[Some reflections on the classification of African obstetric fistulas]. / Quelques réflexions sur la classification de la fistule obstétricale africaine.

UNLABELLED: While the English-speaking world may have reached a consensus about Kees Waaldjik's classification of obstetric fistulas, no unanimity around this classification exists among French-speaking medical workers. The objective of this review is to propose a classification, based on long experience in the care of these women, by setting up a comparison with Waaldjik's. Our classification takes two criteria into account: (1) the environment of the fistula, that is: (a) fistula with a soft (relatively unscarred) vagina, b) fistula with vaginal sclerosis (bands or adhesions, vaginal stenosis or atresia), (c) vesicovaginal fistula associated with a (high or low) rectovaginal fistula or perineal lacerations (first, second or third degree); (2) the anatomical site of fistula, of which there are five types: (a) type I: fistula of the vesicovaginal wall, (b) type II: vesico-cervico-urethral fistula, with two major subgroups: type IIA (without destruction of the urethra) and type IIB (with destruction of the urethra), type IIA being subdivided in three subgroups: IIAa, IIAB and cIAI, (c) type III fistulae trigono-Neck utero-vaginal, (d) type IV: complex mixed fistula, (e) type V, high fistulas: the vesico-cervical-uterine fistula and classical vesicouterine. CONCLUSION: Our classification is simple, not simplistic, with some resemblance to that of Waaldjjik.

Classification of female genito-urinary tract fistula: Inter- and intra-observer correlations.

BACKGROUND: Currently, there is no accepted standardized classification for genital tract fistulae. Many classifications have been proposed previously, mainly based on anatomical locations. This is the first paper on inter- and intra-observer correlations using a recently published classification system based on fixed reference points. AIM: To assess intra- and inter-observer reliability of a new classification for genito-urinary fistula. METHODS: This is a prospective assessment of women with genito-urinary fistula. Women attending the Fistula Clinic in Ethiopia and Liberia were assessed by three fistula surgeons. The women were assessed in the outpatients and the fistulae were staged. In Liberia, where two surgeons were working together, inter-observer reliability was assessed. All women had the fistulae restaged in the operating theatre and intra-observer concordance was assessed. The clinicians were blinded to the outpatient results. RESULTS: A total of 119 women were recruited. All women had intra-observer assessment and had the fistula examined by the same clinician in the outpatients and in the operating theatre. Fifty of these women had inter-observer assessment with two clinicians assessing the same women. The results demonstrated that this classification system had high concordance in intra- and inter-observer reproducibility. CONCLUSION: The new classification for genito-urinary fistulae utilizing fixed reference points is a useful tool in describing fistulae. This study has shown that this classification produced consistency in description amongst different clinicians and also by the same clinician in a different consultation. This therefore allows more precise communication of clinical findings.

Classification of female genito-urinary tract fistula: a comprehensive review.

INTRODUCTION AND HYPOTHESIS: The aim of this paper is to review proposed classifications for genito-urinary fistulae. METHODS: A comprehensive literature review of historical texts, peer review publications, and abstracts was used to compile a listing of the existing genito-urinary fistula classification systems. RESULTS: The absence of an accepted standardized classification for female genito-urinary fistulae has resulted in the proliferation of a number of individually devised categorizations. Fistulae are described by size, location, degree of vaginal scarring, and type (whether it involves the bladder, rectum, intestines, uterus, etc). In addition, most classification systems have not been subjected to outcomes research, making them primarily descriptive in nature. CONCLUSIONS: There is a lack of consensus among fistula surgeons in adopting a standardized classification system or systems. Comparative assessment of studies and outcomes is not possible without a standardized classification system. Currently, there is no accepted standardized classification for female genito-urinary fistula.

Complex obstetric fistulas.

Obstetric fistulas are rarely simple. Most patients in sub-Saharan Africa and parts of Asia are carriers of complex fistulas or complicated fistulas requiring expert skills for evaluation and management. A fistula is predictably complex when it is greater than 4 cm and involves the continence mechanism (the urethra is partially absent, the bladder capacity is reduced, or both); is associated with moderately severe scarring of the trigone and urethrovesical junction; and/or has multiple openings. A fistula is even more complicated when it is more than 6 cm in its largest dimension, particularly when it is associated with severe scarring and the absence of the urethra, and/or when it is combined with a recto-vaginal fistula. The present article reviews the evaluation methods and main surgical techniques used in the management of complex fistulas. The severity of the neurovascular alterations associated with these lesions, as well as inescapable limitations in staff, health facilities, and supplies, make their optimal management very challenging.

Assessment and classification of fistula-in-ano in patients with Crohn's disease by hydrogen peroxide enhanced transanal ultrasound.

Crohn's disease is well known for its perianal complications, among which fistulas-in-ano are the most common abnormalities. Fistulas-in-ano in Crohn's disease tend to be complex and have a high recurrence rate. Therefore the role of surgery is generally more conservative. Hydrogen peroxide enhanced transanal ultrasound has proven superior to physical examination, fistulography, computed tomography, and conventional ultrasound in demonstrating the fistula tract. This study examined the fistula tracks in patients with Crohn's disease. Forty-one patients with Crohn's disease and fistula-in-ano were investigated using physical examination, sondage of the fistula, proctoscopy and transanal ultrasound. Hydrogen peroxide was infused via a small catheter into the fistula. The main track and the ramification of the fistula were classified according to the anatomical Parks' classification. Only 9 (22%) patients had a single inter- or transsphincteric fistula. In 5 (12%) patients a single supra- or extrasphincteric fistula (high fistula) was found, in 14 (34%) more than one fistula track (ramified), and in 13 (32%) an anovaginal fistula. Thus 78% of patients had a surgically difficult to treat fistula. In the ramified fistula the main track follows the Parks' classification, but ramifications can have a bizarre pattern which is not in agreement with this classification. Optimal documentation by means of hydrogen peroxide enhanced transanal ultrasound is therefore mandatory before surgery or before other therapies such as anti-tumor necrosis factor treatment.