1 Simple Fistulas Simple Fistulas Evaluation & Classification Evaluation & Classification Marcella L. Roenneburg, Marcella L. Roenneburg, M.D. M.D. The Weinberg Center for Women The Weinberg Center for Women’s Health & Medicine at Mercy Health & Medicine at Mercy Mercy Medical Center Mercy Medical Center Baltimore, Maryland Baltimore, Maryland The Johns Hopkins Hospital The Johns Hopkins Hospital Baltimore, Maryland Baltimore, Maryland Currently there is Currently there is no no universally universally accepted scientific accepted scientific classification system for fistulas. classification system for fistulas.
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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
• 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
•• 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