My favorite moment in the operating room this year was the reaction to one spoken word by my assistant, and its aftermath. Let me set the stage. For the fistula campaign in Vanga, we operate in a larger room that accommodates two surgical teams. This works quite well for our urology-gynecology team: Dr. Paulin as urologist and fistula surgeon from Kinshasa, and I as gynecologist from the US. We each operate primarily on one side of the room, while also being able to easily stay scrubbed in and sterile while looking over the other’s shoulder to see the demonstration of an interesting finding or a different technique for repair. All fistulas are different, so there are many ways to approach them. Dr. Paulin likely has the most fistula repair experience of any urologist in western Congo, so he naturally tackles the complex ones, and I try to stick with vaginal cases when possible. As we frequently say, that is “ma boutique.”
|Part of the OR team|
On this particular day, Dr. Paulin had labored long and hard with a very difficult case. In that time, I was able to finish two simpler vaginal cases, taking a bow when he looked up with a mixture of surprise and pride. He has mentored me well. The next two patients presented an interesting challenge and we ended up switching sides of the room. I started the abdominal case while Dr. Paulin used his skill to reinforce a weak urethra, an operation which is typically much shorter in duration. Dr. Odjum, a senior staff doctor at Vanga, and I worked quickly on our abdominal case, and the minute we had closed the fistula, he yelled out, “brancard!” which means “stretcher!” Heads whipped around, students stopped talking, and all eyes were on us. Paulin jumped up from his seated position in front of his patient, ran over and peeked over my shoulder in disbelief. Odjum just grinned. We still had to close the bladder and finish other steps, but we had succeeded in closing the fistula, so he wanted everyone to know. When Dr. Paulin and his team finished their case and called out for the stretcher as we were still closing the fascia, they all insisted this was “brancard vrai!” Stretcher for real! Paulin remarked as we were writing our operative notes, “Tu m’a tué!” Translated, dying from laughter.
|Though we worked extremely long hours, we enjoyed camaraderie|
More than double
Due to our delay in Kinshasa (see prev post), we frantically saw the patients lined up for us on Saturday afternoon-evening. We had more than double the number of patients with true fistulas this year than in our campaign in 2019! I worried that we would have to turn some away or somehow triage them and choose who would get an operation this year. Here are some of their stories. *Names have been changed, and photos attached are an assortment from my collection and are simply representative of some of the sweet patients I have met over the years.
Mutala is 31yo, and her story is very similar to many fistula patients. Four years ago, she had a long labor at a local health center, her baby died in utero, and finally was stillborn weighing about 5kg. Adding to her sadness and pain, she found she could not control her urine. She went to a doctor who did not tell her the diagnosis but did give her some medicine which she tried for 2 months without improvement. She went to another health center, but no one helped her. She came to third health center where a doctor offered to operate on her, but not having confidence in the surgery, her parents refused to pay for it. She has been taunted by many, rejected, and people refuse to be in her presence. However, her family supported her to come to Vanga, and thankfully her husband stayed with her. On exam, her entire bladder was open to the vagina. Her urethra was a separate tube without use. The ureters were easily seen within the bladder tissue open to the vagina. Her surgery required a complex procedure which included using a flap of skin and fat pulled down and underneath the newly constructed bladder to support it as she did not have enough vaginal skin remaining.
Amaya heard about our campaign on her radio. She had been leaking urine for over 40 years, after having had a cesarean delivery, presumably for obstructed labor. Her infant did not make it. She was abandoned by her husband. Her mother and sisters supported her, and she had an attempted fistula repair in 1990, but it failed. She came in search of hope again. We found her to have 4 residual holes into her bladder. Due to previous repair, there was significant scar tissue. Both Dr. Paulin and I worked hard and thus far she is dry after surgery. Overall, fistula statistics show that first time repair has 90% chance of healing, 2nd repair is 70%, and 3rd repair only 30% chance. This is why we prefer that no one who is inexperienced attempt a repair.
A gyn case
At 19 years old, she had suffered immensely. For the past 3 years, she had excruciating pain every month, and it was only getting worse. On top of this, she dealt with the shame that she had not yet started her period. Pressure from family to get married and have children is high, so this could make it impossible for her to find a husband in the future. She underwent an abdominal surgery for suspected appendicitis. Still no relief from the pain. Finally, she heard on the radio that there was a gynecologist coming to Vanga. She and her mom set out, on foot I presume, to come see what might be the problem. A simple exam revealed that her vagina was congenitally not open, and an ultrasound revealed a uterus full of liquid. Under spinal anesthesia, I examined her again. I poked a needle in a trajectory toward the uterus. Sure enough, dark blood oozed out. After that, it was a simple cut through the thick septum in the same direction as the needle, and THREE YEARS of menstrual blood poured out, along with all the pain she had endured.
They come in threes
Sana is only 10 years old. Their family heard about the campaign on the radio and were convinced they needed to help her get to Vanga. Her dad brought her. She suffered from urinary incontinence since infancy. Despite trying to toilet train and clean well, she leaked urine all the time. Her family had no idea how to help her until they heard about the campaign in Vanga.
Similarly, Munikasa is only 14 years old and has had leakage since infancy. Her classmates mock her. Her parents went from health center to health center, searching for a solution. She tried various treatments and medicines without help. When they heard on the radio that there was a team coming to Vanga for urinary incontinence, the did not hesitate a minute. They took a motorcycle to a nearby health center where they found a team from Vanga who were there to recruit patients and this is how she was able to come.
Both she and Sana were found to have a rare condition caused by congenital ectopic ureters. Simply put, the tube taking urine from the kidney was connected to the vagina instead of the bladder. Dr. Paulin was easily able to find the ureter, cut it from its connection to the vagina, and reimplant it into the correct position in the bladder. We expect a full recovery and normal life hereafter for both girls. Believe it or not, a third young girl presented on the last day of our campaign, and she will be taken to Kinshasa where Dr. Paulin will be able to perform surgery there.
I am so grateful to report that we were able to include all the fistula patients who presented (on time) into the schedule, although it was packed! We did 8-10 operations a day M-F and then 4 more on Saturday, for a total of 51 operations. In addition, 2 operations will be paid for but done by the local team next week (a colostomy and hysterectomy), and 2 patients that came in the last day of the campaign and were confirmed to have fistulas will be sent to Kinshasa for a fistula campaign which will start March 16 with the urologist and a team from Belgium.
|Postop, we had 36 in one room, and 8 in another|
|Post op care team at the maternity|
The patients ranged from age 10 to approximately 85. They were leaking urine for a range of 6 months to over 40 years. All but two appeared malnourished to some extent, and we have in our procedures to feed them well for the duration of time they are with us and healing after, which can be up to a month. Now we wait for the healing that only comes from the Lord, and we pray they will go home with the knowledge that they are not forgotten, that God loves them, and that they can trust this mission hospital if they have needs in the future or become pregnant again.