Supplementary Material for: The microcirculation of vaginal tissue in women with obstetric vesicovaginal fistula and short-term effects of surgical repair on microvascular parameters

Objectives: To better understand the extent of the ischemic trauma and the effects of surgical repair on the vaginal microcirculation in patients with obstetric vesicovaginal fistula (VVF). Design: In this observational study, we evaluated the vaginal microvasculature surrounding VVF using handheld vital microscopy (HVM) before, during and two weeks after surgical VVF repair. Participants: Seventeen women undergoing VVF repair were included in this study. Setting: The study was conducted in the Fistula Care Centre in Lilongwe, Malawi. Methods: We used HVM with incident dark-field (IDF) imaging to non-invasively visualize the microvasculature of the vaginal tissue surrounding fistulas. The primary outcome was the presence of microvascular flow. Secondary outcomes included angioarchitecture, fistula closure (postoperative dye test) and urinary continence (pad weight test). Results: Microvascular flow was present before, during and after surgical repair in respectively 83.8%, 83.9% and 93.4% of obtained image sequences. The angioarchitecture was normal in 75.8% of the image sequences before surgery, 69.4% at fistula closure and 89.1% two weeks after VVF repair. Fourteen (82.4%) patients had a closed fistula after surgical repair. Limitations: The study was limited by the lack of a control group and the relatively small sample size. Conclusion: Although the vaginal microcirculation in women with VVF is compromised, extensive ischemic damage is not observed in the tissue surrounding fistulas. This suggests significant regenerative capacity of the vaginal vasculature in young women, or less extensive ischemic damage than presumed. Following surgical repair, we observed improvement of microcirculatory flow and angioarchitecture, suggesting that surgery is a good option for patients with obstetric VVF.