Predictive value of classification systems and single fistula-related factors in surgical management of vesicovaginal fistula.

AIMS: The aim of this study was to find the most clinically useful vesicovaginal fistula (VVF) classification system or single fistula-related factor, which would be helpful in determining the most proper management leading to successful treatment. METHODS: Between 2018 and 2020, 30 patients were diagnosed with VVF and underwent the Latzko procedure. Nineteen patients, after previously failed surgery, were injected with platelet-rich-plasma (PRP) before a final attempt to close VVF. Patients with primary VVF were included into the surgery only group and patients with secondary VVF were included into PRP and surgery group. Each patient was classified according to 13 different classification systems. RESULTS: Statistical evaluation revealed some significant differences between the patients who required PRP injection and repeated surgery, compared with patients who were successfully treated at first surgery but only with Lawson, Waaldijk, Arrowsmith, and Tafesse classifications. Patients who succeded with the fistula closure after the first surgical procedure had significantly higher body mass index (BMI) when compared with patients who required PRP injection prior surgical procedure (30.9 vs. 25.7, respectively; p < .05). CONCLUSIONS: None of the classification systems allows to precisely predict VVF surgery outcome. There are several factors such as previous surgery, lack of urethral involvement, lack of circumferential defect which might suggest that PRP injection would help to preserve watertightness of the closure. The most important finding is that overweight is the most positive predicting demographic feature of surgical success. Thus we may conclude that Martius flap technique should be taken into consideration in patients with low BMI.

Obstetric vesico-vaginal fistulas: Midvaginal and juxtacervical fistula repair outcomes in the Democratic Republic of Congo.

OBJECTIVE: This study aims to establish the postoperative success rates of midvaginal versus juxtacervical obstetric vesicovaginal fistula (VVF) repairs. In addition, we aim to quantify the impact of patient sociodemographic variables, fistula classification, and surgical repair techniques associated with postoperative outcomes. METHODS: A retrospective cohort study was conducted involving 420 women who had undergone a primary obstetric VVF repair. All data were collected from the Panzi Hospital, Democratic Republic of Congo between 2015 and 2017. Patient notes were analyzed to determine sociodemographic variables, symptoms, fistula classification, surgical repair techniques, and postoperative follow up. Binary logistic regression presented as χ2 for trend was used to establish P values. RESULTS: Overall, 95.6% and 96.2% of midvaginal and juxtacervical VVF, respectively, underwent a successful repair. The principal prognostic factor associated with a statistically significant likelihood of a successful repair was the degree of fibrosis noted preoperatively (P =0.004, 95% confidence interval [CI] 2.38-94.61). Furthermore, VVF were more likely to have a successful repair if they were closed in two layers (P = 0.004, 95% CI 1.86-25.81) and sutured vertically (P = 0.005, 95% CI 1.16-2.52). CONCLUSION: Overall, high postoperative success rates of obstetric VVF repair can be expected among well-trained surgeons but a complex interplay of factors means that the ability to preoperatively foreshadow individual outcomes remains difficult.

Persistent depression after obstetric fistula repair.

OBJECTIVE: To measure depression over time using the Patient Health Questionnaire 9 (PHQ-9) and identify characteristics associated with persistent depression. METHODS: A database of women undergoing obstetric fistula repair was used to examine associations between depression and variables such as demographics, type of fistula, and postoperative continence status. RESULTS: A total of 797 patients completed the PHQ-9 at the initial preoperative assessment; 365 (45.8%) had a PHQ-9 score of 5 or higher, indicating depression. Preoperatively, depression was associated with women aged 18-34 years, with no children, and with fistula for 5 years or less. Postoperatively, depression was associated with persistent incontinence. Over time, however, depression was rarely found among women returning for follow-up. CONCLUSION: Postoperative depression decreased over time in women who returned for follow-up, either due to selection bias or due to improved adjustment to one's circumstances. This study underscores the need for ongoing follow-up, especially for those not presenting for care or with persistent incontinence.

Panzi score as a parsimonious indicator of urogenital fistula severity derived from Goh and Waaldijk classifications.

OBJECTIVE: To derive a comprehensive system that allows a single score to define relative fistula severity. METHODS: The present observational study included women with urogenital fistula treated at the Panzi Hospital, Democratic Republic of Congo, or its outreach clinics across the Democratic Republic of Congo between September 1, 2013, and December 31, 2014. Fistula severity was assessed by Goh and Waaldijk classifications and surgical success was ascertained. Logistic regression was used to select fistula characteristics predictive of surgical failure, and to preliminarily verify the newly derived Panzi score. RESULTS: Overall, 837 women were included in the analysis. Goh or Waaldijk fistula descriptors associated with a higher probability of poor surgical outcomes in the unadjusted bivariate analysis were circumferential defect (P=0.007), proximity to the external urethral orifice (P=0.001), and size (P=0.001). These fistula characteristics were used to construct the Panzi score, which varied from 3 (most severe) to 0 (minor fistula). For each increase above 0, the odds of surgical failure increase by a factor of 1.65 (P<0.001). CONCLUSION: The Panzi score of urogenital fistula provided a data-driven, simple, comprehensive, and parsimonious score. It could be used to report group data, to provide continuous level data for use in higher order statistics, and to resolve issues such as the cut-off point for referring women to hospital in accordance with fistula complexity.

Genital tract fistula: a case series from a tertiary centre in South Africa.

INTRODUCTION AND HYPOTHESIS: We describe the demographic profile, aetiology, management and surgical outcomes in women with genital tract fistula presenting to a tertiary urogynaecology unit. METHODS: This retrospective audit included 87 patients managed in our unit between 2008 and 2015. Frequencies and means with standard deviations are presented for categorical and continuous data. Continuous dependent variables are categorized as above or below the median for bivariate analyses performed using the chi-squared test (α = 0.05). RESULTS: The mean age of the women was 34.7 years, 64.4% were Black African, 70.2% were multiparous, 49.4% were married, 82.8% were employed, and 21.8% were HIV-infected, with 47.4% on antiretroviral treatment. Vesicovaginal (47.1%) and rectovaginal (41.4%) fistula were the most frequent injuries. The majority of the injuries (67.8%) were obstetric, with 26.4% occurring during caesarean delivery. Repair had been attempted previously in 43.7% of patients. In 63.2% of the repairs the approach was vaginal and in 35.6% abdominal. Interposition grafts were used in 23% of repairs. In 85.1% of patients the initial repair at our centre was successful. Patients with multiple repairs were more likely to have complications (p = 0.03). HIV infection was not significantly associated with complications. CONCLUSIONS: A high rate of successful repair was found, with previous unsuccessful repairs associated with poorer outcomes, highlighting the need for centralized management.

Does the Goh classification predict the outcome of vesico-vaginal fistula repair in the developed world?

INTRODUCTION AND HYPOTHESIS: The Goh Vesico-Vaginal Fistula (VVF) classification has prognostic value in VVF in the developing world (predominantly obstetric), with chances of successful closure decreasing from type 1 to type 4. We evaluated the prognostic value of the Goh classification for VVF of the developed world (predominantly iatrogenic). METHODS: A retrospective review was performed of 63 consecutive patients with a mean age of 53 years (range 21-88) undergoing VVF repair under a single surgeon between 2006 and 2014. Demographic data, aetiology, operative data and final outcome (anatomical and functional) were recorded. Fistulae were classified according to Goh's system and outcomes correlated with this classification. RESULTS: Successful closure at first repair was achieved in 90 % of type 1, 83 % of type 2, 100 % of type 3 and 100 % of type 4 fistulae. At second repair success was achieved in 100 % of all fistulae, irrespective of type. Continence post-anatomical closure was achieved in 100 % of type 1, 83 % of type 2, 83 % of type 3 and 75 % of type 4 fistulae. Fistula size and patient age were significant determinants of successful outcome. CONCLUSION: Anatomical closure was obtained in 90 % of VVF of the developed world at first attempt, 100 % overall, and was not affected by the Goh classification. Continence post-anatomical closure of VVF was 94 % overall and deteriorated with increasing Goh classification type. The Goh classification has no prognostic value regarding anatomical closure in VVF of the developed world, but may be useful in determining the risk of post-anatomical closure urinary incontinence. Smaller fistula size and younger patient age are significant determinants of success.

Obstetric fistula in a district hospital in DR Congo: Fistula still occur despite access to caesarean section.

OBJECTIVE: To study the profile of classification, etiology, and the relation between initial classification, and the results of vesicovaginal fistula surgery in a district hospital in DR Congo. METHODS: This study was based on the analysis of all consecutive patients being treated for VVF in Kisantu between November 2006 and November 2012. The fistula was classified according to the classification of Waaldijk. The location of VVF and degree of fibrosis were noted. Post-operatively, the first examination of patients took place a few days after catheter removal and subsequent review 2-3 months later. Statistical analysis was done in Graphpad Prism 6. RESULTS: Among 146 patients with VVF, 117 had a primary fistula. The majority of fistula was type I (56%) followed by type III (21%). The majority underwent a caesarean section (63.4%). The mean duration of labor was 30.7 hr. Delay in getting a caesarean in time was due to difficulties in reaching the hospital in 55%. Overall, the closure rate after the first surgical treatment was 65%. The continence rate of the patients with a successful closure was 63%. CONCLUSION: VVF can occur after caesarean section because of the prolonged labor that already causes ischemia and necrosis of the bladder wall and vesicovaginal septum before or while the caesarean section is being performed. Access to general hospitals and the management of the pregnant women needs to be improved. Despite a reasonable closure rate of 65%, post-fistula incontinence remains an important clinical problem.

Development and comparison of prognostic scoring systems for surgical closure of genitourinary fistula.

OBJECTIVE: The purpose of this study was to test the diagnostic performance of 5 existing classification systems (developed by Lawson, Tafesse, Goh, Waaldijk, and the World Health Organization) and a prognostic scoring system that was derived empirically from our data to predict fistula closure 3 months after surgery. STUDY DESIGN: Women with genitourinary fistula (n = 1274) who received surgical repair services at 11 health facilities in sub-Saharan Africa and Asia were enrolled in a prospective cohort study. Using one-half of the sample, we created multivariate generalized estimating equation models to obtain weighted prognostic scores for components of each existing classification system and the empirically derived scoring system. With the second one-half, we developed receiver operating characteristic curves using the prognostic scores and calculated areas under the curves (AUCs) and 95% confidence intervals (CIs) for each system. RESULTS: Among existing systems, the scoring systems that represented the World Health Organization, Goh, and Tafesse classifications had the highest predictive accuracy: AUC, 0.63 (95% CI, 0.57-0.68); AUC, 0.62 (95% CI, 0.57-0.68), and AUC, 0.60 (95% CI, 0.55-0.65), respectively. The empirically derived prognostic score achieved similar predictive accuracy (AUC, 0.62; 95% CI, 0.56-0.67); it included significant predictors of closure that are found in the other classification systems, but contained fewer, nonoverlapping components. The differences in AUCs were not statistically significant. CONCLUSION: The prognostic values of existing urinary fistula classification systems and the empirically derived score were poor to fair. Further evaluation of the validity and reliability of existing classification systems to predict fistula closure is warranted; consideration should be given to a prognostic score that is evidence-based, simple, and easy to use.

Comparison of two classification systems for vesicovaginal fistula.

INTRODUCTION AND HYPOTHESIS: This study aims to compare the prognostic value of two obstetric fistula classification systems. METHODS: Prospective analysis of 202 patients evaluated for obstetric fistula (OF) at the General Referral Hospital of Panzi, Bukavu, DRC, from April through December 2009. Fistula classification using both Goh's and Waaldijk's systems, as well as preoperative, surgical, and follow-up assessment were included. Receiver operating characteristics (ROC) curves were used to compare the accuracy of the two systems to discriminate successful closure from persistent fistula. RESULTS: Two hundred two women underwent fistula repair. Ten were lost to follow-up. At longest follow-up, 181 patients (88.3%) had successful fistula closure. On multivariate analysis, the independent variables of multiparity and a primary or secondary repair were more likely to have a successful closure. In Waaldijk's system, no single component was more predictive of successful closure than another. In Goh's system, type 4 fistulae were more likely to have failed closure compared to those with type 1 or 2 (p = 0.0144). When comparing ROC curves, Goh's system had significantly better ability to predict successful closure than the Waaldijk's system, p = 0.0421. CONCLUSIONS: Waaldijk and Goh are the two most commonly used obstetric fistula classification systems. In this series of OF patients at Panzi Hospital in the Democratic Republic of Congo, Goh's classification system demonstrated a significantly better prediction of OF closure than the Waaldijk's system.

[Contribution to the classification of obstetrical vesicovaginal fistula]. / Contribution a la classification de la fistule vesico vaginale obstetricale.

UNLABELLED: Our study was made with the C.H.U of the hospital of the Point G in the Service of Urology in Bamako in Mali. It is about a retrospective study in a service which has a dosage unit in load of F.V.V.O on average two hundred patients per annum. We included in our study all the F.V.V.O examined in the service which had an organic assessment. This assessment noted the aspect of the vagina and the topographic situation of the dent. Sometimes the examination of certain patients required a loco-regional anaesthesia and tests with the methylene blue to individualize the dent. CONCLUSION: The classification proposed is the result of an experiment on the ground. It is a tool for learning thus enabling him to distinguish from the types of dent with their forecast and from the technical epic to realize.

Duration of bladder catheterization after surgery for obstetric fistula.

OBJECTIVE: To compare the surgical outcome at discharge and at 6-months follow up in patients who underwent repair of obstetric fistulae with postoperative bladder catheterization for 10, 12, or 14 days. METHODS: A retrospective study of 212 obstetric fistula patients who underwent repair with postoperative bladder catheterization for 10 days (group 1), 12 days (group 2), and 14 days (group 3) at the Bahir Dar Hamlin Fistula Center in Ethiopia. Fistulas were classified according to Goh's system. RESULTS: There were 68 women (32%) in group 1, 62 women (29%) in group 2, and 82 women (39%) in group 3. There was a significant difference in the extent of urethral involvement, fistula size, and degree of vaginal scarring among the 3 groups, with the more extensively damaged patients catheterized for longer. Breakdown of repair was seen in 1.5% of patients in group 1, none in group 2, and 2% in group 3 (P=0.47). CONCLUSION: Postoperative catheterization for 10 days may be sufficient for management of less complicated obstetric vesicovaginal fistulae.

The classification of obstetric vesico-vaginal fistulas: a call for an evidence-based approach.

Classification systems for vesico-vaginal fistulas (VVFs) are as old as fistula surgery itself. Many classification systems have been proposed over the past 150 years, and nearly all have been based on descriptions of the size and anatomic location of the defect. While useful in communicating the appearance of a given fistula, systems based on size and anatomy do not necessarily give information on the difficulty of repair or the prognosis for successful outcome. This article serves as a call for a classification system for VVFs based on outcome rather than anatomy. Developing a reliable system will require data resources that do not yet exist. Based on incomplete data from a Nigerian VVF center, a possible system is proposed for further study. Once available, an outcome-based classification system could be vital in selecting fistula cases appropriate for training surgeons, and in improving communication with patients.

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.

The immediate management of fresh obstetric fistulas.

OBJECTIVE: It has been a general rule to wait with the repair of an obstetric fistula for a minimum period of 3 months allowing the patient to become an outcast. In a prospective way an immediate management was studied and antibiotics were not used, all according to basic surgical principles. METHODS: A total of 1716 patients with a fistula duration of 3 to 75 days after delivery were treated immediately on presentation by catheter and/or early closure. Instead of antibiotics, a high oral fluid regimen was instituted. The fistulas were classified according to anatomic and physiologic location in types I, IIAa, IIAb, IIBa, and IIBb, and according to size in small, medium, large, and extensive. The operation became progressively more complicated from type I through type IIBb and from small through extensive. RESULTS: At first attempt 1633 fistulas (95.2%) were closed and another 57 could be closed at further attempt(s), accounting for a final closure in 1690 patients (98.5%); 264 patients (15.4%) were healed by catheter only. Of these 1690 patients with a closed fistula, 1575 (93.2%) were continent and 115 (6.8%) were incontinent. The results as to closure and to continence became progressively worse from type I through type IIBb and from small through extensive. Postoperative wound infection was not noted; postoperative mortality was encountered in 6 patients (0.4%). CONCLUSION: This immediate management proves highly effective in terms of closure and continence and will prevent the patient from becoming an outcast with progressive downgrading medically, socially, and mentally.

Surgical classification of obstetric fistulas.

OBJECTIVE: To develop a surgical classification for obstetric fistulas in order to compare surgical techniques and results. METHODS: Based on a retrospective analysis of 775 consecutive fistula patients, the following classification is presented: (type I) fistulas not involving the urethral closing mechanism; (type II) fistulas involving the urethral closing mechanism; and (type III) ureter and other exceptional fistulas. Type II fistulas can be further divided into: (A) without (sub)total urethra involvement, and (B) with (sub)total urethra involvement; and (a) without a circumferential defect, and (b) with a circumferential defect. This classification was applied prospectively in over 2700 consecutive fistula patients. RESULTS: The surgical technique becomes progressively more complicated from type I through type IIBb. The results of closure and continence worsen progressively from type I through type IIBb. Personal experience in the case of type III fistulas is very limited. CONCLUSION: This classification enables a systematic comparison of different surgical techniques and an objective evaluation of results from different centers.

Successful management of vesicovaginal fistulae at St. Gaspar Hospital, Itigi, Singida, Tanzania: a preliminary report.

Twenty five patients with vesicovaginal fistulae were managed at St. Gaspar Hospital, Itigi, Tanzania between February 1993 and March 1994. Most of them, 92% were repaired vaginally routinely using the Martius labial flap and 8% were repaired transabdominally because the fistulae were inaccessible vaginally as they were vesicouterine or vesicocervical fistulae. The success rate was 96% after the first operative attempt.

PIP: Since there are no specialized fistula centers in Tanzania, fistulae are usually repaired in national referral hospitals where other surgical conditions are managed. Only a few small hospitals attempt the repair, forcing women from remote rural areas to travel long distances in search of treatment. St. Gaspar Hospital, in Itigi, however, is a small, rural facility which has offered the routine management of vesicovaginal fistulae (VVF) since February 1993. 25 patients with various sized VVF were managed at the hospital between February 1993 and March 1994. All patients had their fistulae confirmed by vaginal examination using a Sim's speculum. The VVF resulted in 96% of cases from prolonged or difficult labor, with the most common form of VVF being the very large fistulae, among 28%, followed by the big juxta-cervical fistulae, among 24%. Twelve patients were aged 15-24 years, while the remainder were aged 25-40. 92% were repaired vaginally routinely using the Martius labial flap. The remaining 8% were repaired transabdominally given the inaccessibility of vesicouterine or vesicocervical fistulae via the vagina. All patients were administered postoperative prophylactic antibiotics for five days and had indwelling catheters for 14 days. They were then discharged home one or two days after removal of the catheter with advice that they should abstain from sexual intercourse for three months, avoid pregnancy for one year, and deliver by cesarean section should they become pregnant. An outcome was considered successful when the patient left the hospital dry and remained so upon the follow-up visit 6-8 weeks later; the success rate was 96% after the first operative attempt.

Fistulas vesico vaginales / Vesicovaginal fistulas

Se revisaron: etiología, manejo y seguimiento de las pacientes atendidas en el servicio de urología del Hospital San Juan de Dios de Bogotá, entre enero de 1988 y junio de 1993 con DX de fístula vesico-vaginal con el fin de estandarizar el tratamiento de acuerdo a la localización de la fístula, haciendo énfasis en la técnica quirúrgica. El estudio reunió 20 pacientes tratados en la institución en el período de tiempo mencionado. Con base en la revisión teórica, se diseñó un modelo de historia clínica dirigido al estudio específico de esta patología, que aplicada a las historias de las pacientes en mención, permitió las siguientes conclusiones: - Las pacientes consultaron, desde el momento en que apareció la fístula y hasta 23 años después del inicio de los síntomas. - El tiempo mínimo para intervenir con éxito esta patología debe ser de 8 semanas a partir del momento en que se manifiesta la fístula. - Para las fístulas infratrigonales se propone un acceso vaginal, y el reparo debe hacerse en tres planos con sutura 4-0 de ácido poliglicólico. - Las fístulas supratrigonales, se abordaron por vía transvesical, reparándolas también en tres planos con el mismo tipo de sutura. - Recomendamos para todos los casos una derivación tipo cistostomía durante 14 a 24 días

[Vesicovaginal fistula. Apropos of 600 cases]. / Les fistules vésico-vaginales. A propos de 600 cas.

A personal series of 600 cases of vesicovaginal fistula is reviewed. Patients could be classified as a function of site of fistula into 3 groups: I. urethrovaginal fistula (31%); II. cervicovaginal fistula (22%); III. vesicovaginal fistula (46%). Etiology was mainly obstetrical (94%), as was multiparity (69%). An associated lesion was detected in 11% of cases (uterine, ureteral and rectal). Surgery was performed after a minimum period of 3 months with the following results. Type I fistulae, using a low approach and requiring urethral refection, showed good results in only 53% of cases. Type II fistulae, usually treated through a low approach (80%), were relieved in 80% of cases, with the reservation that reinforcement of bladder neck was often necessary. Type III fistulae, treated by a high (60%) or low (40%) approach were nearly always corrected (98%). In 2 cases of destroyed urethra unable to benefit from urethral plastic surgery, bladder repositioning with continent cystostomy was satisfactory. 72 cases with irrecuperable destroyed bladder received definitive high diversion: 34 Coffey, 5 Bricker, and since 1975, 33 continent ileocecal bladders using Benchekrouns' technique.