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Simple FistulasSimple FistulasEvaluation & ClassificationEvaluation & Classification

Marcella L. Roenneburg,Marcella L. Roenneburg, M.D.M.D.

The Weinberg Center for WomenThe Weinberg Center for Women’’ssHealth & Medicine at MercyHealth & Medicine at MercyMercy Medical CenterMercy Medical CenterBaltimore, MarylandBaltimore, Maryland

The Johns Hopkins HospitalThe Johns Hopkins HospitalBaltimore, MarylandBaltimore, Maryland

Currently there is Currently there is nono universally universally accepted scientific accepted scientific

classification system for fistulas.classification system for fistulas.

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International Staging System

•• Allows health care workers from many Allows health care workers from many nations to speak the same languagenations to speak the same language

•• Allows comparisons of outcomes of Allows comparisons of outcomes of various surgeries and treatments.various surgeries and treatments.

•• Should predict success ratesShould predict success rates•• Required for long term scientific study of Required for long term scientific study of

fistulasfistulas

Staging SystemStaging System

•• Simple but completeSimple but complete•• Low TechLow Tech•• LocationLocation

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A. A. BenchekrounBenchekroun, M.D., M.D.

•• II Urethrovaginal fistulaUrethrovaginal fistula•• IIII cervicovaginalcervicovaginal fistulafistula•• IIIIII vesicovaginal fistulavesicovaginal fistula

Based on location with increased success Based on location with increased success rate with increasing numberrate with increasing number

J. J. UrolUrol (Paris) 1987(Paris) 1987

T. E. Elkins, M.D.T. E. Elkins, M.D.A)A) VesicocervicalVesicocervical

B)B) JuxtacervicalJuxtacervical

C)C) MidvaginalMidvaginalVesicovaginalVesicovaginal

D)D) SuburethralSuburethralVesicovaginalVesicovaginal

E)E) UrethrovaginalUrethrovaginal

Based on Location

Am J ObstetGynecology

1994

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Broad Field Injury

Wall, L. 2004

KeesKees WaaldijkWaaldijk, M.D., Ph.D., M.D., Ph.D.

• Type I - not involving closing mechanism• Type II - involving the closing mechanism

– A) without (sub)total urethral involvement• a) without circumferential defect• b) with circumferential defect

– B) with (sub)total urethral involvement• a) without circumferential defect• b) with circumferential defect

• Type III -miscellaneousInternational J Gynecol & Obstet, 1995

Based on Location

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Staging SystemStaging System

•• Simple but completeSimple but complete•• Low TechLow Tech•• LocationLocation•• SizeSize

C.R. Wheeless, M.D.

•• Stage I Stage I -- <2cm fistula above the <2cm fistula above the trigonetrigone(not involving the urethra, (not involving the urethra, trigonetrigone, or , or uretericureteric ridge)ridge)

•• Stage II Stage II -- 22--4cm fistula above the 4cm fistula above the trigonetrigone

•• Stage III Stage III -- 44--6cm fistula above the 6cm fistula above the trigonetrigone ororany size fistula which involves the continence any size fistula which involves the continence mechanism of the proximal urethra, mechanism of the proximal urethra, urethrovesical junction (UVJ), urethrovesical junction (UVJ), trigonetrigoneoror uretericureteric ridgeridge

•• Stage IVStage IV-- 6 cm or greater fistula6 cm or greater fistula

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Surgical Results

Stage I87 pts (39%)

No Surgery8pts (9%)

Lost to F/U20 pts (23%)

WET13pts (15%)

Dry46 pts (53%)

Fistula5 pts (6%)

Urinary Inc8 (9%)

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Stage I Stage I

•• 90% fistulas healed 90% fistulas healed –– 57% Dry57% Dry–– 33% Wet with Incontinence (Before Slings)33% Wet with Incontinence (Before Slings)

•• 10% Persistent Fistulas 10% Persistent Fistulas

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Stage IIStage II

•• 77% Fistulas have healed (10/13)77% Fistulas have healed (10/13)–– 54% Dry (7/13)54% Dry (7/13)–– 23% Urinary Incontinence (3/13)23% Urinary Incontinence (3/13)

•• 23% Failed/Persistent Fistula (3/13)23% Failed/Persistent Fistula (3/13)

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Stage IIIStage III

–– 85% Fistulas have healed (27/32)85% Fistulas have healed (27/32)•• 75% Dry ( 24/32)75% Dry ( 24/32)•• 10% Urinary Incontinence ( 3/32) 10% Urinary Incontinence ( 3/32)

–– 15% Failed/ Persistent Fistula (5/32)15% Failed/ Persistent Fistula (5/32)

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Stage IVStage IV

•• 78% Fistulas have healed (11/14)78% Fistulas have healed (11/14)–– 50% Dry (7/14)50% Dry (7/14)–– 29% Urinary Incontinence (4/14)29% Urinary Incontinence (4/14)

•• 21 % Failed/ Persistent Fistula (3/14)21 % Failed/ Persistent Fistula (3/14)

Staging SystemStaging System

•• Simple but completeSimple but complete•• Low TechLow Tech•• SizeSize•• LocationLocation•• ScarringScarring•• Multiple fistulasMultiple fistulas•• Number of previous unsuccessful repairsNumber of previous unsuccessful repairs

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Staging must be under AnesthesiaStaging must be under Anesthesia

•• Small fistula Small fistula –– Big hole (Big hole (KeesKees))

•• approx. 40% of office examinations have approx. 40% of office examinations have significant variation from EUAsignificant variation from EUA

Standardized Definition of SuccessStandardized Definition of Success

•• Closure of fistula?Closure of fistula?

•• Closure of fistula and no stress, urge or Closure of fistula and no stress, urge or mixed incontinence?mixed incontinence?

•• Closure of fistula, no incontinence and Closure of fistula, no incontinence and able to have intercourse comfortably?able to have intercourse comfortably?

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Urinary IncontinenceUrinary Incontinence

•• 55% of patients with successful closure of 55% of patients with successful closure of their fistulas suffer from urinary their fistulas suffer from urinary incontinenceincontinence–– 31% Stress incontinence31% Stress incontinence–– 4% Detrusor Instability4% Detrusor Instability–– 20% Mixed urinary incontinence20% Mixed urinary incontinence

–– Murray, BJOC, July 2002Murray, BJOC, July 2002

GynetresiaGynetresia & & DyspareuniaDyspareunia

•• Outcome data is lackingOutcome data is lacking

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There is an There is an urgent urgent need to need to develop an International Staging develop an International Staging

System for Vesicovaginal System for Vesicovaginal FistulasFistulas