Title: A systematic review and meta-analysis of urinary incontinence following successful
obstetric fistula repair: findings from five countries in sub-Saharan Africa
Version: 1 Date: 08 Feb 2025
Reviewer's report:
Title: A systematic review and meta-analysis of urinary incontinence following obstetric fistula
repair: findings from 5 sub-Saharan Africa countries
Authors: Azeze GA, Haile KE, Gebeyehu NA, Kena SS, Tsegaye TG, Gebrekida AY, Alelgn
Y, Kassie GA, Asgedom YS
Overall Comment: The authors are to be applauded for their efforts in addressing the
understanding of prevalence rates of this relatively over-looked potential sequelae of successful
obstetric-related vesicovaginal fistula (VVF) closure. In terms of impact on quality of life, it is
significant, as many women under-going surgery more than likely expect the urinary leakage
to stop, not always understanding that despite successful fistula closure, urethral or bladder
insufficiency may exist. Our understanding of the pre-fistula repair counselling regarding the
potential for continued leakage with patients is unclear and also needs to be understood and more
fully addressed. The current results reflect a robust research approach to addressing this issue
which can inform to resource needs in the credible initiative to address this condition which may
reflect multiple causes. It adds to the current literature in this area. Specific comments below.
Specific Comments:
Title: Explains the study; I think it can be made a bit more specific with the suggested revision:
“…following successful obstetric fistula…..”
Running Title: ok, could also make more specific with same point noted above
Abstract: Ditto above point in Objective, otherwise good
Key Words: ok
Registration: ok, confirmed
Background: In general would shorten to 1.5 pages. The information in current paragraphs 1 and
4 can be combined into one more succinct paragraph as any readers of this paper will familiar
with the condition and its causes. Also, many references are a bit outdated and would consider
looking at more recent reports ie references 10, 11, 15, 16, 17. Not necessary to state that fistula
closure can be done using endoscopic approaches as not done in LMICs.
Methods: Appropriate systematic review/ meta-analyses methods utilized. Under “Eligibility
Criteria” line 138, consider “Specifically” instead of Particularly. Please clarify that these were
women that had “successful” VVF repairs. Also clarify the definition of “urinary incontinence”
after successful fistula repair
Results: Overall clearly presented. Line 194, revise has to “had”. Table 1, revise fistula to
“fistula”; please provide footnote to define “sample” and “cases” as well as abbreviations. Figure
2, provide footnote to define “ES”. Would like to see pooled prevalence rates of all individual
countries
Discussion: Can they authors provide a bit of a discussion on the differences in pooled prevalence
rates by country? Line 263, revise now a day to “today”
Line 274, do not see a reference 45. Lines 273-278 regarding treatments of VVF and RVF, not
a topic of this report; could remove. Would make a stronger statement regarding limitation of
not being able to comment on cause/type of UI, ie stress, urgency, overflow from incompete
bladder emptying or hypotonic detrusor muscle, etc
Conclusion: Could state a bit more robustly that credible subjective and objective evaluations
of women are needed to understand the cope of this problem. Further, UI after successful
post-obstetric VVF closure may not respond to current existing treatments of UI in women
that have not sustained damage of significant obstructed labor needing innovation in treatment
approaches.
Tables/Figures: see above comments
Line 302, …..consent to participate “was” instead of is….
Disposition: Minor revisions