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Obstetrical FistulasObstetrical Fistulas
AndreeaAndreea Creanga, M.D.Creanga, M.D.Rene Genadry, M.D.Rene Genadry, M.D.
Obstetrical Fistulas Obstetrical Fistulas
PreventablePreventable
TreatableTreatable
2
Obstetrical FistulasObstetrical Fistulas
Result from prolonged, obstructed and Result from prolonged, obstructed and neglected laborneglected labor
Coupled with a lack of medical Coupled with a lack of medical intervention to relieve it intervention to relieve it
Obstetrical Fistulas Obstetrical Fistulas DefinitionDefinition
Tissue destruction due to prolonged Tissue destruction due to prolonged pressure of the head during pressure of the head during obstructed labor (ischemic lesion).obstructed labor (ischemic lesion).
Tissue laceration during instrumental Tissue laceration during instrumental delivery, cesarean section or cesarean delivery, cesarean section or cesarean hysterectomy.hysterectomy.
3
Maternal Morbidity & MortalityMaternal Morbidity & Mortality
WHO, 2005WHO, 2005
Maternal Mortality RatiosMaternal Mortality Ratios
WHO, 2005WHO, 2005
4
ObjectivesObjectives
Overview clinical literatureOverview clinical literatureReview reported evaluation, Review reported evaluation, management and outcomesmanagement and outcomesIdentify complications of treatmentIdentify complications of treatmentIntroduce elements of classificationIntroduce elements of classificationPropose clinical points of discussionPropose clinical points of discussion
Key PointsKey Points
Overview Overview Evaluation issuesEvaluation issuesManagement issuesManagement issuesOutcomes issuesOutcomes issuesUnresolved issuesUnresolved issues
5
Overview Overview
Obstetrical FistulasObstetrical Fistulas
Obstructed neglected laborObstructed neglected laborDifficult operative deliveryDifficult operative deliveryTraditional surgical practicesTraditional surgical practicesPelvic immaturityPelvic immaturityNutritional deficienciesNutritional deficienciesSocioSocio--cultural factorscultural factors
6
Predisposing Conditions Predisposing Conditions
Early age at labor with pelvic immaturityEarly age at labor with pelvic immaturityAndroid or anthropoid pelvisAndroid or anthropoid pelvisGenital mutilationGenital mutilationCultural and social factors impeding careCultural and social factors impeding careEconomic factors impeding access and Economic factors impeding access and availability of careavailability of care
Fistula Development (I)Fistula Development (I)
Anterior vaginal wall, bladder base and urethra Anterior vaginal wall, bladder base and urethra are compressed between the fetal head and the are compressed between the fetal head and the posterior surface of the pubisposterior surface of the pubis
In prolonged obstructed labor, pressure necrosis In prolonged obstructed labor, pressure necrosis of the anterior vaginal wall and the underlying of the anterior vaginal wall and the underlying bladder neck occursbladder neck occurs
More extensive necrosis involves urethra, trigone More extensive necrosis involves urethra, trigone and anterior cervixand anterior cervix
7
Fistula Development (II)Fistula Development (II)
If mother survives, a macerated fetus is If mother survives, a macerated fetus is expelled 3expelled 3--4 days later4 days later
Sloughing of devitalized tissue (bladder, vagina) Sloughing of devitalized tissue (bladder, vagina) 10 days later10 days later
Wide area of pressure results in an anatomical Wide area of pressure results in an anatomical area widely affected by scarring and area widely affected by scarring and devascularizationdevascularization
Types of Obstetrical Types of Obstetrical Fistulas (Elkins)Fistulas (Elkins)
Vesicouterine(cervical)Vesicouterine(cervical)--c/sc/s and inletand inletJuxtacervicalJuxtacervical-- obstruction at pelvic obstruction at pelvic intletintletMidvaginalMidvaginal-- midpelvicmidpelvic obstructionobstructionSuburethralSuburethral-- base of pubic bonebase of pubic boneTotal urethral lossTotal urethral loss-- obstruction at pelvic obstruction at pelvic outletoutletCombined VVFCombined VVF--RVFRVF-- long and obstructed long and obstructed laborlaborUreterovaginalUreterovaginal--C/S & C/H C/S & C/H
8
Obstetric Labor Injury ComplexObstetric Labor Injury Complex
UrologicalUrologicalGynecologicalGynecologicalRectalRectalOrthopedicOrthopedicNeuroNeuro--vascularvascularDermatologicalDermatologicalPsychologicalPsychological
Arrowsmith, Hamlin & Wall, 1996Arrowsmith, Hamlin & Wall, 1996
Extent of InjuryExtent of Injury
Isolated VVF are more common than Isolated VVF are more common than combined VVF & RVF (n=309)combined VVF & RVF (n=309)–– 78 % VVF, 15% VVF & RVF, 7% RVF78 % VVF, 15% VVF & RVF, 7% RVF–– 70% complicated70% complicated
Much scarringMuch scarringTotal destruction of urethraTotal destruction of urethraUretericUreteric orifices at edge or outside fistulaorifices at edge or outside fistulaSmall bladderSmall bladderVVF & RVF VVF & RVF Presence of calculiPresence of calculi
Kelly, 1993Kelly, 1993
9
Obstetrical FistulasObstetrical Fistulas
Very little scientific research publishedVery little scientific research published–– Remote areasRemote areas–– Limited resourcesLimited resources
Only one RCT (n=79) on IV AB Only one RCT (n=79) on IV AB -- no no benefit regarding success or incontinencebenefit regarding success or incontinence
One comparative retrospective study One comparative retrospective study (n=49) (n=49) -- better results with Martiusbetter results with Martius
Unresolved Issues Unresolved Issues -- Epidemiology Epidemiology --No standard data collectionNo standard data collection–– Facility vs. Population basedFacility vs. Population basedNo standard reportingNo standard reporting–– Difficult crossDifficult cross--study comparisonsstudy comparisonsNo supported conclusion on impact of:No supported conclusion on impact of:–– Decreasing age of marriage Decreasing age of marriage –– Delaying the first birthDelaying the first birth–– Family planning useFamily planning use–– Antenatal and birth careAntenatal and birth care
10
Unresolved IssuesUnresolved Issues--PhysiopathologyPhysiopathology--
No studies on fistula prevention and role of:No studies on fistula prevention and role of:–– AgeAge–– ParityParity–– Degree of necrosis Degree of necrosis
No standard classificationNo standard classification
Evaluation IssuesEvaluation Issues
Low techLow tech
Complete Complete
11
Historical PeriodsHistorical Periods
““PrePre--leakleak”” ((10001000 BCBC--1300 1300 ADAD ))
““MendMend--thethe--leakleak”” (1300(1300--1940)1940)““MegaMega--leakleak”” (1940(1940--1990)1990)““ParaPara--leakleak”” (1990(1990--2000)2000)““NeverNever--leakleak”” (2000(2000 ))
Elkins, 1997Elkins, 1997
InvestigationInvestigation
Confirm Confirm extraurethralextraurethral urinary leakageurinary leakageVisualize leakage site(s)Visualize leakage site(s)Assess vaginal mobility, length & scarsAssess vaginal mobility, length & scarsAssess bladder capacity, neck and Assess bladder capacity, neck and upper tractupper tractAssess perineumAssess perineumUse liberal sedation or EUAUse liberal sedation or EUA
12
Physical Findings in VVFPhysical Findings in VVF
123 patients with VVF (Senegal)123 patients with VVF (Senegal)10 associated fistulas10 associated fistulas
5 5 vesicouterinevesicouterine fistulasfistulas4 4 rectovaginalrectovaginal fistulasfistulas1 1 ureterovaginalureterovaginal fistulafistula
50% associated lesions 50% associated lesions (vagina, urethra, bladder, perineum)(vagina, urethra, bladder, perineum)
34% radiological anomalies34% radiological anomalies
GueyeGueye, 1992, 1992
Preoperative ConsiderationsPreoperative Considerations
Accurate diagnosisAccurate diagnosis
Recognize associated abnormalitiesRecognize associated abnormalities
Timing of surgeryTiming of surgery
13
AssociatedAssociated Pathology (I)Pathology (I)
Sphincteric abnormalitiesSphincteric abnormalities
Secondary fistulaSecondary fistula
Urethral defectsUrethral defects
Ureteral fistula / obstructionUreteral fistula / obstruction
Coexistent Coexistent uretericureteric injuries in 10injuries in 10--15% 15% of patients with VVFof patients with VVF
Frequency of Urethral DestructionFrequency of Urethral Destruction
17.76721996Falandry
9.19031991Loran et al.
31.06001987Benchekroun et al.
9.85781983Chiche et al.
24.22801982Docquier
52.02251962Carayon et al.
20.61311953Couvelaire
% urethral destruction
# casesYearAuthor
14
Associated Pathology (II)Associated Pathology (II)
Genital prolapseGenital prolapse
Low bladder complianceLow bladder compliance
Detrusor instabilityDetrusor instability
Unresolved IssuesUnresolved Issues--DiagnosisDiagnosis--No standard evaluationNo standard evaluationNo standard identification of coNo standard identification of co--morbiditiesmorbidities–– Foot dropFoot drop–– Fecal incontinence Fecal incontinence –– POPPOP–– UTIUTI–– Amenorrhea Amenorrhea –– Sexual dysfunctionSexual dysfunction
15
Management IssuesManagement Issues
Preventive measuresPreventive measures
Optimal approachesOptimal approaches
Comprehensive careComprehensive care
ManagementManagement
Immediate drainageImmediate drainageLocal cutaneous care +/Local cutaneous care +/-- infection treatmentinfection treatmentNutritional careNutritional careCounseling and consentCounseling and consentSurgical treatmentSurgical treatmentPostoperative carePostoperative careRehabilitation and reintegrationRehabilitation and reintegration
16
Preoperative CarePreoperative Care
Adequate diagnosisAdequate diagnosisTreat infections (Treat infections (schistosomiasisschistosomiasis, malaria, TB, LGV), malaria, TB, LGV)Treat anemiaTreat anemiaGood nutritionGood nutritionEstrogen therapyEstrogen therapyRemove stones (6 weeks)Remove stones (6 weeks)AB ?AB ? (RCT (RCT -- Tomlinson, 1998)Tomlinson, 1998)
Timing of Repair Timing of Repair
First attempt most successful!First attempt most successful!
Mature fistula concept Mature fistula concept -- SimsSims–– 22--4 months4 months–– Initial drainage results in few closuresInitial drainage results in few closures
Immediate repair to prevent social ostracismImmediate repair to prevent social ostracism–– 170 consecutive patients <3 months170 consecutive patients <3 months–– Closure (n=156) & continence (n=146) Closure (n=156) & continence (n=146) -- WaaldjikWaaldjik
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Early RepairEarly Repair
Exam every 2 weeks for pliabilityExam every 2 weeks for pliability--usually 4usually 4--8 weeks after injury 8 weeks after injury (Carr & (Carr & Webster, 1996)Webster, 1996)
In recurrent fistulas, liberal use of In recurrent fistulas, liberal use of Martius graft and interval 3Martius graft and interval 3--6 months 6 months post repair post repair ((RangnekarRangnekar et al., 2000)et al., 2000)
Route of RepairRoute of Repair
VaginalVaginal
AbdominalAbdominal
Combined (vaginal & abdominal)Combined (vaginal & abdominal)
? Laparoscopic? Laparoscopic
18
General Principles of RepairGeneral Principles of Repair
Adequate operative exposureAdequate operative exposure
Tension free, multiple layer closureTension free, multiple layer closure
Bladder drainage Bladder drainage
+/+/-- Pedicle graft interpositionPedicle graft interposition
Vaginal RepairVaginal Repair
Preferred methodPreferred method
Absence of need for abdominal repairAbsence of need for abdominal repair
19
Indications for Vaginal RepairIndications for Vaginal Repair
Simple fistulaSimple fistulaUrethral fistulaUrethral fistulaAbsent CI:Absent CI:–– Poor exposurePoor exposure–– Vaginal scarring & stenosisVaginal scarring & stenosis–– Small bladderSmall bladder–– Abdominal pathologyAbdominal pathology–– Need for ureteral reimplantationNeed for ureteral reimplantation
Abdominal RepairAbdominal Repair
Most complex fistulasMost complex fistulasComplicated fistulasComplicated fistulas
Disadvantage:Disadvantage:–– CostCost–– Complications Complications
20
Indications For Abdominal RepairIndications For Abdominal Repair
Insufficient vaginal sizeInsufficient vaginal size
Inadequate operative exposureInadequate operative exposure
Ureteral fistula / obstructionUreteral fistula / obstruction
Access Access omentalomental graftgraft
Concomitant abdominal pathologyConcomitant abdominal pathology
Low bladder complianceLow bladder compliance
Operative TechniqueOperative Technique--Abdominal RepairAbdominal Repair--
Catheterize uretersCatheterize ureters
Circumscribe fistulaCircumscribe fistula
Dissect bladder wall flapsDissect bladder wall flaps
Omental interpositionOmental interposition
21
Combined RepairCombined Repair
When single route inadequate (poor When single route inadequate (poor exposure) or insufficient (not successful)exposure) or insufficient (not successful)
When previously failed trigonal or When previously failed trigonal or supratrigonalsupratrigonal repairrepair
When When omentalomental interposition necessary interposition necessary while fistula exposed from belowwhile fistula exposed from below
Requirements For Requirements For Successful Technique (I)Successful Technique (I)Freedom from local infection/inflammationFreedom from local infection/inflammationIdentification of all fistulas and pathologyIdentification of all fistulas and pathologyAdequate exposureAdequate exposureWide mobilization of vagina & bladderWide mobilization of vagina & bladderFistula excision not always necessaryFistula excision not always necessaryUse of appropriate suture material outside Use of appropriate suture material outside bladder mucosabladder mucosa
22
Requirements for Requirements for Successful Technique (II)Successful Technique (II)TensionTension--free closure of bladder free closure of bladder (multiple layers)(multiple layers)Graft when indicatedGraft when indicatedPostPost--operative bladder drainageoperative bladder drainageContinent diversion may be necessary Continent diversion may be necessary after multiple failed attemptsafter multiple failed attempts
? When primary diversion? When primary diversion
Surgical Graft TechniquesSurgical Graft Techniques
Labial fat and BC muscle(Martius)Labial fat and BC muscle(Martius)Full thickness labial graftFull thickness labial graft
RectusRectus muscle flapmuscle flap
GracilisGracilis musclemuscleOmental pedicleOmental pediclePeritoneal flapPeritoneal flapFree blabber mucosal autograftFree blabber mucosal autograft
No randomized dataNo randomized data
23
Urinary DiversionsUrinary Diversions
Extremely limited acceptabilityExtremely limited acceptability--–– 0.6% of 2484 patients (Hilton/Nigeria)0.6% of 2484 patients (Hilton/Nigeria)
Short and long term morbidityShort and long term morbidity–– 1/7 fatality; 1/7 reoperation day 101/7 fatality; 1/7 reoperation day 10
Risk of metabolic, infectious, obstructive Risk of metabolic, infectious, obstructive and renal disorders and renal disorders Long term complications in remote Long term complications in remote situations (Hodges/Uganda)situations (Hodges/Uganda)
Postoperative CarePostoperative Care
Adequate bladder drainage 2Adequate bladder drainage 2--3 weeks3 weeksHigh fluid input and outputHigh fluid input and outputPostoperative AB prophylaxisPostoperative AB prophylaxisAvoid excessive activity 4Avoid excessive activity 4--6 weeks6 weeksPerineal hygienePerineal hygienePelvic rest 3 monthsPelvic rest 3 months
24
Complications of TreatmentComplications of Treatment
Persistent incontinencePersistent incontinenceGynatresiaGynatresiaDyspareunia Dyspareunia UretericUreteric injuryinjuryIrritative lower tract symptomsIrritative lower tract symptomsSmall scarred bladderSmall scarred bladder
Postoperative MorbiditiesPostoperative Morbidities
AmenorrheaAmenorrheaAnuriaAnuriaAtresiaAtresiaBladder stonesBladder stonesGynatresiaGynatresiaIncontinence (urinary or fecal)Incontinence (urinary or fecal)Leg weaknessLeg weaknessSuperficial wound infectionSuperficial wound infectionUrinary retentionUrinary retentionUrinary tract infectionUrinary tract infection
25
AmenorrheaAmenorrhea
PituitaryPituitary--hypothalamic dysfunction (63%)hypothalamic dysfunction (63%)AshermanAsherman’’ss syndromesyndromeSheehanSheehan’’s syndromes syndromePIDPID
Amenorrhea several months to 15 yrs in 66 Amenorrhea several months to 15 yrs in 66 patients; in 55 of these, menses returned patients; in 55 of these, menses returned within 6 months after repair. (within 6 months after repair. (EvohEvoh, 1979), 1979)
Postoperative Complications (I)Postoperative Complications (I)
56 patients repaired56 patients repaired–– 10 mild SUI, 3 type II, 5 type III10 mild SUI, 3 type II, 5 type III–– 8 DI8 DI–– 8 Gynatresia8 Gynatresia–– 10 dyspareunia10 dyspareunia–– 8 foot drop8 foot drop–– 4 amenorrhea4 amenorrhea
Elkins, 1994Elkins, 1994
26
Postoperative Complications (II)Postoperative Complications (II)
When at UVJ:When at UVJ:–– 40% SUI40% SUI–– 2% vs. 20% hemorrhage when 2% vs. 20% hemorrhage when juxtacervicaljuxtacervical
When midvaginal:When midvaginal:–– 60% gynatresia &/or 60% gynatresia &/or –– small bladder with instabilitysmall bladder with instability
Elkins, 1994Elkins, 1994
Management Factors Management Factors
Comprehensive evaluationComprehensive evaluationFixity of vaginal structures Fixity of vaginal structures Experience and surgical skillsExperience and surgical skillsPrevious attemptsPrevious attemptsLate referralLate referralMobilization of tissuesMobilization of tissuesLayer closure without tensionLayer closure without tensionTreat infections: malaria, TB, LGV, Treat infections: malaria, TB, LGV, SchistosomiasisSchistosomiasis
27
Unresolved IssuesUnresolved Issues--ManagementManagement--Timing of repairTiming of repairRoute of repairRoute of repairNewer techniquesNewer techniquesTechniques for incontinenceTechniques for incontinencePostoperative carePostoperative careUnmet needs of surgical treatmentUnmet needs of surgical treatmentManagement of complications Management of complications
Outcome Issues Outcome Issues
Predictive factorsPredictive factors
Definition of successDefinition of success
Standard reportingStandard reporting
28
Overall Success RatesOverall Success Rates
Author # casesAuthor # cases % success % success WachawanWachawan 163163 59.159.1RatheeRathee 4949 71.471.4FalandryFalandry 261261 81.281.2GhororoGhororo 4848 81.381.3EnqueteEnquete AfuAfu 418418 82.082.0DocquierDocquier 394394 83.083.0BenchekrounBenchekroun 598598 84.084.0RafiqueRafique 4242 85.785.7GueyeGueye 111111 86.086.0BhattacharyaBhattacharya 6262 87.187.1Kelly & Kelly & KwastKwast 309309 88.088.0MuletaMuleta 12101210 92.692.6ElkinsElkins 100100 95.095.0HiltonHilton 24842484 97.797.7WaaldjikWaaldjik 17161716 98.598.5
OutcomeOutcome-- Primary Repair (I)Primary Repair (I)
87.087.0272720012001CarrerasCarrerasLatzkoLatzko
7.47.487.487.423023019921992FalandryFalandryChassarChassar Moir Moir Martius Martius
9.09.084.784.71138113819981998KellyKellyMartius Martius GracilisGracilis muscle muscle Urethral reconstructionUrethral reconstructionUreter reimplantationUreter reimplantation
77.0311988Elkins
Latzko Martius Latzko + MartiusMobilization + MartiusMobilization
59.159.1828219831983WadhawanWadhawanTransvaginalTransvaginalflapsplittingflapsplittingMartius Martius
Vaginal
98.0421991EnzelbergerChassar Moir
96.0251990ElkinsModified Martius flap
70.0641989IloabachieVaginal
%Incontinence
Success rate (%)# casesYearAuthorProcedureApproach
29
OutcomeOutcome-- Primary Repair (II)Primary Repair (II)
Approach Procedure Author Year Total # cases
Success rate (%)
Vesical autoplasty; transvesical, extraperitoneal or transperitpneovesical
Gil-Vernet
1989 39 100.0
Transvesical, simple layered
Motiwala
1991 58 95.0
Transperitoneal +/- omental flap
Motiwala
1991 10 90.0
Modified O’Conor – transvesical, no flap
Moriel
1993 16 100.0
Abdominal
O’Conor
Demirel
1993 17 94.0
Outcome Primary RepairOutcome Primary Repair
6.595.217162004Waaldijk6.288.03091993Kelly & Kwast-85.017891989Ward
11.088.05001989Waaldijk-75.03691989 Lawson-90.01501989Ojengbede-95.01001989Martey-61.03251988Ahmad
10.083.02481983Kelly12.074.01521973Ashworth10.071.0701967Bird
Incontinence(%) after
successful closure
Success rate (%)
Total#
casesYearAuthor
Unreported procedures
30
Outcome Outcome
No standard definition of success!No standard definition of success!–– Closure of fistulaClosure of fistula–– Repair incontinenceRepair incontinence–– Restore ability to have sexual intercourseRestore ability to have sexual intercourse–– Return of menstruationReturn of menstruation–– ReRe--integration into societyintegration into society
Predictors of Adverse OutcomePredictors of Adverse Outcome
Subjective observations of moderate to Subjective observations of moderate to severe scarring or damage to urethra or severe scarring or damage to urethra or bladder neck bladder neck (Arrowsmith)(Arrowsmith)Type of fistula and state of Type of fistula and state of perifistularperifistulartissues, but also 1tissues, but also 1stst procedure procedure ((GueyeGueye))Location most significant Location most significant ((GassessewGassessew))# previous attempts, severity, health, # previous attempts, severity, health, facilities, experience & expertise facilities, experience & expertise (Kelly)(Kelly)
31
Differences between fistula repairs resulting in failure or cure at the Addis Ababa Fistula Hospital
1987-1988
* p<0.001; ** p<0.0005Kelly & Kwast, 1993
4.44.4**
1.91.9**
7.17.1**
1.11.1**
47.247.2**
40.740.7**
58.358.3****
4848212178781212
517517446446
639639
17.117.18.58.5
38.638.69.99.9
90.190.181.781.7
100.0100.0
121266
262677
64645858
7171
RUPTURED UTERUSRUPTURED UTERUSLIMB CONTRACTURESLIMB CONTRACTURESPREOPERATIVE FEEDINGPREOPERATIVE FEEDING≥≥ 4 ATTEMPTS AT REPAIR4 ATTEMPTS AT REPAIRTRANSFUSION BLOOD/PLASMATRANSFUSION BLOOD/PLASMAANESTHESIA IN ADDITION TO ANESTHESIA IN ADDITION TO SPINALSPINALFISTULA COMPLICATED FISTULA COMPLICATED (much scarring, total destruction of (much scarring, total destruction of the urethra, the urethra, uretericureteric orifices at the orifices at the edge of, or outside the fistula, small edge of, or outside the fistula, small bladder, RVF associated, calculi)bladder, RVF associated, calculi)
%%##%%##Cure (n=1096)Cure (n=1096)Failure (n=71)Failure (n=71)
Fistula characteristicsFistula characteristics
Outcome With GraftOutcome With Graft
41170013Vesicovaginal
fistula(n=34)
311107Urethrovaginalfistula involving
bladder neck (n=12)
Failure
IncontinentHealedFailureIncontine
ntHeale
d
Anatomic repair (n=25)Martius flap (n=21)
Type of fistula
Rangnekar et al., 2000
32
OutcomeOutcome-- Recurrent FistulasRecurrent Fistulas
70.066.733.3
54309
1989LawsonUnreported procedures12≥3
81.065.024842003HiltonUnreported procedures1
2
100.0421989Gil-Vernet
Abdominal(vesicalautoplasty,omental graft)
Abdominal1-7
96.0981994Arrowsmith
Abdominal(O’Conor) OrVaginal(Martius)
Abdominal(O’Conor) OrVaginal(Martius)
1-3
Successrate(%)
#casesYearAuthor
Procedure atlast repair
attempt
Type of priorprocedure
# repairs
Treatment SuccessTreatment Success
When is success defined:When is success defined:–– At discharge? 7At discharge? 7--14 days14 days–– Long term? > 6 monthsLong term? > 6 months
Single vs. Multiple repair operations:Single vs. Multiple repair operations:–– Report success for 1Report success for 1stst, 2, 2ndnd, 3, 3rdrd, etc, etc–– Report success combined rate for all Report success combined rate for all
operationsoperations
33
Outcome Outcome -- # Procedures# Procedures
Arrowsmith, 1993Arrowsmith, 1993
Outcome & # procedures % patients % cumulative
Dry (1) 81.0 % (n=79) 81.0 % Dry (2) 8.0 % (n=8) 89.0 % Dry (3) 4.0 % (n=4) 93.0 %
Dry (>3) 3.0 % (n=3) 96.0 %
Incontinent 4.0 % (n=4)
Total 100.0 % (n=98)
Fistula CureFistula Cure
For a 100% cure, the following For a 100% cure, the following conditions must be fully satisfied:conditions must be fully satisfied:–– Complete continence by day and nightComplete continence by day and night–– Bladder capacity> 170mlBladder capacity> 170ml–– No SIUNo SIU–– Normal coitus without dyspareuniaNormal coitus without dyspareunia–– No traumatic amenorrheaNo traumatic amenorrhea–– Ability to bear childrenAbility to bear children
Coetzee & Lightgow, 1996Coetzee & Lightgow, 1996
34
Subsequent Pregnancy (I)Subsequent Pregnancy (I)
C/SC/S12 of 33 patients pregnant within 1 12 of 33 patients pregnant within 1 year of repair delivered vaginallyyear of repair delivered vaginallyCriteria for vaginal delivery:Criteria for vaginal delivery:–– NonNon--recurring cause of obstructed laborrecurring cause of obstructed labor–– Graft interposition at closureGraft interposition at closure–– InIn--hospital closely supervised deliveryhospital closely supervised delivery
Kelly, 1979
Subsequent Pregnancy (II)Subsequent Pregnancy (II)
Determinant factors of successDeterminant factors of success–– Antenatal supervision, nutrition, UTI Rx Antenatal supervision, nutrition, UTI Rx –– Improved maternal educationImproved maternal education
Elective C/S for all fistula patientsElective C/S for all fistula patientsElements of continued improvementElements of continued improvement–– Continued education against harmful socioContinued education against harmful socio--
cultural practices that prevent antenatal care cultural practices that prevent antenatal care and early use of Ob careand early use of Ob care
Emembolu, 1992
35
Unresolved IssuesUnresolved Issues--OutcomeOutcome--
No standard definition of cureNo standard definition of cureNo standard classificationNo standard classificationNo standard reporting systemNo standard reporting system–– TimeTime–– Number of procedures and typeNumber of procedures and type–– Type of fistula repairType of fistula repair–– Associated morbiditiesAssociated morbidities
ClassificationClassification
AnatomyAnatomyFunctionFunctionSurgical complexitySurgical complexityOutcome predictabilityOutcome predictability
36
Classification systems for VVFClassification systems for VVF
Grade 1: Normal, healthy tissuesGrade 1: Normal, healthy tissuesGrade 2: Mild scarringGrade 2: Mild scarringGrade 3: More scarring, poor vaginal accessGrade 3: More scarring, poor vaginal accessGrade 4: Repeat repairGrade 4: Repeat repairGrade 5: Inoperable per vaginaGrade 5: Inoperable per vaginaType A: Less than 1 cm diameterType A: Less than 1 cm diameterType B: Over 1 but less than 2 cm diameterType B: Over 1 but less than 2 cm diameterType C: Over 2 cm diameterType C: Over 2 cm diameterType D: Any of above type with rectovaginal fistulaType D: Any of above type with rectovaginal fistula
McConnachieMcConnachie19581958
1. 1. UethroUethro--vaginal, confined to urethravaginal, confined to urethra2. Fistula at bladder neck or root of urethra2. Fistula at bladder neck or root of urethra3. Body & floor of bladder destroyed3. Body & floor of bladder destroyed4. 4. UteroUtero--vesical fistulavesical fistula
SimmsSimms18521852
ClassificationClassificationAuthorAuthorYearYear
ClassificationClassificationAuthorAuthorYearYear
1. 1. JuxtaJuxta--urethralurethral2. Mid2. Mid--vaginalvaginal3. High3. High4. Massive4. Massive5. Other5. Other
TahzibTahzib19851985
1. 1. JuxtaurethralJuxtaurethral2. Vault2. Vault3. Mid3. Mid--vaginalvaginal4. 4. JuxtacervicalJuxtacervical
LawsonLawson19721972
1. Simple 1. Simple vesicovesico--vaginal fistulavaginal fistula2. Simple recto2. Simple recto--vaginal fistulavaginal fistula3. Simple urethra3. Simple urethra--vaginal fistulavaginal fistula4. Vesico4. Vesico--uterine fistulauterine fistula5. Difficult high recto5. Difficult high recto--vaginal fistulavaginal fistula6. Difficult urinary fistula 6. Difficult urinary fistula -- complexcomplex
Hamlin &Hamlin &NicholsonNicholson
19691969
37
ClassificationClassificationAuthorAuthorYearYear
1. 1. JuxtaJuxta urethralurethral2. 2. JuxtaJuxta cervicalcervical3. Gynecological3. Gynecological4. Giant fistula 4. Giant fistula 5. Mid vaginal 5. Mid vaginal 6. Vesico uterine6. Vesico uterine
IloabachieIloabachie19921992
1. Simple1. Simple-- far from ureters, urethra intactfar from ureters, urethra intact2. Complex 2. Complex –– partial or total loss of urethrapartial or total loss of urethra3. Complicated 3. Complicated –– total loss of urethra +/total loss of urethra +/-- RVFRVF
GueyeGueye19921992
ClassificationClassificationAuthorAuthorYearYear
1. Vesico1. Vesico--cervicalcervical2. 2. JuxtaJuxta--cervicalcervical3. Mid3. Mid--vaginal vaginal vesicovesico--vaginalvaginal4. Sub4. Sub--urethral urethral vesicovesico--vaginalvaginal5. Urethro5. Urethro--vaginalvaginal
ElkinsElkins19941994
I I -- fistula not involving closing mechanismfistula not involving closing mechanism
IIAaIIAa–– fistula involving closing mechanism, without (sub)total fistula involving closing mechanism, without (sub)total urethra & without circumferential defecturethra & without circumferential defect
IIAbIIAb––fistula involving closing mechanism, without (sub)total fistula involving closing mechanism, without (sub)total urethra & with circumferential defecturethra & with circumferential defect
IIBaIIBa––fistula involving closing mechanism, with (sub)total fistula involving closing mechanism, with (sub)total urethra & without circumferential defecturethra & without circumferential defect
IIBbIIBb––fistula involving closing mechanism, with (sub)total fistula involving closing mechanism, with (sub)total urethra & with circumferential defecturethra & with circumferential defect
III III -- involving ureter & other exceptional fistulasinvolving ureter & other exceptional fistulas
WaaldijkWaaldijk19951995
38
ClassificationClassificationAuthorAuthorYearYear
1. Simple1. Simple2. Complex 2. Complex –– poor access for repair, significant tissue poor access for repair, significant tissue
loss, loss, uretericureteric involvement, coexistent RVF. involvement, coexistent RVF.
HiltonHilton19941994
1. Simple 1. Simple 2. Complex, fistulas involving other organs: 2. Complex, fistulas involving other organs:
urethra, ureter, uterus, rectum urethra, ureter, uterus, rectum
McKay McKay 20042004
1. Simple 1. Simple --minimal vaginal scarring and good bladder minimal vaginal scarring and good bladder volume volume
2. Complex 2. Complex --severe vaginal scarring and /or reduced severe vaginal scarring and /or reduced bladder volume, needing some degree of bladder volume, needing some degree of vaginoplastyvaginoplasty or even reconstruction of the or even reconstruction of the vagina.vagina.
Browning Browning 20042004
ClassificationClassificationAuthorAuthorYearYear
1. Simple 1. Simple –– the healing quality of the tissue margins are virtually the healing quality of the tissue margins are virtually normal and these can be resolved by simple, meticulously suturednormal and these can be resolved by simple, meticulously sutured, , layer closure.layer closure.
2. Complex 2. Complex –– recurrent fistulas, fistulas with extensive tissue loss, recurrent fistulas, fistulas with extensive tissue loss, developmental deficiencies, impaired healing potential of its developmental deficiencies, impaired healing potential of its margins, all fistulas that involve the sphincter mechanism, postmargins, all fistulas that involve the sphincter mechanism, post--obstetric and urethraobstetric and urethra--vaginal.vaginal.
ChappleChapple20052005
Type 1: Distal edge of fistula > 3.5 cm from external urinary meType 1: Distal edge of fistula > 3.5 cm from external urinary meatusatusType 2: Distal edge of fistula 2.5Type 2: Distal edge of fistula 2.5-- 3.5 cm from external urinary meatus3.5 cm from external urinary meatusType3: Distal edge of fistula 1.5Type3: Distal edge of fistula 1.5--<2.5 cm from external urinary meatus<2.5 cm from external urinary meatusType 4: Distal edge of fistula < 1.5 cm from external urinary meType 4: Distal edge of fistula < 1.5 cm from external urinary meatusatus
(a) Size < 1.5 cm, in the largest diameter(a) Size < 1.5 cm, in the largest diameter(b) Size 1.5(b) Size 1.5--3 cm, in the largest diameter3 cm, in the largest diameter(c) Size > 3 cm, in the largest diameter(c) Size > 3 cm, in the largest diameter
i. None or only mild fibrosis (around fistula and/or vagina) andi. None or only mild fibrosis (around fistula and/or vagina) and/or /or vaginal length > 6 cm, normal capacityvaginal length > 6 cm, normal capacity
ii. Moderate or severe fibrosis (around fistula and/or vagina) aii. Moderate or severe fibrosis (around fistula and/or vagina) and/or nd/or reduced vaginal length and/or capacityreduced vaginal length and/or capacity
iii. Special consideration e.g iii. Special consideration e.g postradiationpostradiation, , uretericureteric involvement, involvement, circumferential fistula, previous repaircircumferential fistula, previous repair
GohGoh20042004
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Classification systems for RVFClassification systems for RVFClassificationClassificationAuthorAuthorYearYear
Type 1: Distal edge of fistula > 3.5 cm from hymenType 1: Distal edge of fistula > 3.5 cm from hymenType 2: Distal edge of fistula > 3.5 cm from hymenType 2: Distal edge of fistula > 3.5 cm from hymenType3: Distal edge of fistula > 3.5 cm from hymenType3: Distal edge of fistula > 3.5 cm from hymenType 4: Distal edge of fistula > 3.5 cm from hymenType 4: Distal edge of fistula > 3.5 cm from hymen
(a) Size < 1.5 cm, in the largest diameter(a) Size < 1.5 cm, in the largest diameter(b) Size 1.5(b) Size 1.5--3 cm, in the largest diameter3 cm, in the largest diameter(c) Size > 3 cm, in the largest diameter(c) Size > 3 cm, in the largest diameter
i. No or mild fibrosis around fistula and/or vaginai. No or mild fibrosis around fistula and/or vaginaii. Moderate or severe fibrosisii. Moderate or severe fibrosisiii. Special consideration e.g. iii. Special consideration e.g. postradiationpostradiation, previous repair., previous repair.
GohGoh20042004
II--loss of perineal body not associated with an identifiable fistuloss of perineal body not associated with an identifiable fistulous lous tracttract
IIII--loss of perineal body associated with a fistulous tract involvinloss of perineal body associated with a fistulous tract involving g the lower third of the vaginathe lower third of the vagina
IIIIII--fistulas involving the lower third of the vagina with an intact fistulas involving the lower third of the vagina with an intact or or attenuated perineal body.attenuated perineal body.
IVIV--fistulas involving the middle third of the vaginafistulas involving the middle third of the vaginaVV--fistulas involving the upper part of the vaginafistulas involving the upper part of the vagina
RosensheinRosenshein19801980
ClassificationClassification
Comparative assessment of the published Comparative assessment of the published fistula literature is currently impossiblefistula literature is currently impossible
–– No accepted standardized methodNo accepted standardized method–– Previously based on type, size and sitePreviously based on type, size and site–– No definition of terminology used No definition of terminology used
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Classification IssuesClassification Issues
Size (length and width)Size (length and width)LocationLocationDegree of vaginal scarringDegree of vaginal scarringNumber of fistulasNumber of fistulasAttachment to pelvic wallAttachment to pelvic wallCondition of urethral sphincterCondition of urethral sphincterLocation of ureteral orificesLocation of ureteral orificesComplicating factors: RVF, inflammationComplicating factors: RVF, inflammation
VVF TypeVVF Type
SimpleSimpleComplexComplexComplicatedComplicated
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Simple VVFSimple VVFCharacteristicsCharacteristics
Single openingSingle openingLess than 2 cmLess than 2 cmMinimal scarringMinimal scarringVagina > 6 cmVagina > 6 cm
Complex VVFComplex VVFCharacteristicsCharacteristics
Multiple openingsMultiple openings2 2 -- 4 cm in size4 cm in sizeFailed previous repairFailed previous repairModerate scarring; scarred trigone, UVJModerate scarring; scarred trigone, UVJVagina <4 cmVagina <4 cmPartially absent urethraPartially absent urethraVesicocervicalVesicocervical (uterine)(uterine)
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Complicated VVFComplicated VVFCharacteristicsCharacteristics
Over 4 cm in sizeOver 4 cm in sizeShort vagina (<4 cm)Short vagina (<4 cm)Absent urethraAbsent urethraReduced bladder capacityReduced bladder capacityUreteral involvementUreteral involvementRVFRVFSevere scarringSevere scarring
VVF SiteVVF Site
UrethralUrethralTrigonalTrigonalSupratrigonal Supratrigonal UrethrotrigonalUrethrotrigonal
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VVF ClassificationVVF Classification
Type IType I-- SimpleSimpleType II Type II –– ComplexComplexType III Type III –– Complicated Complicated
A A -- UrethralUrethralB B -- Trigonal Trigonal C C -- SupratrigonalSupratrigonalD D -- Urethrotrigonal Urethrotrigonal
-- 1, 2, 3... # repair attempts1, 2, 3... # repair attempts
ConclusionsConclusions
Urgent need for prevention Urgent need for prevention Urgent need for standard classificationUrgent need for standard classificationNeed for management protocolsNeed for management protocolsNeed for trainingNeed for trainingNeed for researchNeed for research
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Unresolved IssuesUnresolved Issues--Topics for DiscussionTopics for Discussion--
Simple fistulasSimple fistulasComplex fistulasComplex fistulasComplicated fistulasComplicated fistulasComplications of fistula treatmentComplications of fistula treatment
Simple Fistulas (I)Simple Fistulas (I)
Role of preventive bladder drainageRole of preventive bladder drainagePreoperative carePreoperative careOptimal length of postoperative drainageOptimal length of postoperative drainagePostop care and recurrence preventionPostop care and recurrence preventionIncontinence managementIncontinence managementLong term followLong term follow--up of repaired fistulasup of repaired fistulas
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Simple Fistulas (II)Simple Fistulas (II)
Optimal lowOptimal low--tech repair & trainingtech repair & trainingCriteria for referralCriteria for referralWhen to use graftWhen to use graftWhen to use an abdominal routeWhen to use an abdominal routeNewer techniquesNewer techniquesLong term true successLong term true successFate of subsequent pregnancyFate of subsequent pregnancy
Complex Fistulas (I)Complex Fistulas (I)
Frequency and incidence of Frequency and incidence of associated injuriesassociated injuriesFrequency of upper tract abnormalitiesFrequency of upper tract abnormalitiesRole of ureteral catheterizationRole of ureteral catheterizationOptimal graftingOptimal graftingWhen to sling concomitantlyWhen to sling concomitantly
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Complex Fistulas (II)Complex Fistulas (II)
When to augment bladder or substituteWhen to augment bladder or substituteWhen to augment vagina and howWhen to augment vagina and howWhen to combine approachesWhen to combine approachesHow many repeatsHow many repeatsWhen to consider diversionWhen to consider diversionUrethral reconstructionUrethral reconstructionComplete urethral lossComplete urethral loss
Complicated Fistulas (I)Complicated Fistulas (I)
What diagnostic studiesWhat diagnostic studiesWhen primary diversion and whichWhen primary diversion and whichOptimal approach to RVFOptimal approach to RVFRole of augmentation graftRole of augmentation graftAssessment of defecatory dysfunctionAssessment of defecatory dysfunctionAssociated injuriesAssociated injuries
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Complicated Fistulas (II)Complicated Fistulas (II)
Where to carry out complex proceduresWhere to carry out complex proceduresOptimal followOptimal follow--up of diverted up of diverted patientspatientsLong term studies on sexual functionLong term studies on sexual functionOptimal skin careOptimal skin careChildren issuesChildren issues
Complications of Repair (I)Complications of Repair (I)
Vaginal Vaginal AtresiaAtresia–– Optimal approach, vaginal, abdominalOptimal approach, vaginal, abdominal–– Optimal materialOptimal material–– Long term resultsLong term results–– Functional resultsFunctional results
Urinary Diversion Urinary Diversion –– Long term followLong term follow--upup–– Optimal followOptimal follow--upup–– Morbidity and mortalityMorbidity and mortality–– Optimal reimplantationOptimal reimplantation–– Mobile vs. Fixed unitsMobile vs. Fixed units
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Complications of Repair (II)Complications of Repair (II)
Urinary IncontinenceUrinary Incontinence–– Incidence of neurologic dysfunctionIncidence of neurologic dysfunction–– Incidence of contracted bladderIncidence of contracted bladder–– Optimal sphincter repair and timingOptimal sphincter repair and timing–– When and what slingWhen and what sling–– When and what augmentationWhen and what augmentation
CriteriaCriteriaFollowFollow--upupMaterialMaterial
A Call to ActionA Call to Action
TrainingTrainingResearchResearchSpecialized centersSpecialized centersEarly interventionEarly interventionPrevention Prevention
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I am old, and need to remember. I am old, and need to remember. You are young, and need to learn.You are young, and need to learn.
If I forget the words, will you If I forget the words, will you remember the music?remember the music?
Ashanti proverb
Thank You!Thank You!