I read with interest the article by Hilton [1], which sheds light on changes in the aetiology of urogenital fistulae, and states: “It has long been held as conventional wisdom that urogenital fistulae in low-income and middle-income countries are almost exclusively of obstetric aetiology, related to prolonged neglected obstructed labour, whereas those seen in high-income countries are largely iatrogenic in nature”. Then: “a growing perception amongst those working in the field that an increasing proportion of urogenital fistulae in low-income and middle-income countries may be iatrogenic, resulting from caesarean section”.

I would like to highlight that in 2013 we published a small series of urogenital fistulae from a tertiary care centre in Saudi Arabia [2]. This series showed that of the 16 cases, 12 (75 %) involved iatrogenic obstetrical surgical complications; of those, 8 (50 %) were complications of caesarean section (CS). Three cases were caused by complications relating to repeat CS, and 2 cases occurred following cervical cerclage. The remaining 4 cases (25 %) were complications following different types of hysterectomy. Our series provides some evidence that iatrogenic obstetrical surgical complications are becoming the commonest cause of urogenital fistulae in high-income countries with advanced obstetrical care, which is different from what has previously been documented.