Table 1 summarizes the cases of urethrocutaneous fistula encountered within the ZAZIC VMMC program.
Table 1
Summary of urethrocutaneous fistulae cases reported by ZAZIC
Case
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
Year of VMMC
|
2013
|
2014
|
2015
|
2016
|
2017
|
2019
|
2019
|
Age (years)
|
22
|
14
|
10
|
11
|
12
|
12
|
13
|
Circumcision method
|
Forceps guided
|
Forceps guided
|
Forceps guided
|
Dorsal slit
|
Dorsal slit
|
Dorsal slit
|
Dorsal slit
|
Site
|
Outreach
|
Circumcising cadre
|
Doctor
|
Doctor
|
Doctor
|
Nurse
|
Nurse
|
Doctor
|
Nurse
|
Surgeon experience in VMMC
|
1 year
|
2 years
|
2 years
|
4 years
|
4 months
|
6 years
|
5 years
|
Suture material/needle size
|
3/0 vicryl, 26mm, 3/8 circular reverse cutting needle
|
Diathermy used
|
No
|
Days to fistula diagnosis after VMMC
|
2
|
7
|
15
|
42
|
18
|
17
|
14
|
Number of repair attempts
|
10
|
3
|
None
|
3
|
3
|
2
|
1
|
Surgeon Expertise and Repair Dates (month/year)
|
GP 1-Aug 2014
GP 1-Aug 2014
GP 1-Aug 2014
GP 1-Sept 2014
Urologist 1-May 2014
Urologist 1- Nov 2014
Urologist 1-May 2015
Urologist 2-November 2015
Urologist 1&2-Mar 2017
WHO Urologist-Oct 2019
|
General Surgeon 1-May 2015
Urologist 2-Oct 2016
Urologist 2 -Jan 2018
|
Conservative management by GPs 2 and 3 - March 2015
|
General Surgeon 1-Jan 2017
Urologist 2- Jan 2018
Urologist 1- Sept 2020
|
Urologist 2-Jun 2017
Urologist 2 -Nov 17
W.H.O Urologist- Oct 2020
|
Urologist 1-May 2019
Urologist 1-Sept 2020
|
Urologist 1- Mar 2020
|
Days to healing
|
2,241
|
1,830
|
21
|
1,413
|
940
|
244
|
196
|
Secondary diagnosis
|
Infection
|
Infection
|
Infection
|
None
|
Infection
|
Infection
|
Infection
|
Outcome
|
Healed
|
Healed
|
Healed
|
Healed
|
Healed
|
Unhealed
|
Healed
|
Case 1
In 2013, a 22 year old male was circumcised at an outreach site by a trained physician with one-year experience through the FG method, using the routine 3/0 vicryl suture on a 26mm 3/8 circle reverse cutting needle for suturing. No diathermy. At the day 2 post-VMMC review, a gap was noted on the wound with urine leaking. The client was referred to a district hospital where he was reviewed by a Government Medical Officer (General Practitioner (GP)) who diagnosed fistula on the ventral side of the penis around the frenulum; the client was discharged home on daily saline baths and scheduled for repair after two weeks. Four unsuccessful repair surgeries were subsequently performed by the GP within six weeks of hospital stay; in each of the 4 procedures, the GP placed sutures too close the fistula. Nine months after the circumcision, a consultant urologist reviewed the client and noted extensive scarring and fibrosis. Five additional repair attempts were made by four different urologists over the next 47 months. Each repair appeared initially successful but ultimately resulted in postoperative infection where the sutures broke down and the fistula started leaking again. The tenth repair was performed by WHO specialists in 2019 (2244 days post VMMC). The repair was successful. Client healed completely.
Case 2
In 2014, a 14 year old male was circumcised at an outreach site by a trained physician with two years’ experience using the FG method, a 3/0 vicryl suture on a 26mm, 3/8 circle reverse cutting needle for suturing, and no diathermy. 2-day post-VMMC review noted the client had poor hygiene and received post-operative wound care counseling. The client presented on day seven post-VMMC with complaints of pus oozing from the frenulum. Wound cleaning was done using iodine solution and the client was given oral Amoxicillin 500mg for seven days. On day ten post-VMMC, the client noted little improvement and returned to the clinic. Examination revealed pus oozing from the frenulum with urine leaking on the ventral aspect of the penis. A diagnosis of fistula was made. The client was admitted to hospital where he received Ceftriaxone 1000mg intravenously for one week and Metronidazole 500mg for two weeks and a urethral catheter was inserted. The client was later reviewed and discharged by a general surgeon who referred him to a urologist. Reconstructive surgery was postponed several times due to other emergency cases. After several further postponements of the surgery, the client’s parents lost confidence and stopped attending further reviews. In early 2015, the parents were contacted and offered an option of a private practitioner for the repair, but they refused until late 2015 (525 days post-VMMC) when they consented to surgery and the first repair was done by a general surgeon. He was discharged after two weeks post repair operation with a urethral catheter which was removed after six weeks. On removal of the catheter a pinhole size fistula was noted and the surgeon was hopeful the wound would close spontaneously. The client was again reviewed in early 2016 and urine was still leaking. He was booked for another surgery but the parents did not consent. Later in 2016 the client presented with history of passing blood in urine and was referred to a urologist. A diagnosis of bladder stone was made and the urologist removed the stone and performed a second fistula repair during the same operation (914 days post-VMMC), closing the wound in two layers before placing both suprapubic and urethral catheters for 10 days. In early 2017, the client reported that the fistula had started leaking again. A team of two urologists reviewed him and observed a pinhole fistula but deferred repair to allow for spontaneous closure. He was reviewed six months later and the fistula was noted to be still leaking. The third fistula repair in early 2018 (1355 days post-VMMC) resulted in a wound infection one-month post repair operation; the sutures broke down and the fistula reopened. After conservative management and observation, a review done after about 16 months (1832 days post-VMMC) found that the fistula had closed spontaneously.
Case 3
In 2015, a 10 year old male was circumcised at an outreach site by a trained physician with 2 years’ experience using the FG method, a 3/0 vicryl suture on a 26mm 3/8 circle reverse cutting needle for suturing and no diathermy. Day 2 and day 7 reviews were reportedly uneventful. The client presented on day 15 post-VMMC with a complaint of urine leaking around the wound. On examination, the wound looked infected and three fistulae openings were noted with urine leaking on the ventral aspect of the penis around the frenulum. Immediate management by two Government Medical Officers (GPs) involved cleaning with iodine solution, catheterization for two weeks, and intravenous Ceftriaxone for seven days. The client was seen by a general surgeon two weeks after the initial management who noted that there was no urine leakage upon removal of the catheter. The general surgeon confirmed fistula healing at 6 the weeks post-VMMC review.
Case 4
In 2016, an 11 year old male was circumcised at an outreach site by a trained nurse with four years’ experience, using the DS method, a 3/0 vicryl suture on a 26mm 3/8 circle reverse cutting needle for suturing and no diathermy. Normal findings were reportedly observed on day 2 and day 7 reviews. The client presented at the clinic on day 42 post-VMMC complaining of passing urine from the ventral and lateral aspect of the penis. On examination, a small opening was noted on the ventral aspect of the penis without leakage while another opening on the right lateral side of the penis along the circumcision suture line was observed to be leaking urine. A diagnosis of fistulae was made. On day 73 post-VMMC, a General Surgeon confirmed urine leakage from the two openings and planned for repair which was done on day 110. Two months after the repair, the client was reviewed by a team of two urologists who observed that the fistula was pinpoint in size, not leaking and gave the fistula a chance to close spontaneously. About one year after the first repair, the client presented again at the clinic with complaints of urine leakage. Client had a second repair attempt a year after the first attempt (day 473 post VMMC). The second repair attempt was not successful and client continued to leak urine. Follow-up surgery was deferred for the WHO workshop. However, the client’s school obligations prevented participation. A third repair by a urologist was performed in September 2020. A review at two weeks post repair operation (day 1462 post-VMMC) and review 2 months post repair operation confirmed healing.
Case 5
In 2017, a 12 year old male was circumcised at an outreach site by a trained nurse with four months’ experience, using the DS method, a 3/0 vicryl suture on a 26mm 3/8 circle reverse cutting needle for suturing and no diathermy. Normal findings were reportedly observed on day 2 and day 7 reviews. On day 18 post-VMMC, the client noticed urine leaking on the underside of the penis. He presented to the clinic two days later where a clean wound with some urine drops leaking on the frenulum along the suture line was observed. A diagnosis of fistula was made, and the client was referred to a urologist at tertiary hospital a day later. He was admitted, catheterized and started on Ceftriaxone 1g intravenously for a week. The client was discharged to an outpatient clinic where he continued with daily wound cleaning using iodine solution. At day 61 post-VMMC, the wound was clean but the fistula was still leaking. The client continued on a urethral catheter until 92 days post-VMMC, when a surgical repair was attempted. A one-month post-repair review (day 122 post-VMMC) found a small opening that was leaking urine. A second surgical repair at 270 days post-VMMC resulted in post-operative infection: sutures broke down and the fistula started leaking. A third and successful fistula repair was done by WHO specialists two years after the second repair (961 days post-VMMC).
Case 6
In 2019, a 12 year old male was circumcised at an outreach site by a trained nurse using the DS method, a 3/0 vicryl suture on a 26mm 3/8 circle reverse cutting needle for suturing and no diathermy. Normal findings were reportedly observed on day 2 and day 7 reviews. On day 17 post-VMMC, the client presented to the clinic complaining of urine dripping from the underside of the penis. He reported that he had stopped saline baths for wound cleaning and was, instead, applying Cotrimoxazole tablets provided by his grandmother directly on the wound. On examination, a septic wound was noted on the frenulum and urine was leaking through the wound. A diagnosis of fistula was made and the client was admitted to hospital under the care of a GP for wound cleaning, insertion of urethral catheter, and Amoxicillin Clavulanate 375 mg for a week. He was referred to a urologist who advised to keep the catheter for a further three weeks. After the three weeks, the catheter was removed and the fistula was still open. An attempt at repair was done by a team of two urologists 135 days post-VMMC. Upon removal of the catheter one month later, the urologists noted that the fistula had closed. Six months post first repair, the client again reported urine leaking. A second repair was performed by a urologist in September 2020. Review two weeks later by a urologist (244 days post-VMMC) suggested healing. Six weeks later, a VMMC nurse observed urine leakage during a scheduled review and referred client to a urologist. Client was reviewed by the urologist two months after repair operation who confirmed a recurrent pinhole fistula at 3 o’clock position. Surgical repair of the recurrent fistula was postponed for nine months to allow for spontaneous healing.
Case 7
In 2019, a 13 year old male was circumcised at an outreach site by a trained nurse with five years’ experience using the DS method, a 3/0 vicryl suture on a 26mm 3/8 circle needle for suturing and no diathermy. The client did not attend day 2 and day 7 reviews. Client follow up was not conducted due to an incomplete client address captured at enrollment. He presented to the clinic on day 14 post-VMMC, complaining of pain and urine leaking from near his circumcision wound. Examination showed wound dehiscence and a fistula on the ventrolateral (4 o’clock) position. Immediate management by a Government Medical Officer included wound cleaning, oral Amoxicillin Clavulanate 625 mg and Paracetamol 1000 mg for a week. The client was reviewed on day 28 post-VMMC by a urologist who recommended continued wound care and oral Amoxicillin Clavulanate whenever necessary. Reviews at both day 41 and day 55 post-VMMC, revealed a clean wound which was healing well but with urine still leaking. On day 161 post-VMMC, the urologist performed a fistula repair and a urethral catheter was left in situ. Amoxicillin Clavulanate 625mg for a week, Paracetamol 1g for three days, Mupirocin ointment applied for 2 weeks with alternate days of cleaning and dressing for the initial week were prescribed. At 23 days post repair (day 184 post VMMC), the urologist review concluded that the fistula had completely healed.
Fistula rates:
Over six years, fistula cases were reported at 5 of 55 (9%) ZAZIC facilities (Table 2). One facility reported 3 fistula cases resulting from 3 different providers over a five-year period. Site fistula rates ranged from 4,2 to 12,2 per 100,000 VMMCs, see Table 2.
Table 2
|
Site A
|
Site B
|
Site C
|
Site D
|
Site E
|
Global (WHO data)
|
Global (PEPFAR data)
|
# of Fistulae
|
1
|
1
|
1
|
3
|
1
|
32
|
41
|
*Total VMMCs/site
|
15 737
|
23 711
|
8 005
|
34 198
|
8176
|
**16 790 262
|
***14 900 000
|
Fistula rate per 100,000 VMMCs
|
6,4
|
4,2
|
12,5
|
8,8
|
12,2
|
0,19
|
0,28
|
*ZAZIC VMMCs, March 2013-October 2019; **Total Global VMMCs, 2014–2018*** Total Global VMMCs, 2015–2019 |