closely-related surgical procedures may create platforms of capacity that maximize impact in LMIC. Pelvic organ prolapse (POP) and genital fistula care provide an example. Although POP affects many more women in LMICs than fistula, donor support for fistula treatment in LMICs has been underway for decades, whereas treatment for POP is usually limited to hysterectomy-based surgical treatment, occurring with little to no donor support. This capacity-building discrepancy has resulted in POP care that is often non-adherent to international standards and in non-integration of POP and fistula services, despite clear areas of similarity and overlap. The objective of this study was to assess the feasibility and potential value of integrating POP services at fistula centers.

Fistula repair sites supported by the Fistula Care Plus project were surveyed on current demand for and capacity to provide POP, in addition to perceptions about integrating POP and fistula repair services.

Respondents from 26 hospitals in sub-Saharan Africa and South Asia completed the survey. Most fistula centers (92%) reported demand for POP services, but many cannot meet this demand. Responses indicated a wide variation in assessment and grading practices for POP; approaches to lower urinary tract symptom evaluation; and surgical skills with regard to compartment-based POP, and urinary and rectal incontinence. Fistula surgeons identified integration synergies but also potential conflicts.

Integration of genital fistula and POP services may enhance the quality of POP care while increasing the sustainability of fistula care.