Diagnosis and management of ureterovaginal fistula in a resource limited setting: a 12 years’ experience at four fistula surgery centers in Uganda

Diagnosis and management of ureterovaginal fistula in a resource limited setting: a 12 years’ experience at four fistula surgery centers in Uganda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Diagnosis and management of ureterovaginal fistula in a resource limited setting: a 12 years’ experience at four fistula surgery centers in Uganda Rogers Kajabwangu, Verena Geissbüehler, Leevan Tibaijuka, Onesmus Byamukama, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2837073/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Ureterovaginal fistulae usually follow iatrogenic injury to the ureter during pelvic surgery. This manifests as urine incontinence and results in serious psychosocial effects to the women. Ureterovaginal fistulae unlike vesicovaginal fistulae present challenges in diagnosis and management especially in resource constrained settings. Objective: To describe the magnitude, aetiology, diagnosis, management and outcomes of ureterovaginal fistula at four fistula surgery centres in Uganda over a twelve-year period. Methods: A retrospective review of charts for women who had fistula repair at four regional fistula repair centres in Uganda from 2010 to 2021 was conducted. The diagnosis of ureterovaginal fistula was made clinically using a combination of a history of leakage of urine through the vagina following a pelvic surgery, absence of visible anterior vaginal wall defect on speculum examination, a negative methylene blue dye test, and a three-swab test. All women were managed using open transvesical ureteral reimplantation with or without Boari flap. A ureteral stent and Foley catheter were left in situ for 2 weeks. The outcome of surgery (successful fistula repair with urine continence) was determined at 2 months post-surgery. This was confirmed through a vaginal speculum exam. Results: Overall, there were 477 women who were managed for genito-urinary fistulae during the study period. Approximately 1 in every 10 women with genitourinary fistula had uretero-vaginal fistula (n=47, 9.8%). The mean age of the women with ureterovaginal fistula was 31.9 (SD ±11.8) years. Majority of the ureterovaginal fistulae (n=33, 70.7%) followed caesarean sections done at general hospitals (n=22, 46.8%) by medical officers (n=32, 68.1%). The clinical assessment method used in this study was accurate in diagnosing ureterovaginal fistula. Successful fistula repair with urine continence using the open transvesical ureteral reimplantation was achieved in 45 (95.7%) of the cases. Conclusion: Iatrogenic ureterovaginal fistulae are common in Uganda and most follow caesarean section performed at lower-level health facilities by medical officers. In resource limited settings where advanced diagnostic techniques aren’t available or not affordable, a simple but careful step-wise clinical evaluation described in this study is effective in making a diagnosis. Open transvesical ureteral re-implantation fistula repair technique has a high successful repair rate with urine continence. Ureterovaginal fistula ureteral injury ureteral reimplantation Resource limited setting Figures Figure 1 Background A ureterovaginal fistula is an abnormal communication between the ureter and the vagina that often results from unidentified accidental injury to the ureter during pelvic surgery( 1 ). The ureter is susceptible to injury during pelvic surgery because of its close proximity to pelvic structures such as the uterus, cervix, broad ligament and urinary bladder ( 2 ). Furthermore, anatomical changes during pregnancy and pelvic pathologies like fibroids, ovarian masses, endometriosis, pelvic inflammatory disease, and adhesions from previous abdominal surgery lead to alteration in the course of the pelvic ureter making it more susceptible to injury especially if the surgeon has limited skills ( 3 ). Mechanisms of ureteric injuries include; contusion, kinking, devascularisation, laceration, suture-ligation, and circumferential transection( 4 ). Ureterovaginal fistula is one of the sequelae of ureteric injury, the others being ureteric obstruction, loss of kidney function and death( 5 ). Ureterovaginal fistulas often present with urinary incontinence which has a lot of devastating effects on the quality of life of the affected women in form of mental, social, marital and financial repercussions( 6 ) . In high-income countries, ureteral injury is more common during gynecological surgery than obstetric procedures ( 7 ). Open gynecological surgery procedures account for 0.5 to 1.5% of the injuries while laparoscopic surgeries account for 0.5 to 14% ( 8 ). However, this seems to be different in the low- and middle-income countries where most of the injuries follow emergency obstetric surgeries with cesarean section accounting for more than 50% of cases while hysterectomy and uterine repair for ruptured uterus account for about 27% ( 9 ). Efforts to make cesarean section and other emergency operations more accessible in these countries have been fairly successful but have not been followed with strategies to ensure that the surgeries are safe ( 10 ). There are still surgical training challenges coupled with human resource shortages possibly explaining the surgical errors that lead to these injuries ( 11 ). The diagnosis and management of ureterovaginal fistula in low resource settings is a challenge. The standard diagnosis usually involves a combination of history of urine incontinence following a pelvic surgery, dual-dye test, intravenous pyelogram, cystoscopy and CT urogram ( 12 – 14 ). However, these advanced tests are not readily available and not affordable in the low-income countries which calls for the use of low cost but equally sensitive diagnostic methods to make a diagnosis. The treatment of ureterovaginal fistula has evolved drastically over the past 50 years from open ureteral reimplantation to newer effective and less invasive procedures like endoscopic ureteral stenting ( 15 ). However, these newer less invasive techniques are not readily available to women in the low-income countries. There is paucity of data on the diagnosis, management and outcomes of ureterovaginal fistula yet this evidence is important for advocacy in scaling up the prevention and treatment for this devastating condition in the resource limited settings where women with fistula face various challenges in accessing care ( 16 ). Therefore, in this study, we aimed to describe the aetiology, diagnosis, management and outcomes of ureterovaginal fistula at four rural fistula surgery centres in Uganda. Methods Study design and study setting This was a retrospective chart review of women who had fistula surgery at four rural fistula repair centers in Uganda from 2010 to 2021. The centers included; Mbarara Regional Referral Hospital in Southwestern Uganda, Lira Regional Referral Hospital in Northern Uganda, Kitovu Mission hospital in Central Uganda and Bwindi community Hospital in Western Uganda. The surgical team was led by fistula surgeons from Mbarara University of Science and Technology. Study population and recruitment We reviewed all files of women that were managed for genitourinary fistula at the four centers between 2010 and 2021. From these, we identified all those that had a diagnosis of ureterovaginal fistula for data collection. Diagnosis of ureterovaginal fistula Ureterovaginal fistula was diagnosed in women who had all the following: Leakage of urine per vagina Any pelvic surgery preceding the urine leakage: cesarean section, uterine repair for ruptured uterus, obstetric hysterectomy, and elective hysterectomy for gynecological conditions. Urine pooling in the vagina with no obvious defect along the entire anterior vaginal wall on speculum examination A negative methylene blue dye test after backfilling the bladder with a minimum of 120 mls of diluted methylene blue A three-swab test (3 cotton swabs placed at different levels in the vagina) after the methylene blue test where none of the swabs was stained with methylene blue but all wet with urine. The diagnosis of ureterovaginal fistula was then confirmed by intraoperative findings of absence of spillage of urine from the affected ureteral orifice on cystotomy. The standard confirmatory diagnostic tests like intravenous pyelogram, CT pyelogram and cystoscopy were not done because they are neither available nor affordable. Surgical technique The women underwent surgical repair of ureterovaginal fistula after obtaining informed consent. All the women had a laparotomy with exploration of the ureteric bed on both sides to identify the affected ureter. The affected side was usually the one where the ureter was dilated. A cystotomy with exploration of the trigone and visualization of the ureteral orifices was done to finally confirm the diagnosis of ureterovaginal fistula and the side affected. This was done after giving the patient an intravenous bolus of 10mg of Frusemide. The affected ureter was the one which wasn’t spilling urine through its ureteric orifice. After identifying the affected ureter, it was mobilized from its peritoneal and broad ligament attachments up to the point of injury. The bladder was also mobilized from its pelvic attachments. This was done to minimize tension during re-implantation. The main procedure that was done was a ureteroneocystostomy (implantation of the injured ureter into the bladder) with absorbable sutures. In cases where the ureter had been injured at a relatively high level (above the pelvic brim) resulting in significant loss of ureteral length, a Boari flap was performed. In all cases, a ureteric stent was inserted and attached to the Foley catheter. The bladder was then closed in 2 layers with absorbable suture. Both the urethral stent and Foley catheter were removed after 2weeks. The women stayed in hospital under observation until removal of the Foley catheter. All surgeries were performed by a team of urogynecologists/ fistula surgeons, as part of routine management of genitourinary fistula in these fistula repair centers. The women were discharged and reviewed after two months. The outcome of surgery was determined at 2 months after surgery. This was either successful fistula closure (patient continent of urine at 2 months post-surgery) or unsuccessful fistula closure (patient still leaking urine at 2 months post-surgery). A speculum exam with participant in lithotomy was done to confirm absence or presence of urine leakage. Data collection A data capture tool was used to collect information on baseline characteristics of the study participants, perioperative findings and outcome of surgery. The baseline characteristics included: Sociodemographic characteristics (age, occupation, parity at fistula development and marital status). Clinical characteristics (duration with incontinence, antecedent surgery, level of the health facility where the antecedent surgery was performed, and cadre of the surgeon that performed the antecedent surgery). The level of health facility was classified according to Uganda Ministry of Health system into; Referral hospital including National and Regional (one with specialists like obstetricians), general hospital (no specialists but surgeries are done by a medical doctor with a first degree otherwise called a medical officer), and a health center IV which is the lowest level facility in the Ugandan health system where a caesarean section can be performed by a medical officer. The cadre of surgeon that performed the antecedent surgery was classified into; intern doctor (one who has just completed medical school and undergoing one year of clinical apprenticeship), medical officer (a doctor who has completed internship), resident (a doctor undergoing speciality training in obstetrics and gynecology) and specialist (one who has graduated from residency). The perioperative information that was collected included: Diagnostic method used (clinical evaluation using history, speculum examination, methylene blue test and 3 swab-test). Ureter affected (Right, left or bilateral) Site of ureteric injury (within the pelvis or above the pelvic brim) Type of surgery performed (ureteral re-implantation alone, ureteral re-implantation with a Boari flap) Complications of surgery (intraoperative hemorrhage that required transfusion and wound infection that required daily dressing) The outcome of surgery was determined at 2 months after surgery. This was either successful fistula closure (patient continent of urine at 2 months post-surgery) or unsuccessful fistula closure (patient still leaking urine at 2 months post-surgery). Statistical analysis Data were cleaned, entered in Excel and exported to Stata version 15 for analysis. Categorical data were presented as frequencies. Descriptive statistics were used to present the data. The proportion of successful fistula repair with continence was determined by dividing the number of women who were continent of urine at 2 months post-surgery by the total number who came for the follow-up visit and expressed as a percentage. Ethical considerations Ethical approval s were obtained from the Mbarara University of Science and Technology (MUST) Research Ethics Committee and the Uganda National Council of Science and Technology number (UNCST) number HS368ES. Results Demographic and clinical characteristics of the participants The demographic and clinical characteristics of the participants are shown in Table 1 . A total of 477 genitourinary fistulae were managed during the study period. Of these, 47 (9.9%) had ureterovaginal fistulae, vesicovaginal fistulae (146, 30.6%), vesicocervical fistulae (72, 15.1%), urethrovaginal fistulae (181, 37.9%), and vaginal vault (31, 6.5%). The mean age at diagnosis of the women with ureterovaginal fistula was 31.9 (SD ± 11.8) years. Majority were of parity > 4 (n = 25, 53.2%, range 1–7) and had been with urine incontinence for more than a year at the time of diagnosis (n = 17, 36.2%). Most fistulae (n = 33, 70.7%) developed after a caesarean section while 9 (19.5%) occurred after a hysterectomy for obstetric indications mainly ruptured uterus. Most of these antecedent surgeries (n = 22, 46.8%) were performed at general hospitals, and by medical officers (n = 32, 68.1%). Table 1 Demographic and clinical characteristics of the patients Characteristic N = 47 Description Frequency, n Percentage Age 35years 22 46.8 Occupation Unemployed 43 91.5 Employed 4 8.5 Marital status Single 5 10.6 Married 36 76.6 Divorced/separated/widowed 6 12.8 Parity at diagnosis 1 10 21.3 2–4 12 25.5 ≥ 5 25 53.2 Duration of incontinence < 3 months 16 34.0 3 months − 1year 14 29.8 ≥ 1year 17 36.2 Antecedent surgery Caesarean section 33 70.7 Obstetric Hysterectomy 9 19.5 Hysterectomy for gynaecological indications 5 9.8 Level of facility for antecedent surgery Referral hospital 19 40.4 General hospital 22 46.8 Health centre IV 6 12.8 Cadre of surgeon that performed antecedent surgery Intern doctor 7 14.9 Medical Officer 32 68.1 Resident 4 8.5 Specialist 4 8.5 Perioperative characteristics of the participants The perioperative characteristics of the patients are shown in Table 2 . For all the participants, the step-wise clinical assessment was accurate in diagnosing ureterovaginal fistula. At surgery, the left ureter was the most affected (n = 24, 51.1%). Most injuries to the ureter (n = 45, 95.6%) occurred within the pelvis while in 2 women it occurred above the pelvic brim. The commonest fistula repair surgery done was ureteric reimplantation alone 45(95.7%) while in 2(4.3%) patients, a Boari flap was performed due to a short ureter. The surgical complications encountered included; intraoperative hemorrhage that required blood transfusion in 5 (11%) of the women and post-operative wound infection (n = 5, 11%). The women with wound infection all improved following daily dressing and antibiotic treatment. Table 2 Perioperative characteristics of the participants (N = 47) Characteristic Description Frequency Percentage Affected ureter Left 24 51.1 Right 12 25.5 Bilateral 11 23.4 Level of injury Above pelvic brim 2 4.3 Below pelvic brim 45 95.7 Surgery performed Ureteric re-implantation alone 45 95.7 Ureteric re-implantation with Boari flap 2 4.3 * Surgical complications No complication 40 85.1 Intra-operative hemorrhage 5 11.0 Wound infection 5 11.0 Note: * The number of complications exceeds the number of patients because 3 patients had more than one complication. Outcomes of surgery Out of the 47 women managed for ureterovaginal fistula, 45 (95.7%) had successful closure of the fistula with continence. This is shown in Fig. 1 . Discussion This study set out to describe the magnitude, etiology, diagnosis and management of iatrogenic ureterovaginal fistula in a resource limited setting. We found that ureterovaginal fistula is common, occurring in 1 in 10 women with genitourinary fistula. Ureterovaginal fistula commonly followed obstetric operations especially cesarean section performed by lower cadre surgeons (medical officers). A simple step-wise clinical evaluation combined with intraoperative findings is effective in diagnosing ureterovaginal fistula and locating the affected side. The success rate of open transvesical ureteral reimplantation in this setting is 95.7%. The magnitude of 10% is similar to that found by Shaw and colleagues in a study done at 3 Cleveland clinics in the United states of America ( 17 ). However, this proportion is higher than the 4.6% (273/5,959) found in a review done in 11 African countries by Raassen and colleagues ( 18 ). As reported in this review, iatrogenic ureterovaginal fistulas were likely to occur in surgeries done by lower cadres especially medical officers. This is not surprising because medical officers are usually recent graduates of medicine with very little surgical experience who get posted to general hospitals and health center IVs to work independently. Since most of the emergency obstetric surgeries especially Cesarean section in Uganda are done by medical officers ( 19 ), it explains the high proportion of iatrogenic ureterovaginal fistula in this study. Further to this, the cesarean delivery rates in Uganda have increased from 8.5% in 2012 to 11% in 2016 ( 20 ) but these haven’t been matched by improvement in human resource to provide safe cesarean section. Surgical training challenges coupled with human resource shortages still exist possibly explaining the surgical errors that lead to these injuries( 11 ) ( 21 ) . In agreement with previous studies in the low income countries, most of the ureterovaginal fistulae in our study followed injuries sustained during obstetric surgeries particularly cesarean section ( 2 , 9 ) as opposed to studies done in high income countries where majority are due to gynecological surgeries ( 7 , 22 , 23 ). Like in other low income countries, obstructed labour and repeat caesarean section are the commonest indications for cesarean section in Uganda ( 24 , 25 ). In prolonged obstructed labour, the fetal head gets deeply impacted in the maternal pelvis and lateral extension of a low transverse uterine incision may occur during delivery resulting into excessive hemorrhage. Ureteric injury in this case usually results from desperate attempts to achieve hemostasis without proper identification of the ureter ( 26 , 27 ). Scar tissue and adhesions from prior cesarean section may distort the pelvic anatomy and alter the course of the ureter making it more likely to be injured in repeat cesarean sections ( 18 , 28 ). The left ureter was affected more compared to the right, as has been found in several other studies ( 2 , 18 , 29 ). This is because the left ureter is slightly nearer to the cervix compared to the right and is also obscured by the sigmoid mesocolon ( 18 , 30 ). In this study, the diagnosis of ureterovaginal fistula was accurately made from a simple clinical evaluation which involved a combination of: history of urine incontinence following a pelvic surgery, absence of visible defect on speculum examination, negative methylene blue dye test, and 3-swab test. A similar method was used in a rural hospital with limited resources in Nigeria ( 31 ). This is in contrast to complex and expensive methods used in the high-income countries that involve the use of dual-dye test, intravenous pyelogram, cystoscopy and CT urogram on top of the clinical evaluation ( 13 , 14 , 27 ). However, these investigative techniques are neither available nor affordable in the low-income countries ( 31 ). This therefore justifies the need to employ simple and cheap methods that are equally sensitive in diagnosing ureterovaginal fistula in the resource limited countries. In contrast to Randawa et al, we did not do an abdominal ultrasound to evaluate the ureter and kidneys for hydroureter and or hydronephrosis in order to determine the affected side ( 31 ). This is because the ultrasound may be misleading since absence of hydronephrosis does not necessarily imply that the particular side is not affected especially if the leakage from the injured ureter occurred immediately after the obstruction or if the ureter was just transected ( 32 ). We therefore identified the affected side intraoperatively by opening the bladder and visualizing the ureteric orifices for urine spillage. Our surgical technique of laparotomy with ureteroneocystostomy/ ureteral reimplantation was effective in achieving continence. This is not different from findings in other similar studies ( 2 , 3 , 33 ), implying that this method can effectively be used in the repair of ureterovaginal fistulae in properly selected patients especially in distal ureteral injuries. In more proximal injuries where the ureteral length is inadequate, a Boari flap can be used to ease tension on the anastomosis between ureter and bladder ( 34 ). However, newer and less invasive techniques of managing ureterovaginal fistula employed in the high-income countries like endoscopic ureteral stenting were not used in this study. This is because these methods are not readily available and surgeons with skills to perform them are limited. Conclusions Iatrogenic uretero-vaginal fistulae are common in our setting being detected in 1 in 10 women with genitourinary fistula and most follow caesarean section done at lower health facilities by medical officers. Simple but careful step-wise clinical evaluation is effective in diagnosing ureterovaginal fistula where other investigative techniques aren’t available. Open transvesical ureteral reimplantation is highly effective in treating ureterovaginal fistula in resource limited settings where use of newer less invasive procedures may not be possible. We also recommend that medical doctors conducting caesarean section and other pelvic surgeries should receive regular training in essential surgical skills to reduce on the burden of this devastating condition. Abbreviations CT: Computed tomography MRRH: Mbarara Regional Referral Hospital MUST: Mbarara University of Science and Technology UNCST: Uganda National Council of Science and Technology UNFPA: United Nations Fund for Population Activities Declarations Ethical approval and consent to participate: ethical approvals were obtained from the Mbarara University of science and Technology (MUST) Research Ethics committee and the Uganda National Council of Science and Technology (UNCST) number HS368ES. Written consent was obtained from all the patients prior to surgery. All the experiment protocol for involving humans was in accordance to guidelines of national/ international/ institutional or declaration of Helsinki. Consent to publication: Not applicable Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding : We received funding from Else Kroner Fresenius Foundation in Germany, grant number 2018_HA148, to conduct this study. The funders had no role in the study design, data collection, data analysis and interpretation. Author’s contribution : RK and KM conceived the idea, supervised data collection and wrote the first draft. VG, LT, OB PK, BA, TM, PK, HL, JN and LHM participated in data analysis and interpretation. All authors read, revised and approved the final draft of the manuscript. Acknowledgements: The authors are grateful to the staff at the four fistula surgery sites for the assistance given during the data collection. We also thank Medlend medical missions, Medicine for humanity, Uganda Ministry of Health, UNFPA and Else Kröner-Fresenius Foundation for funding the fistula surgery camps. References Andersen LM, Jerbi K, Dalal SS. Can EEG and MEG detect signals from the human cerebellum? Neuroimage. 2020; 215: 116817. https://doi.org/10.1016/j.neuroimage.2020.116817 Todd NPM, Rosengren SM, Colebatch JG. Ocular vestibular evoked myogenic potentials (OVEMPs) produced by impulsive transmastoid accelerations. Clin Neurophysiol. 2008a;119: 1638–1651. https://doi.org/10.1016/j.clinph.2008.03.009 Rosengren SM, Todd NP, Colebatch JG. Vestibular evoked myogenic potentials evoked by brief interaural head acceleration: properties and possible origin. J Appl Physiol. 2009;107: 841–852. https://doi.org/10.1152/japplphysiol.00296.2009 Todd NPM, Govender S, Colebatch JG. The inion response revisited: evidence for a possible cerebellar contribution to vestibular-evoked potentials produced by air-conducted sound stimulation. J Neurophysiol. 2017;117: 1000–1013. https://doi.org/10.1152/jn.00545.2016 Todd NPM, Govender S, Colebatch JG. Vestibular cerebellar evoked potentials in humans and their modulation during optokinetic stimulation. J Neurophysiol. 2018b;120: 3099–3109. https://doi.org/10.1152/jn.00502.2018 Todd NPM, Rosengren SM, Colebatch JG. A source analysis of short-latency vestibular evoked potentials produced by air- and bone-conducted sound. Clin Neurophysiol. 2008b;119:1881–1894. https://doi.org/10.1016/j.clinph.2008.03.027 Todd NPM, Paillard AC, Kluk K, Whittle E, Colebatch JG. Source analysis of short and long latency vestibular-evoked potentials (VsEPs) produced by left vs. right ear air-conducted 500 Hz tone pips. Hearing Res. 2014;312: 91–102. https://doi.org/10.1016/j.heares.2014.03.006 Todd NPM, Govender S, Colebatch JG. Vestibular-dependent inter-stimulus interval effects on sound evoked potentials of central origin. Hear Res. 2016; 341, 190-201. Todd NPM, Govender S, Lemieux L, Colebatch JG. Source analyses of axial and vestibular evoked potentials associated with brainstem-spinal reflexes show cerebellar and cortical contributions. Neurosci Lett. 2021b;757:135960. https://doi.org/10.1016/j.neulet.2021.135960 Govender S, Todd NPM, Colebatch JG. Effects of posture on cerebellar evoked potentials (CEPs) following brief impulsive stimuli at the mastoid and trunk. Exp Brain Res. 2022; 240:1371–1385. https://doi.org/10.1007/s00221-022-06335-5 Todd NPM, Govender S, Colebatch JG. The human electrocerebellogram (ECeG) recorded non-invasively using scalp electrodes. Neurosci Lett. 2018a;682: 124–131. https://doi.org/10.1016/j.neulet.2018.06.012 Todd NPM, Govender S, Colebatch JG. Modulation of the human electro-cerebellogram (ECeG) during vestibular and optokinetic stimulation. Neurosci Lett. 2019;712: 134497. https://doi.org/10.1016/j.neulet.2019.134497 Eccles JC, Ito M, Szentagothai J. The cerebellum as a neuronal machine. Springer, Berlin; 1967. Govender S, Todd NPM, Colebatch JG. Mapping the vestibular cerebellar evoked potential (VsCEP) following air- and bone-conducted vestibular stimulation. Exp Brain Res. 2020; 238: 601–620. https://doi.org/10.1007/s00221-020-05733-x Todd NPM, Govender S, Colebatch JG. Non-invasive recording from the human cerebellum during a classical conditioning paradigm using the otolith-evoked blink reflex. Neurosci Lett. 2021a;765: 136270. https://doi.org/10.1016/j.neulet.2021.136270 Albus JS. A theory of cerebellar function. Math Biosci. 1971; 10: 25-61. https://doi.org/10.1016/0025-5564(71)90051-4 Jirenhed DA, Hesslow G. Are Purkinje cell pauses drivers of classically conditioned blink responses? Cerebellum. 2016; 15: 526–534. https://doi.org/10.1007/s12311-015-0722-4 Todd NPM, Govender S, Keller PE, Colebatch JG. Electrophysiological activity from over the cerebellum and cerebrum during eye blink conditioning in human subjects. Physiol Rep. 2023;11: e15642. https://doi.org/10.14814/phy2.15642 Gerwig M, Kolb FP, Timmann D. The involvement of the human cerebellum in eyeblink conditioning. Cerebellum. 2007; 6: 38– 57. https://doi.org/10.1080/14734220701225904 Rasmussen A, Jirenhed DA. Learning and timing of voluntary blink responses match eyeblink conditioning. Sci Rep. 2017;7: 3404. https://doi.org/10.1038/s41598-017-03343-2 Prochazka A, Clarac F, Leob GE, Rothwell JC, Wolpaw JR. What do reflex and voluntary mean? Modern views on an ancient debate. Exp Brain Res. 2000; 130: 417-432. Jirenhed DA, Rasmussen A, Johansson F, Hesslow G. Learned response sequences incerebellar Purkinje cells. Proc Natl Acad Sci USA. 2017; 114: 6127–6132. https://doi.org/10.1073/pnas.1621132114 Llinás RR. Cerebellar motor learning versus cerebellar motor timing: the climbing fibre story. J Physiol. 2011; 589 :3423–3432. https://doi.org/10.1113/jphysiol.2011.207464 Ivry RB, Keele SW. Timing functions of the cerebellum. J Cogn Neurosci. 1989; 1: 136–152. https://doi.org/10.1162/jocn.1989.1.2.136 Buzsáki G. Rhythms of the brain. Oxford University Press; 2006. Groth JD, Sahin M. High frequency synchrony in the cerebellar cortex during goal directed movements. Front Syst Neurosci. 2015; 9: 98. https://doi.org/10.3389/fnsys.2015.00098 Govender S, Dennis DL, Colebatch JG. Vestibular evoked myogenic potentials (VEMPs) evoked by air- and bone-conducted stimuli in vestibular neuritis. Clin Neurophysiol. 2015; 126: 2004–2013. https://doi.org/10.1016/j.clinph.2014.12.029 Teo JT, van de Warrenburg BP, Schneider SA, Rothwell JC, Bhatia KP. Neurophysiological evidence for cerebellar dysfunction in primary focal dystonia. J Neurol Neurosurg Psychiatry. 2009;80: 80–83. https://doi.org/10.1136/jnnp.2008.144626 Samuelsson JG, Sundaram P, Khan S, Sereno M I, Hämäläinen MS. Detectability of cerebellar activity with magnetoencephalography and electroencephalography. Hum Brain Mapp. 2020;41: 2357–2372. https://doi.org/10.1002/hbm.24951 Bosch TJ, Groth C, Eldridge TA, Gnimpieba EZ, Baugh LA, Singh A. Altered Cerebellar Oscillations in Parkinson's Disease Patients during Cognitive and Motor Tasks. Neurosci. 2021; 475: 185–196. https://doi.org/10.1016/j.neuroscience.2021.08.021 Fraisse P, Repp BH. Anticipation of rhythmic stimuli: Speed of establishment and precision of synchronization (1966). Psychomusicol: Music Mind Brain. 2012; 22: 84–93. https://doi.org/10.1037/a0028758 Keller PE, Novembre G, Hove MJ. Rhythm in joint action: psychological and neurophysiological mechanisms for real-time interpersonal coordination. Philos Trans R Soc Lond B Biol Sci. 2014; 369: 20130394. https://doi.org/10.1098/rstb.2013.0394 Repp BH. Sensorimotor synchronization: a review of the tapping literature. Psychon Bull Rev. 2005;12 : 969–992. https://doi.org/10.3758/bf03206433 Repp BH, Su YH. Sensorimotor synchronization: a review of recent research (2006-2012). Psychon Bull Rev. 2013;20: 403–452. https://doi.org/10.3758/s13423-012-0371-2 Novembre G, Knoblich G, Dunne L, Keller PE. Interpersonal synchrony enhanced through 20 Hz phase-coupled dual brain stimulation. Soc Cogn Affect Neurosci. 2017; 12: 662–670. https://doi.org/10.1093/scan/nsw172 Hove MJ, Balasubramaniam R, Keller PE. The time course of phase correction: a kinematic investigation of motor adjustment to timing perturbations during sensorimotor synchronization. J Exp Psychol Hum Percept Perform. 2014; 4: 2243–2251. https://doi.org/10.1037/a0037826 Mota IA, Lins OG. Bereitschaftspotentials preceding spontaneous and voluntary eyelid blinks in normal individuals. Clin Neurophysiol. 2017; 128: 100–105. https://doi.org/10.1016/j.clinph.2016.10.010 Walter WG, Cooper R, Aldridge VJ, McCallum WC, Winter AL. Contingent negative variation: an electric sign of sensorimotor association and expectancy in the human brain. Nature. 1964; 203: 380–384. https://doi.org/10.1038/203380a0 Shibasaki H, Barrett G, Halliday E, Halliday AM. Cortical potentials following voluntary and passive finger movements. Electroencephalogr Clin Neurophysiol. 1980; 50: 201–213. https://doi.org/10.1016/0013-4694(80)90147-9 Aramideh M, Ongerboer de Visser BW. Brainstem reflexes: electrodiagnostic techniques, physiology, normative data, and clinical applications. Muscle Nerve. 2002; 26: 14–30. https://doi.org/10.1002/mus.10120 Kheradmand A, Zee DS. Cerebellum and ocular motor control. Front Neurol. 2011; 2: 53. https://doi.org/10.3389/fneur.2011.00053 Hashimoto M, Ohtsuka K. Transcranial magnetic stimulation over the posterior cerebellum during visually guided saccades in man. Brain. 1995; 118: 1185–1193. https://doi.org/10.1093/brain/118.5.1185 Ryun S, Kim JS, Jeon E, Chung C K. Movement-related sensorimotor high-gamma activity mainly represents somatosensory feedback. Front Neurosci. 2017;11: 408. https://doi.org/10.3389/fnins.2017.00408 Jiang T, Liu S, Pellizzer G, Aydoseli A, Karamursel S, Sabanci PA, Sencer A, Gurses C, Ince NF. Characterization of hand clenching in human sensorimotor cortex using high-, and ultra-high frequency band modulations of electrocorticogram. Front Neurosci. 2018; 12: 110. https://doi.org/10.3389/fnins.2018.00110 Umeda T, Koizumi M, Katakai Y, Saito R, Seki K. Decoding of muscle activity from the sensorimotor cortex in freely behaving monkeys. Neuroimage. 2019;197: 512–526. https://doi.org/10.1016/j.neuroimage.2019.04.045 Green JT, Ivry RB, Woodruff-Pak DS. Timing in eyeblink classical conditioning and timed-interval tapping. Psychol Sci. 1999; 10 : 19–23. https://doi.org/10.1111/1467-9280.00100 De Zeeuw CI, Ten Brinke MM. Motor learning and the cerebellum. Cold Spring Harb Perspect Biol. 2015; 7: a021683. https://doi.org/10.1101/cshperspect.a021683 Llinás RR. The olivo-cerebellar system: a key to understanding the functional significance of intrinsic oscillatory brain properties [Review]. Front Neural Circuits. 2014;7. https://doi.org/10.3389/fncir.2013.00096 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2837073","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":193819802,"identity":"054f45e6-9985-4cf9-a2df-45d70b87a1ce","order_by":0,"name":"Rogers Kajabwangu","email":"","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rogers","middleName":"","lastName":"Kajabwangu","suffix":""},{"id":193819805,"identity":"c7d27aea-7f11-4e96-b7ca-09d9234aa13c","order_by":1,"name":"Verena Geissbüehler","email":"","orcid":"","institution":"St. Claraspital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Verena","middleName":"","lastName":"Geissbüehler","suffix":""},{"id":193819806,"identity":"badd025b-b87a-45de-998c-256240570624","order_by":2,"name":"Leevan Tibaijuka","email":"","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Leevan","middleName":"","lastName":"Tibaijuka","suffix":""},{"id":193819808,"identity":"ea9ce320-9a83-48e8-9721-a0d861ae43dc","order_by":3,"name":"Onesmus Byamukama","email":"","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Onesmus","middleName":"","lastName":"Byamukama","suffix":""},{"id":193819809,"identity":"7e30fa2f-8806-4c82-95bc-0ee54e7f581d","order_by":4,"name":"Paul Kato Kalyebara","email":"","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Paul","middleName":"Kato","lastName":"Kalyebara","suffix":""},{"id":193819810,"identity":"c101ed94-5a41-4b4d-a163-d332b9a80264","order_by":5,"name":"Brenda Ainomugisha","email":"","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Brenda","middleName":"","lastName":"Ainomugisha","suffix":""},{"id":193819811,"identity":"4d05d571-6783-439f-8c6c-0f99a58052aa","order_by":6,"name":"Thomas Margolis","email":"","orcid":"","institution":"University of California, Los Angeles","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Margolis","suffix":""},{"id":193819812,"identity":"3b5bbf43-3100-4e75-a892-8a2430ad85c1","order_by":7,"name":"Henry Lukabwe","email":"","orcid":"","institution":"Kisiizi Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Henry","middleName":"","lastName":"Lukabwe","suffix":""},{"id":193819813,"identity":"8c243a8b-476f-495e-b656-3c74099aa759","order_by":8,"name":"Joseph Njagi","email":"","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"","lastName":"Njagi","suffix":""},{"id":193819814,"identity":"3db57316-16fa-4a73-8939-ec29bac1cba4","order_by":9,"name":"Henry Mark Lugobe","email":"","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Henry","middleName":"Mark","lastName":"Lugobe","suffix":""},{"id":193819815,"identity":"9415e3cd-5ce8-4020-b36b-0ff21775fe6c","order_by":10,"name":"Musa Kayondo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYDACHjDJzMBPuhbJBiB1gCQtBgeI1aLbc/iZxMcd1nLG184Yf/7AYCfPIJF+Aa8Ws7NtZpIzz6Qbm93OMZM4wJBs2CCRU4Bfy3kGM2netsOJ24BagA5jTmCQyEkgoIX9G1jL5tk5xh8OMNQToeVsD8SWDdI5BkCHHQZqST+AX8uZM8WWM9vSjSVup5VJnDE4btjG8wavDqCW9I03PrZZy/HPTt78oaKiWp6fPf0Bfj0MDCwSCLYBAwMbA48BIS3MH9AE2AnaMgpGwSgYBSMLAABkGETDROseCwAAAABJRU5ErkJggg==","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Musa","middleName":"","lastName":"Kayondo","suffix":""}],"badges":[],"createdAt":"2023-04-19 13:59:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2837073/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2837073/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":36226227,"identity":"89e40d76-a831-4ff0-a3ec-d199cacf456f","added_by":"auto","created_at":"2023-04-24 14:51:01","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":25629,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOutcomes of surgery\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2837073/v1/5448f5aadc634ed870ffb110.jpg"},{"id":42914991,"identity":"ee802cfb-3010-4add-b19c-791538141341","added_by":"auto","created_at":"2023-09-11 06:22:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":456519,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2837073/v1/394866ba-bd71-4be5-acb1-54859b88c3f9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Diagnosis and management of ureterovaginal fistula in a resource limited setting: a 12 years’ experience at four fistula surgery centers in Uganda","fulltext":[{"header":"Background","content":"\u003cp\u003eA ureterovaginal fistula is an abnormal communication between the ureter and the vagina that often results from unidentified accidental injury to the ureter during pelvic surgery(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The ureter is susceptible to injury during pelvic surgery because of its close proximity to pelvic structures such as the uterus, cervix, broad ligament and urinary bladder (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Furthermore, anatomical changes during pregnancy and pelvic pathologies like fibroids, ovarian masses, endometriosis, pelvic inflammatory disease, and adhesions from previous abdominal surgery lead to alteration in the course of the pelvic ureter making it more susceptible to injury especially if the surgeon has limited skills (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Mechanisms of ureteric injuries include; contusion, kinking, devascularisation, laceration, suture-ligation, and circumferential transection(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUreterovaginal fistula is one of the sequelae of ureteric injury, the others being ureteric obstruction, loss of kidney function and death(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Ureterovaginal fistulas often present with urinary incontinence which has a lot of devastating effects on the quality of life of the affected women in form of mental, social, marital and financial repercussions(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003eIn high-income countries, ureteral injury is more common during gynecological surgery than obstetric procedures (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Open gynecological surgery procedures account for 0.5 to 1.5% of the injuries while laparoscopic surgeries account for 0.5 to 14% (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, this seems to be different in the low- and middle-income countries where most of the injuries follow emergency obstetric surgeries with cesarean section accounting for more than 50% of cases while hysterectomy and uterine repair for ruptured uterus account for about 27% (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Efforts to make cesarean section and other emergency operations more accessible in these countries have been fairly successful but have not been followed with strategies to ensure that the surgeries are safe (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). There are still surgical training challenges coupled with human resource shortages possibly explaining the surgical errors that lead to these injuries (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe diagnosis and management of ureterovaginal fistula in low resource settings is a challenge. The standard diagnosis usually involves a combination of history of urine incontinence following a pelvic surgery, dual-dye test, intravenous pyelogram, cystoscopy and CT urogram (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, these advanced tests are not readily available and not affordable in the low-income countries which calls for the use of low cost but equally sensitive diagnostic methods to make a diagnosis.\u003c/p\u003e \u003cp\u003eThe treatment of ureterovaginal fistula has evolved drastically over the past 50 years from open ureteral reimplantation to newer effective and less invasive procedures like endoscopic ureteral stenting (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However, these newer less invasive techniques are not readily available to women in the low-income countries.\u003c/p\u003e \u003cp\u003eThere is paucity of data on the diagnosis, management and outcomes of ureterovaginal fistula yet this evidence is important for advocacy in scaling up the prevention and treatment for this devastating condition in the resource limited settings where women with fistula face various challenges in accessing care (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTherefore, in this study, we aimed to describe the aetiology, diagnosis, management and outcomes of ureterovaginal fistula at four rural fistula surgery centres in Uganda.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and study setting\u003c/h2\u003e \u003cp\u003eThis was a retrospective chart review of women who had fistula surgery at four rural fistula repair centers in Uganda from 2010 to 2021. The centers included; Mbarara Regional Referral Hospital in Southwestern Uganda, Lira Regional Referral Hospital in Northern Uganda, Kitovu Mission hospital in Central Uganda and Bwindi community Hospital in Western Uganda. The surgical team was led by fistula surgeons from Mbarara University of Science and Technology.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy population and recruitment\u003c/h2\u003e \u003cp\u003e We reviewed all files of women that were managed for genitourinary fistula at the four centers between 2010 and 2021. From these, we identified all those that had a diagnosis of ureterovaginal fistula for data collection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDiagnosis of ureterovaginal fistula\u003c/h2\u003e \u003cp\u003eUreterovaginal fistula was diagnosed in women who had all the following:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLeakage of urine per vagina\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAny pelvic surgery preceding the urine leakage: cesarean section, uterine repair for ruptured uterus, obstetric hysterectomy, and elective hysterectomy for gynecological conditions.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eUrine pooling in the vagina with no obvious defect along the entire anterior vaginal wall on speculum examination\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eA negative methylene blue dye test after backfilling the bladder with a minimum of 120 mls of diluted methylene blue\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eA three-swab test (3 cotton swabs placed at different levels in the vagina) after the methylene blue test where none of the swabs was stained with methylene blue but all wet with urine.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe diagnosis of ureterovaginal fistula was then confirmed by intraoperative findings of absence of spillage of urine from the affected ureteral orifice on cystotomy. The standard confirmatory diagnostic tests like intravenous pyelogram, CT pyelogram and cystoscopy were not done because they are neither available nor affordable.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSurgical technique\u003c/h2\u003e \u003cp\u003eThe women underwent surgical repair of ureterovaginal fistula after obtaining informed consent. All the women had a laparotomy with exploration of the ureteric bed on both sides to identify the affected ureter. The affected side was usually the one where the ureter was dilated. A cystotomy with exploration of the trigone and visualization of the ureteral orifices was done to finally confirm the diagnosis of ureterovaginal fistula and the side affected. This was done after giving the patient an intravenous bolus of 10mg of Frusemide. The affected ureter was the one which wasn\u0026rsquo;t spilling urine through its ureteric orifice.\u003c/p\u003e \u003cp\u003eAfter identifying the affected ureter, it was mobilized from its peritoneal and broad ligament attachments up to the point of injury. The bladder was also mobilized from its pelvic attachments. This was done to minimize tension during re-implantation. The main procedure that was done was a ureteroneocystostomy (implantation of the injured ureter into the bladder) with absorbable sutures. In cases where the ureter had been injured at a relatively high level (above the pelvic brim) resulting in significant loss of ureteral length, a Boari flap was performed. In all cases, a ureteric stent was inserted and attached to the Foley catheter. The bladder was then closed in 2 layers with absorbable suture. Both the urethral stent and Foley catheter were removed after 2weeks. The women stayed in hospital under observation until removal of the Foley catheter. All surgeries were performed by a team of urogynecologists/ fistula surgeons, as part of routine management of genitourinary fistula in these fistula repair centers. The women were discharged and reviewed after two months. The outcome of surgery was determined at 2 months after surgery. This was either successful fistula closure (patient continent of urine at 2 months post-surgery) or unsuccessful fistula closure (patient still leaking urine at 2 months post-surgery). A speculum exam with participant in lithotomy was done to confirm absence or presence of urine leakage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eA data capture tool was used to collect information on baseline characteristics of the study participants, perioperative findings and outcome of surgery.\u003c/p\u003e \u003cp\u003eThe baseline characteristics included:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSociodemographic characteristics (age, occupation, parity at fistula development and marital status).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eClinical characteristics (duration with incontinence, antecedent surgery, level of the health facility where the antecedent surgery was performed, and cadre of the surgeon that performed the antecedent surgery). The level of health facility was classified according to Uganda Ministry of Health system into; Referral hospital including National and Regional (one with specialists like obstetricians), general hospital (no specialists but surgeries are done by a medical doctor with a first degree otherwise called a medical officer), and a health center IV which is the lowest level facility in the Ugandan health system where a caesarean section can be performed by a medical officer. The cadre of surgeon that performed the antecedent surgery was classified into; intern doctor (one who has just completed medical school and undergoing one year of clinical apprenticeship), medical officer (a doctor who has completed internship), resident (a doctor undergoing speciality training in obstetrics and gynecology) and specialist (one who has graduated from residency).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe perioperative information that was collected included:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDiagnostic method used (clinical evaluation using history, speculum examination, methylene blue test and 3 swab-test).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eUreter affected (Right, left or bilateral)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSite of ureteric injury (within the pelvis or above the pelvic brim)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eType of surgery performed (ureteral re-implantation alone, ureteral re-implantation with a Boari flap)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eComplications of surgery (intraoperative hemorrhage that required transfusion and wound infection that required daily dressing)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe outcome of surgery was determined at 2 months after surgery. This was either successful fistula closure (patient continent of urine at 2 months post-surgery) or unsuccessful fistula closure (patient still leaking urine at 2 months post-surgery).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were cleaned, entered in Excel and exported to Stata version 15 for analysis. Categorical data were presented as frequencies. Descriptive statistics were used to present the data. The proportion of successful fistula repair with continence was determined by dividing the number of women who were continent of urine at 2 months post-surgery by the total number who came for the follow-up visit and expressed as a percentage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003es were obtained from the Mbarara University of Science and Technology (MUST) Research Ethics Committee and the Uganda National Council of Science and Technology number (UNCST) number HS368ES.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDemographic and clinical characteristics of the participants\u003c/h2\u003e \u003cp\u003eThe demographic and clinical characteristics of the participants are shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A total of 477 genitourinary fistulae were managed during the study period. Of these, 47 (9.9%) had ureterovaginal fistulae, vesicovaginal fistulae (146, 30.6%), vesicocervical fistulae (72, 15.1%), urethrovaginal fistulae (181, 37.9%), and vaginal vault (31, 6.5%). The mean age at diagnosis of the women with ureterovaginal fistula was 31.9 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;11.8) years. Majority were of parity\u0026thinsp;\u0026gt;\u0026thinsp;4 (n\u0026thinsp;=\u0026thinsp;25, 53.2%, range 1\u0026ndash;7) and had been with urine incontinence for more than a year at the time of diagnosis (n\u0026thinsp;=\u0026thinsp;17, 36.2%). Most fistulae (n\u0026thinsp;=\u0026thinsp;33, 70.7%) developed after a caesarean section while 9 (19.5%) occurred after a hysterectomy for obstetric indications mainly ruptured uterus. Most of these antecedent surgeries (n\u0026thinsp;=\u0026thinsp;22, 46.8%) were performed at general hospitals, and by medical officers (n\u0026thinsp;=\u0026thinsp;32, 68.1%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and clinical characteristics of the patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;25yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25-35yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;35years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorced/separated/widowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eParity at diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eDuration of incontinence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 months \u0026minus;\u0026thinsp;1year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;1year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAntecedent surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCaesarean section\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObstetric Hysterectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHysterectomy for gynaecological indications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eLevel of facility for antecedent surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReferral hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth centre IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eCadre of surgeon that performed antecedent surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntern doctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical Officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpecialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePerioperative characteristics of the participants\u003c/h2\u003e \u003cp\u003eThe perioperative characteristics of the patients are shown in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. For all the participants, the step-wise clinical assessment was accurate in diagnosing ureterovaginal fistula. At surgery, the left ureter was the most affected (n\u0026thinsp;=\u0026thinsp;24, 51.1%). Most injuries to the ureter (n\u0026thinsp;=\u0026thinsp;45, 95.6%) occurred within the pelvis while in 2 women it occurred above the pelvic brim. The commonest fistula repair surgery done was ureteric reimplantation alone 45(95.7%) while in 2(4.3%) patients, a Boari flap was performed due to a short ureter. The surgical complications encountered included; intraoperative hemorrhage that required blood transfusion in 5 (11%) of the women and post-operative wound infection (n\u0026thinsp;=\u0026thinsp;5, 11%). The women with wound infection all improved following daily dressing and antibiotic treatment.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative characteristics of the participants (N\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAffected ureter\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eLevel of injury\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbove pelvic brim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBelow pelvic brim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e95.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSurgery performed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUreteric re-implantation alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e95.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUreteric re-implantation with Boari flap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e*\u003cb\u003eSurgical complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e85.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntra-operative hemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eNote: *\u003c/b\u003e The number of complications exceeds the number of patients because 3 patients had more than one complication.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes of surgery\u003c/h2\u003e \u003cp\u003eOut of the 47 women managed for ureterovaginal fistula, 45 (95.7%) had successful closure of the fistula with continence. This is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study set out to describe the magnitude, etiology, diagnosis and management of iatrogenic ureterovaginal fistula in a resource limited setting. We found that ureterovaginal fistula is common, occurring in 1 in 10 women with genitourinary fistula. Ureterovaginal fistula commonly followed obstetric operations especially cesarean section performed by lower cadre surgeons (medical officers). A simple step-wise clinical evaluation combined with intraoperative findings is effective in diagnosing ureterovaginal fistula and locating the affected side. The success rate of open transvesical ureteral reimplantation in this setting is 95.7%.\u003c/p\u003e \u003cp\u003eThe magnitude of 10% is similar to that found by Shaw and colleagues in a study done at 3 Cleveland clinics in the United states of America (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). However, this proportion is higher than the 4.6% (273/5,959) found in a review done in 11 African countries by Raassen and colleagues (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). As reported in this review, iatrogenic ureterovaginal fistulas were likely to occur in surgeries done by lower cadres especially medical officers. This is not surprising because medical officers are usually recent graduates of medicine with very little surgical experience who get posted to general hospitals and health center IVs to work independently. Since most of the emergency obstetric surgeries especially Cesarean section in Uganda are done by medical officers (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), it explains the high proportion of iatrogenic ureterovaginal fistula in this study. Further to this, the cesarean delivery rates in Uganda have increased from 8.5% in 2012 to 11% in 2016 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) but these haven’t been matched by improvement in human resource to provide safe cesarean section. Surgical training challenges coupled with human resource shortages still exist possibly explaining the surgical errors that lead to these injuries(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003eIn agreement with previous studies in the low income countries, most of the ureterovaginal fistulae in our study followed injuries sustained during obstetric surgeries particularly cesarean section (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) as opposed to studies done in high income countries where majority are due to gynecological surgeries (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Like in other low income countries, obstructed labour and repeat caesarean section are the commonest indications for cesarean section in Uganda (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). In prolonged obstructed labour, the fetal head gets deeply impacted in the maternal pelvis and lateral extension of a low transverse uterine incision may occur during delivery resulting into excessive hemorrhage. Ureteric injury in this case usually results from desperate attempts to achieve hemostasis without proper identification of the ureter (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Scar tissue and adhesions from prior cesarean section may distort the pelvic anatomy and alter the course of the ureter making it more likely to be injured in repeat cesarean sections (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe left ureter was affected more compared to the right, as has been found in several other studies (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). This is because the left ureter is slightly nearer to the cervix compared to the right and is also obscured by the sigmoid mesocolon (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, the diagnosis of ureterovaginal fistula was accurately made from a simple clinical evaluation which involved a combination of: history of urine incontinence following a pelvic surgery, absence of visible defect on speculum examination, negative methylene blue dye test, and 3-swab test. A similar method was used in a rural hospital with limited resources in Nigeria (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). This is in contrast to complex and expensive methods used in the high-income countries that involve the use of dual-dye test, intravenous pyelogram, cystoscopy and CT urogram on top of the clinical evaluation (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). However, these investigative techniques are neither available nor affordable in the low-income countries (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). This therefore justifies the need to employ simple and cheap methods that are equally sensitive in diagnosing ureterovaginal fistula in the resource limited countries. In contrast to Randawa et al, we did not do an abdominal ultrasound to evaluate the ureter and kidneys for hydroureter and or hydronephrosis in order to determine the affected side (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). This is because the ultrasound may be misleading since absence of hydronephrosis does not necessarily imply that the particular side is not affected especially if the leakage from the injured ureter occurred immediately after the obstruction or if the ureter was just transected (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). We therefore identified the affected side intraoperatively by opening the bladder and visualizing the ureteric orifices for urine spillage.\u003c/p\u003e \u003cp\u003eOur surgical technique of laparotomy with ureteroneocystostomy/ ureteral reimplantation was effective in achieving continence. This is not different from findings in other similar studies (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), implying that this method can effectively be used in the repair of ureterovaginal fistulae in properly selected patients especially in distal ureteral injuries. In more proximal injuries where the ureteral length is inadequate, a Boari flap can be used to ease tension on the anastomosis between ureter and bladder (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). However, newer and less invasive techniques of managing ureterovaginal fistula employed in the high-income countries like endoscopic ureteral stenting were not used in this study. This is because these methods are not readily available and surgeons with skills to perform them are limited.\u003c/p\u003e "},{"header":"Conclusions","content":"\u003cp\u003eIatrogenic uretero-vaginal fistulae are common in our setting being detected in 1 in 10 women with genitourinary fistula and most follow caesarean section done at lower health facilities by medical officers. Simple but careful step-wise clinical evaluation is effective in diagnosing ureterovaginal fistula where other investigative techniques aren’t available. Open transvesical ureteral reimplantation is highly effective in treating ureterovaginal fistula in resource limited settings where use of newer less invasive procedures may not be possible. We also recommend that medical doctors conducting caesarean section and other pelvic surgeries should receive regular training in essential surgical skills to reduce on the burden of this devastating condition.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCT: Computed tomography\u003c/p\u003e\n\u003cp\u003eMRRH: Mbarara Regional Referral Hospital\u003c/p\u003e\n\u003cp\u003eMUST: Mbarara University of Science and Technology\u003c/p\u003e\n\u003cp\u003eUNCST: Uganda National Council of Science and Technology\u003c/p\u003e\n\u003cp\u003eUNFPA: United Nations Fund for Population Activities\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate:\u0026nbsp;\u003c/strong\u003eethical approvals were obtained from the Mbarara University of science and Technology (MUST) Research Ethics committee and the Uganda National Council of Science and Technology (UNCST) number HS368ES. Written consent was obtained from all the patients prior to surgery. All the experiment protocol for involving humans was in accordance to guidelines of national/ international/ institutional or declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publication:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: We received funding from Else Kroner Fresenius Foundation in Germany, grant number 2018_HA148, to conduct this study. The funders had no role in the study design, data collection, data analysis and interpretation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contribution\u003c/strong\u003e:\u0026nbsp;RK and KM conceived the idea, supervised data collection and wrote the first draft. \u0026nbsp;VG,\u0026nbsp;LT, OB PK, BA, TM, PK, HL, JN and LHM\u0026nbsp;participated in data analysis and interpretation. \u0026nbsp;All authors read, revised and approved the final draft of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors are grateful to the staff at the four fistula surgery sites for the assistance given during the data collection. We also thank Medlend medical missions, Medicine for humanity, Uganda Ministry of Health, UNFPA and Else Kr\u0026ouml;ner-Fresenius Foundation for funding the fistula surgery camps.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAndersen LM, Jerbi K, Dalal SS. Can EEG and MEG detect signals from the human cerebellum? Neuroimage. 2020; 215: 116817. https://doi.org/10.1016/j.neuroimage.2020.116817\u003c/li\u003e\n\u003cli\u003eTodd NPM, Rosengren SM, Colebatch JG. Ocular vestibular evoked myogenic potentials (OVEMPs) produced by impulsive transmastoid accelerations. Clin Neurophysiol. 2008a;119: 1638\u0026ndash;1651. https://doi.org/10.1016/j.clinph.2008.03.009\u003c/li\u003e\n\u003cli\u003eRosengren SM, Todd NP, Colebatch JG. Vestibular evoked myogenic potentials evoked by brief interaural head acceleration: properties and possible origin. J Appl Physiol. 2009;107: 841\u0026ndash;852. https://doi.org/10.1152/japplphysiol.00296.2009\u003c/li\u003e\n\u003cli\u003eTodd NPM, Govender S, Colebatch JG. The inion response revisited: evidence for a possible cerebellar contribution to vestibular-evoked potentials produced by air-conducted sound stimulation. J Neurophysiol. 2017;117: 1000\u0026ndash;1013. https://doi.org/10.1152/jn.00545.2016\u003c/li\u003e\n\u003cli\u003eTodd NPM, Govender S, Colebatch JG. Vestibular cerebellar evoked potentials in humans and their modulation during optokinetic stimulation. J Neurophysiol. 2018b;120: 3099\u0026ndash;3109. https://doi.org/10.1152/jn.00502.2018\u003c/li\u003e\n\u003cli\u003eTodd NPM, Rosengren SM, Colebatch JG. A source analysis of short-latency vestibular evoked potentials produced by air- and bone-conducted sound. Clin Neurophysiol. 2008b;119:1881\u0026ndash;1894. https://doi.org/10.1016/j.clinph.2008.03.027\u003c/li\u003e\n\u003cli\u003eTodd NPM, Paillard AC, Kluk K, Whittle E, Colebatch JG. Source analysis of short and long latency vestibular-evoked potentials (VsEPs) produced by left vs. right ear air-conducted 500 Hz tone pips. Hearing Res. 2014;312: 91\u0026ndash;102. https://doi.org/10.1016/j.heares.2014.03.006\u003c/li\u003e\n\u003cli\u003eTodd NPM, Govender S, Colebatch JG. Vestibular-dependent inter-stimulus interval effects on sound evoked potentials of central origin. Hear Res. 2016; 341, 190-201.\u003c/li\u003e\n\u003cli\u003eTodd NPM, Govender S, Lemieux L, Colebatch JG. Source analyses of axial and vestibular evoked potentials associated with brainstem-spinal reflexes show cerebellar and cortical contributions. Neurosci Lett. 2021b;757:135960. https://doi.org/10.1016/j.neulet.2021.135960\u003c/li\u003e\n\u003cli\u003eGovender S, Todd NPM, Colebatch JG. Effects of posture on cerebellar evoked potentials (CEPs) following brief impulsive stimuli at the mastoid and trunk. Exp Brain Res. 2022; 240:1371\u0026ndash;1385. https://doi.org/10.1007/s00221-022-06335-5\u003c/li\u003e\n\u003cli\u003eTodd NPM, Govender S, Colebatch JG. The human electrocerebellogram (ECeG) recorded non-invasively using scalp electrodes. Neurosci Lett. 2018a;682: 124\u0026ndash;131. https://doi.org/10.1016/j.neulet.2018.06.012\u003c/li\u003e\n\u003cli\u003eTodd NPM, Govender S, Colebatch JG. Modulation of the human electro-cerebellogram (ECeG) during vestibular and optokinetic stimulation. Neurosci Lett. 2019;712: 134497. https://doi.org/10.1016/j.neulet.2019.134497\u003c/li\u003e\n\u003cli\u003eEccles JC, Ito M, Szentagothai J. The cerebellum as a neuronal machine. Springer, Berlin; 1967.\u003c/li\u003e\n\u003cli\u003eGovender S, Todd NPM, Colebatch JG. Mapping the vestibular cerebellar evoked potential (VsCEP) following air- and bone-conducted vestibular stimulation. Exp Brain Res. 2020; 238: 601\u0026ndash;620. https://doi.org/10.1007/s00221-020-05733-x\u003c/li\u003e\n\u003cli\u003eTodd NPM, Govender S, Colebatch JG. Non-invasive recording from the human cerebellum during a classical conditioning paradigm using the otolith-evoked blink reflex. Neurosci Lett. 2021a;765: 136270. https://doi.org/10.1016/j.neulet.2021.136270\u003c/li\u003e\n\u003cli\u003eAlbus JS. A theory of cerebellar function. Math Biosci. 1971;\u003cem\u003e \u003c/em\u003e10: 25-61. https://doi.org/10.1016/0025-5564(71)90051-4\u003c/li\u003e\n\u003cli\u003eJirenhed DA, Hesslow G. Are Purkinje cell pauses drivers of classically conditioned blink responses? Cerebellum. 2016; 15:\u003cem\u003e \u003c/em\u003e526\u0026ndash;534. https://doi.org/10.1007/s12311-015-0722-4\u003c/li\u003e\n\u003cli\u003eTodd NPM, Govender S, Keller PE, Colebatch JG. Electrophysiological activity from over the cerebellum and cerebrum during eye blink conditioning in human subjects. Physiol Rep. 2023;11: e15642. https://doi.org/10.14814/phy2.15642\u003c/li\u003e\n\u003cli\u003eGerwig M, Kolb FP, Timmann D. The involvement of the human cerebellum in eyeblink conditioning. Cerebellum. 2007; 6: 38\u0026ndash; 57. https://doi.org/10.1080/14734220701225904\u003c/li\u003e\n\u003cli\u003eRasmussen A, Jirenhed DA. Learning and timing of voluntary blink responses match eyeblink conditioning. Sci Rep. 2017;7: 3404. https://doi.org/10.1038/s41598-017-03343-2\u003c/li\u003e\n\u003cli\u003eProchazka A, Clarac F, Leob GE, Rothwell JC, Wolpaw JR. What do reflex and voluntary mean? Modern views on an ancient debate. Exp Brain Res. 2000; 130: 417-432.\u003c/li\u003e\n\u003cli\u003eJirenhed DA, Rasmussen A, Johansson F, Hesslow G. Learned response sequences incerebellar Purkinje cells. Proc Natl Acad Sci USA. 2017; 114: 6127\u0026ndash;6132. https://doi.org/10.1073/pnas.1621132114\u003c/li\u003e\n\u003cli\u003eLlin\u0026aacute;s RR. Cerebellar motor learning versus cerebellar motor timing: the climbing fibre story. J Physiol. 2011; 589\u003cem\u003e \u003c/em\u003e:3423\u0026ndash;3432. https://doi.org/10.1113/jphysiol.2011.207464\u003c/li\u003e\n\u003cli\u003eIvry RB, Keele SW. Timing functions of the cerebellum. J Cogn Neurosci. 1989; 1: 136\u0026ndash;152. https://doi.org/10.1162/jocn.1989.1.2.136\u003c/li\u003e\n\u003cli\u003eBuzs\u0026aacute;ki G. \u003cem\u003eRhythms of the brain.\u003c/em\u003e Oxford University Press; 2006.\u003c/li\u003e\n\u003cli\u003eGroth JD, Sahin M. High frequency synchrony in the cerebellar cortex during goal directed movements. Front Syst Neurosci. 2015; 9: 98. https://doi.org/10.3389/fnsys.2015.00098\u003c/li\u003e\n\u003cli\u003eGovender S, Dennis DL, Colebatch JG. Vestibular evoked myogenic potentials (VEMPs) evoked by air- and bone-conducted stimuli in vestibular neuritis. Clin Neurophysiol. 2015; 126: 2004\u0026ndash;2013. https://doi.org/10.1016/j.clinph.2014.12.029\u003c/li\u003e\n\u003cli\u003eTeo JT, van de Warrenburg BP, Schneider SA, Rothwell JC, Bhatia KP. Neurophysiological evidence for cerebellar dysfunction in primary focal dystonia. J \u003cem\u003e \u003c/em\u003eNeurol Neurosurg Psychiatry. 2009;80: 80\u0026ndash;83. https://doi.org/10.1136/jnnp.2008.144626\u003c/li\u003e\n\u003cli\u003eSamuelsson JG, Sundaram P, Khan S, Sereno M I, H\u0026auml;m\u0026auml;l\u0026auml;inen MS. Detectability of cerebellar activity with magnetoencephalography and electroencephalography. Hum Brain Mapp. 2020;41: 2357\u0026ndash;2372. https://doi.org/10.1002/hbm.24951\u003c/li\u003e\n\u003cli\u003eBosch TJ, Groth C, Eldridge TA, Gnimpieba EZ, Baugh LA, Singh A. Altered Cerebellar Oscillations in Parkinson\u0026apos;s Disease Patients during Cognitive and Motor Tasks. Neurosci. 2021; 475: 185\u0026ndash;196. https://doi.org/10.1016/j.neuroscience.2021.08.021\u003c/li\u003e\n\u003cli\u003eFraisse P, Repp BH. Anticipation of rhythmic stimuli: Speed of establishment and precision of synchronization (1966). Psychomusicol: Music Mind Brain. \u003cem\u003e \u003c/em\u003e2012; 22: 84\u0026ndash;93. https://doi.org/10.1037/a0028758\u003c/li\u003e\n\u003cli\u003eKeller PE, Novembre G, Hove MJ. Rhythm in joint action: psychological and neurophysiological mechanisms for real-time interpersonal coordination. Philos Trans R Soc Lond B Biol Sci. 2014; 369: 20130394. https://doi.org/10.1098/rstb.2013.0394\u003c/li\u003e\n\u003cli\u003eRepp BH. Sensorimotor synchronization: a review of the tapping literature. Psychon Bull Rev. 2005;12\u003cem\u003e \u003c/em\u003e: 969\u0026ndash;992. https://doi.org/10.3758/bf03206433\u003c/li\u003e\n\u003cli\u003eRepp BH, Su YH. Sensorimotor synchronization: a review of recent research (2006-2012). Psychon Bull Rev. 2013;20:\u003cem\u003e \u003c/em\u003e 403\u0026ndash;452. https://doi.org/10.3758/s13423-012-0371-2\u003c/li\u003e\n\u003cli\u003eNovembre G, Knoblich G, Dunne L, Keller PE. Interpersonal synchrony enhanced through 20 Hz phase-coupled dual brain stimulation. Soc Cogn Affect Neurosci. 2017; 12:\u003cem\u003e \u003c/em\u003e662\u0026ndash;670. https://doi.org/10.1093/scan/nsw172\u003c/li\u003e\n\u003cli\u003eHove MJ, Balasubramaniam R, Keller PE. The time course of phase correction: a kinematic investigation of motor adjustment to timing perturbations during sensorimotor synchronization. J Exp Psychol Hum Percept Perform. 2014; 4: 2243\u0026ndash;2251. https://doi.org/10.1037/a0037826\u003c/li\u003e\n\u003cli\u003eMota IA, Lins OG. Bereitschaftspotentials preceding spontaneous and voluntary eyelid blinks in normal individuals. Clin Neurophysiol. 2017; 128: 100\u0026ndash;105. https://doi.org/10.1016/j.clinph.2016.10.010\u003c/li\u003e\n\u003cli\u003eWalter WG, Cooper R, Aldridge VJ, McCallum WC, Winter AL. Contingent negative variation: an electric sign of sensorimotor association and expectancy in the human brain. Nature. 1964; 203: 380\u0026ndash;384. https://doi.org/10.1038/203380a0\u003c/li\u003e\n\u003cli\u003eShibasaki H, Barrett G, Halliday E, Halliday AM. Cortical potentials following voluntary and passive finger movements. Electroencephalogr Clin Neurophysiol. 1980; 50: 201\u0026ndash;213. https://doi.org/10.1016/0013-4694(80)90147-9\u003c/li\u003e\n\u003cli\u003eAramideh M, Ongerboer de Visser BW. Brainstem reflexes: electrodiagnostic techniques, physiology, normative data, and clinical applications. Muscle Nerve. 2002; 26: 14\u0026ndash;30. https://doi.org/10.1002/mus.10120\u003c/li\u003e\n\u003cli\u003eKheradmand A, Zee DS. Cerebellum and ocular motor control. Front Neurol. 2011; 2: 53. https://doi.org/10.3389/fneur.2011.00053\u003c/li\u003e\n\u003cli\u003eHashimoto M, Ohtsuka K. Transcranial magnetic stimulation over the posterior cerebellum during visually guided saccades in man. Brain. 1995; 118: 1185\u0026ndash;1193. https://doi.org/10.1093/brain/118.5.1185\u003c/li\u003e\n\u003cli\u003eRyun S, Kim JS, Jeon E, Chung C K. Movement-related sensorimotor high-gamma activity mainly represents somatosensory feedback. Front Neurosci. 2017;11: 408. https://doi.org/10.3389/fnins.2017.00408\u003c/li\u003e\n\u003cli\u003eJiang T, Liu S, Pellizzer G, Aydoseli A, Karamursel S, Sabanci PA, Sencer A, Gurses C, Ince NF. Characterization of hand clenching in human sensorimotor cortex using high-, and ultra-high frequency band modulations of electrocorticogram. Front Neurosci. 2018; 12: 110. https://doi.org/10.3389/fnins.2018.00110\u003c/li\u003e\n\u003cli\u003eUmeda T, Koizumi M, Katakai Y, Saito R, Seki K. Decoding of muscle activity from the sensorimotor cortex in freely behaving monkeys. Neuroimage. 2019;197: 512\u0026ndash;526. https://doi.org/10.1016/j.neuroimage.2019.04.045\u003c/li\u003e\n\u003cli\u003eGreen JT, Ivry RB, Woodruff-Pak DS. Timing in eyeblink classical conditioning and timed-interval tapping. \u003cem\u003ePsychol Sci. \u003c/em\u003e1999; \u003cem\u003e10\u003c/em\u003e: 19\u0026ndash;23. https://doi.org/10.1111/1467-9280.00100\u003c/li\u003e\n\u003cli\u003eDe Zeeuw CI, Ten Brinke MM. Motor learning and the cerebellum. Cold Spring\u003cem\u003e \u003c/em\u003eHarb Perspect Biol. \u003cem\u003e \u003c/em\u003e2015; 7: a021683. https://doi.org/10.1101/cshperspect.a021683\u003c/li\u003e\n\u003cli\u003eLlin\u0026aacute;s RR. The olivo-cerebellar system: a key to understanding the functional significance of intrinsic oscillatory brain properties [Review]. Front Neural Circuits. 2014;7. https://doi.org/10.3389/fncir.2013.00096\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ureterovaginal fistula, ureteral injury, ureteral reimplantation, Resource limited setting","lastPublishedDoi":"10.21203/rs.3.rs-2837073/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2837073/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Ureterovaginal fistulae usually follow iatrogenic injury to the ureter during pelvic surgery. This manifests as urine incontinence and results in serious psychosocial effects to the women. Ureterovaginal fistulae unlike vesicovaginal fistulae present challenges in diagnosis and management especially in resource constrained settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To describe the magnitude, aetiology, diagnosis, management and outcomes of ureterovaginal fistula at four fistula surgery centres in Uganda over a twelve-year period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A retrospective review of charts for women who had fistula repair at four regional fistula repair centres in Uganda from 2010 to 2021 was conducted. The diagnosis of ureterovaginal fistula was made clinically using a combination of a history of leakage of urine through the vagina following a pelvic surgery, absence of visible anterior vaginal wall defect on speculum examination, a negative methylene blue dye test, and a three-swab test. All women were managed using open transvesical ureteral reimplantation with or without Boari flap. A ureteral stent and Foley catheter were left in situ for 2 weeks. The outcome of surgery (successful fistula repair with urine continence) was determined at 2 months post-surgery. This was confirmed through a vaginal speculum exam.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Overall, there were 477 women who were managed for genito-urinary fistulae during the study period. Approximately 1 in every 10 women with genitourinary fistula had uretero-vaginal fistula (n=47, 9.8%). The mean age of the women with ureterovaginal fistula was 31.9 (SD ±11.8) years. Majority of the ureterovaginal fistulae (n=33, 70.7%) followed caesarean sections done at general hospitals (n=22, 46.8%) by medical officers (n=32, 68.1%). The clinical assessment method used in this study was accurate in diagnosing ureterovaginal fistula. Successful fistula repair with urine continence using the open transvesical ureteral reimplantation was achieved in 45 (95.7%) of the cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eIatrogenic ureterovaginal fistulae are common in Uganda and most follow caesarean section performed at lower-level health facilities by medical officers. In resource limited settings where advanced diagnostic techniques aren’t available or not affordable, a simple but careful step-wise clinical evaluation described in this study is effective in making a diagnosis. Open transvesical ureteral re-implantation fistula repair technique has a high successful repair rate with urine continence.\u003c/p\u003e","manuscriptTitle":"Diagnosis and management of ureterovaginal fistula in a resource limited setting: a 12 years’ experience at four fistula surgery centers in Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-04-24 14:50:57","doi":"10.21203/rs.3.rs-2837073/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f90bdae7-4755-4a51-84ca-036739313582","owner":[],"postedDate":"April 24th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-09-11T06:14:15+00:00","versionOfRecord":[],"versionCreatedAt":"2023-04-24 14:50:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2837073","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2837073","identity":"rs-2837073","version":["v1"]},"buildId":"re_ckhLnmML6MCF96OHNJ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}