Obstetrical Fistulas

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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

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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.

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Maternal Morbidity & MortalityMaternal Morbidity & Mortality

WHO, 2005WHO, 2005

Maternal Mortality RatiosMaternal Mortality Ratios

WHO, 2005WHO, 2005

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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

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Overview Overview


Obstructed neglected laborObstructed neglected laborDifficult operative deliveryDifficult operative deliveryTraditional surgical practicesTraditional surgical practicesPelvic immaturityPelvic immaturityNutritional deficienciesNutritional deficienciesSocioSocio--cultural factorscultural factors

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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


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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


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

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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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


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

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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


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

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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


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!

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Obstetrical Fistulas