Few morbidities give pain and discomfort to women as genital fistula. Obstetrical origin (dystocia blocked delivery labor) is most frequent. It can be by other circumstances as pelvic cancer, congenital, trauma accident and rarely urogenital infections.
The iatrogenic fistula results from pelvic surgery (urology, obstetric gynecology, rectum). It can happen also by instrumental manipulations on the pelvic organs  - , or negative traditional practice like excision (clitoris and or vular lips ablation). They are rare in developed countries   . Its prevalence worldwide ranges from 6% to 24%  .
Fistulas is still a public health problem in in-coming countries. Data from the literature on iatrogenic fistulas are still poor. So we were interested in this pathology for the circumstances and prognosis. The study was carried at the National Reference Center for Obstetric Fistulas (CNRFO) in Niamey. This is a retrospective descriptive study (over 5 years) (23/5/2013 -22/5/2018) on iatrogenic female genital fistulas.
1.1. Inclusion Criteria
Any female genital fistula noted following gynecological or urological surgery and or traditional practices on the female genital tract (excision), hospitalised in CNRFO during the period concerned and for which the file is usable.
1.2. Non-Inclusion Criteria
Any case of female genital fistula occurring during a cesarean section for dystocia blocked labor of more than 12 hours (117 cases), case associated with invasive pelvic cancer (1 case), accidental injury (0 case) by caustic products (0 case) or pelvic irradiation (0 case) and any case of incomplete file (2 cases).
1.3. Collection of Data
We collected continuous data at CNRFO for a period of three weeks on the basis of a pre-established survey form and hospital records during the study period.
All ethics procedures were respected.
We recorded 743 cases of genital female fistula at CNRFO, including 35 cases of iatrogenic origin (4.71%) (Table 1).
The average age was 35 years old, extremes 19 and 62 years old, 57.15% of the patients were over 30 years old. In 80% of cases, patients had at least 2 previous parities.
Table 1. Patients age years old.
The main circumstances were obstetrical (54.28%) mainly the hemostasis (Table 2).
Table 2. Distribution of circumstances of the FGF.
Hysterectomy was the main circumstance of uretero-vaginal and vesico-vaginal fistulas, while traditional harmful practice (excision), was responsible for uretro-vaginal fistula (Table 3).
Table 3. Circumstance of FGF.
Distribution according to the type of treatment (Table 4):
Table 4. Surgical treatment.
The treatment results after 3 months follow-up noted fistula closed and 29 patients dry (82.87%), 1 case (2.85%) closed with stress incontinency and 1 case (2.85%) non closed fistula. 4 patients treated by transurethral bladder probe were dry.
Fistula was closed and urinary continency in 30 cases (85.72%). 4 cases (11.43%) all cured with transurethral bladder probe treatment. The average length of hospital stay was 20 days (extremes 14 - 30 days), 20 ± 7 days.
During five years, CNRFO 4.71% of all female genital fistulas hosptalised, were iatrogenic. The age group most concerned was 19 - 29 years old, less 40 years old represented 57.15%, average age 35 years old, extremes 19 - 62 years old, as in the previous study, Niger, 2018  the age group of 20 - 29 years was the most concerned. Although age old is not a risk factor of iatrogenic genital fistulas  - , it is important to mention in our study patients were young, 57.14% less 40 years old. The patients had 4 parities average, extremes 0 - 10 including large multiparous (37.14%) (37.14%), primiparous (11.43%), Idi  Niger, 2018 finds 47.32% of primiparous, 39.85% multiparous. while Kazadi  reports 3 parity average.
3.2. Circumstances of Lesion
The most frequent causes were obstetrical surgery (54.28%): including 6 cesarean sections (17.14%), 4 hysterectomies for uterine rupture (11.43%) and 9 hemostasis hysterectomies (25.71%). Then gynecological causes (40%) including: 9 hysterectomies (25.71%) for fibroid, 2 hysterectomies for stage B2 cervix cancer (5.71%) 1 hysterectomy for genital prolapsed (2.86%), 2 of genital excision (5.71%) and 2 cystocele cures. In this study, hysterectomy was the main occasion for iatrogenic fistulas (71.43%) then cesarean section (17.14%). Farih  in Morocco, 2018 for 18 cases vaginal vesico-fistula, 12 cases were post-surgical (7 hysterectomies and 5 cesarean sections Odezebe at the Brazzavaville University Hospital  reported 11 cases (32.35%) of post-cesarean fistulas and 6 cases (17.64%) of post hysterectomy fistulas in a series of 34 urogenital fistulas.
For Onsrud , the Democratic Republic of Congo on 229 cesarean, 55 fistulas (24%) were considered as iatrogens. Nawaz  in a retrospective study covering 13 years recorded 213 cases of urogenital fistulas of which 25 cases (18.79%) were post hysterectomy and 9 (6.77%) were post cesarean. In Goktas study , 71.5% of fistula were surgical complication.
3.3. Anatomopathological Findings
Farih  Morocco 2018 reported 12 cases of post-surgical vesico-vaginal fistula (3 by hysterectomy for uterine rupture, 1 hemostasis hysterectomy, 3 cases of hysterectomy for fibroid, 3 cases cesarean section for fetal distress and 2 cases of cesarean section for fetal-pelvic disproportion). El Tabey  in 18-years experience observed for 120 fistulas, 90 were vesico-vaginal, 14 uretro-vaginal, 2 vesico-uterines and one uretero-uterine, 13 ureteral ligations. Nawaz , in a retrospective study covering 13 years recorded 213 cases of urogenital fistulas, of which 133 (62.44%) vesico-vaginal, 54 (25.35%) uretero-vaginal and 26 (12.2%) uretero-vaginal. The circumstances of occurrence were hysterectomy and cesarean section. El Lamine I  reports a retrospective series of 46 cases of urogenital fistulas collected in 7 years among which 2% were of iatrogenic cause, they were vesico-vaginal (48%), unilateral uretero-vaginal (30%), bilateral (13%) and vesico-uterine (9%). The iatrogenic causes were gynecological (57%) and obstetrical (41%). Goktas  reports 42 cases of uro-genital fistulas collected from May 2001 to June 2010: 28 vesico-vaginal fistulas, 11 vaginal uretro and 3 vesico-uterine fistulas. These fistulas were consecutive to surgery (71.5%) and to obstetric trauma (28.5%). In lot of publications vesico-uterine fistula as a rare complication of cesarean section, estimated 1% - 4% of all urogenital fistulas  - .
Upper fistula is treated by abdominal way       . The vaginal way is indicated for uretro-vaginal and vesico-vaginal fistula. The goal was to restore as possible, the anatomical and functional integrity of the urinary and genital tractus. Thus 18 fistulas (14 uretero-vaginal and 4 ureteral were repaired by ureteral reimplantation according to Leadbetter-Politano technique which is the most commonly used. It can be used even for higher lesions of the ureter  . The fistulorraphy concerned 12 fistulas (9 vesico-vaginal, 2 vesico-uterine and one uretero-vaginal). One case of urethroplasty was reported. Manconi  reports 3 cases of terminal terminus anastomosis, 2 cases of ureteral reimplantation and a psoic bladder. Modi  reported 18 cases of vaginal uretro fistulas collected between 2003 and 2007 following hysterectomy, the treatment was by laparoscopic ureteral reimplantation and Posoas hitch.
The treatment results after 3 months follow-up noted fistula closed and patient dry in 29 cases (82.87%), 1 case (2.85%) closed with stress incontinency and 1 case (2.85%) non-closed fistula. 4 patients treated by trans urethral bladder probe were dry (11.43%). For Bouya et al. , there were 20 cases of healing 76.92%), 3 cases of failure (11.53%), 3 cases with persistence of urinary incontinence despite the anatomical closure of the fistula.
Female genital fistula is a morbidity but not vital danger. It is a big public health problem in Niger country. Our study concerns 35 cases of iatrogenic fistulas in 5 years treated at the CNRFO in Niamey. They are pelvic surgery complications (obstetric, gynecological, urological surgery) and genital mutilation of urogenital tract (excision). The better knowledge of urogenital/female anatomy relative modification may improve pelvic surgery. The surgical techniques and active action against traditional genital mutilation can avoid iatrogenic genital fistula. The treatment result is almost excellent when done by trained and skilled surgeons. The small vesico-vaginal could be closed by transvaginal bladder probe.
 Obarisiagbon, E.O., Olagbuj, B.N., Omora, V.C., Oguike, T.C. and Ande, A.B.A. (2011) Iatrogenic Urological Injuries Complicating Obstetric and Gynecological Procedure. Singapore Medical Journal, 52, 738-741.
 Labarrère, A., Gueye, A., Ouaki, F., et al. (2011) Fistule urogénitale obstétricale: A propos de deux fistules uretèro vaginale. Alternative thérapeutique à propos de 10 cas. Observation en France. Gynécologie Obstétrique & Fertilité, 39, 328-331.
 Anou Kouma, T., Attipoub, K.K., Agoda-Koussemac, L.K., et al. (2010) Aspect épidémiologique, étiologique et thérapeutique de la fistule obstétricale au Togo. Progrès en Urologie, 20, 71-76.
 Idi, N., Brah, N.A.H.M., Idrissa, A., Djangnikpo, L. and Assoumana, Z. (2018) Multicentric Study of 148 New Cases of Female Genital Fistula Niger. Open Journal of Obstetrics and Gynecology, 8, 1631-1639.
 Onsrud, M., Sjoveean, S. and Mukwege, D. (2011) Cesarean Delivery Related Fistula in the Democratic Republic of Congo. International Journal of Gynecology & Obstetrics, 114, 10-14.
 Nawaz, H., Khan, M., Tareen, F.M., et al. (2010) Retrospective Study of 213 Cases of Female Urogenital Fistulae at the Department of Urology & Transplantation Civil Hospital Quetta, Pakistan. Journal of Pakistan Medical Association, 60, 28-32.
 Farih, M.H., Tazi, M.F., El Mohamed, J.E. and Mellas, S. (2018) Fistule vesico vaginale à propos de 18 cas, étude descriptive et analytique, service d’urologie CHU Hassan II de Fès Maroc. Thèse de Médecine.
 El Tabey, N.A., Ali El Dein, B., Shaaban, A.A., El Kappany, H.A., Mokhtar, A.A., El Azab, M., et al. (2006) Urological Trauma after Gynecological and Obstetric Surgeries, Experience with These Injuries over the Last 18 Years. Scandinavian Journal of Urology and Nephrology, 40, 225-231.
 El-Lamine, I.K. (2008) Urogenital Fistulae: Changing Trends and Personal Experience of 46 Cases. International Urogynecology Journal and Pelvic Floor Dysfunction, 19, 267-272.
 Nafiou, I., Djangnikpo, L., Sani, R., Harouna, S. and Chekaraou, L. (2017) Fistules génitales féminines d’origine obstétricale. Etude multicentrique prospective a propos de 148 nouveaux cas. Niger OJOG 2018, 8.
 Drissi, M., Karmouni, T., Tazi, K., El Khader, K., Koutuni, A., et al. (2008) Vesico Uterine Fistulas: Ban Experience of 17 Year. Progrès en Urologie, 18, 173-176.
 Michel, S. and Baggish, M.D. (2010) Urinary Tract Injuries Secondary to Gynecologic Laparoscopic Surgery: Analysis of 75 Case. Journal of Gynecologic Surgery, 26, 79-92.
 Modi, P., Gupta, R. and Rizvi, S.J. (2008) Laparoscopic Ureteroneocystostomy and Psoas Hitch for Post Hysterectomy, Ureterovaginal Fistula. The Journal of Urology, 180, 615.