Australian and New Zealand Journal of Obstetrics and Gynaecology2004; 502 - PDF document

Australian and New Zealand Journal of Obstetrics and Gynaecology2004; 502Ð504Blackwell Publishing, Ltd. A new classiÞcation for female genital tract ÞstulaJudith T. W. GOHDepartment of Urogynaecology, Royal WomenÕs Hospital, Carlton, Victoria, Australia CorrespondenceDr Judith Goh, Department of Urogynaecology, Royal WomenÕs Hospital, Carlton VIC 3053, Australia. Email: jtwgoh@hotmail.comReceived 9 June 2004; accepted 3 July 2004. emale genital tract ÞstulaAustralian and New Zealand Journal of Obstetrics and Gynaecology2004; 502Ð504Presence of inßammation/infection Ð in the presence ofinßammation and/or infection, surgery should be deferredSite of Þstula Ð currently, anatomical location is utilised(Table 1)Size of Þstula Ð the size of each Þstula should be docu-mented as it can inßuence subsequent bladder capacityand may affect detrusor functionScarring or tissue deÞcit Ð many smaller Þstulae can beassociated with signiÞcant scarring or vaginal stenosis.Scarring can limit access to the Þstula and markedlyincrease the degree of difÞculty encountered at time ofsurgery. Scarring and vaginal stenosis can also be a causeof sexual dysfunction following Þstula surgeryAdherence to the pubic symphysis or the pubic bone Ð insome instances, in particular distal genitourinary Þstulae,there can be a complete circumferential loss of the urethra.In these circumferential Þstulae, the anterior urethral wallis frequently adherent to the periosteum of the posterioraspect of the pubic symphysis and the urethra is immobile;these women are at risk of postÞstula urinary incontinencewith a Ôdrain-pipeÕ functionless urethraRelationship between ureteric oriÞce and the edge of theand associated with infection and ongoing inßammation.In the presence of ongoing inßammation and/or infectionthe calculi should be removed and Þstula closure delayed.Proposed new classiÞcation for genital tract standardise the classiÞcation system, reduce subjectivetion and to assess possible long-term complication risks,this new classiÞcation considers a number of items:Fixed reference points are utilised to allow standardisation ofdescription and comparison by different observers. The externalurinary meatus is used for the Þxed reference for urinary Þstula and the hymen for genito-anorectal ÞLength of vagina allows assessment of the relative size andposition of the Þstula and is also a risk factor for subsequentfor pelvic organ dysfunction and incontinence. The sphinctericmechanisms for both genitor-urinary and genito-anorectal Þstulaeare situated more than 3.5 cm from the Þxed reference points.Size of Þstula is measured in centimetres in the maximumantero-posterior and transverse dimensions. Fistula size hasbeen cited in the past, although not consistently, as a riskfactor for pelvic organ dysfunction.It also has implicationson anatomical closure, tissue deÞcit and use of graft tissue toaugment the Þstula repair.The number of Þstula (genito-urinary and anorectal) atSpecial circumstances are conditions that have a negativeimpact on surgical closure of the Þstula (e.g. surgical repairTabPrevious genitourinary Þstula classiÞcationClassiÞcation systemDescriptionMarion Sims (1852)i. Urethro-vaginal ii. Bladder neck iii. Body and ßoor of bladder iv. Utero-vesicalGrade 1: normal healthy tissuesGrade 2: mild scarringGrade 3: more scarring, poor vaginal accessGrade 4: Repeat repairGrade 5: Inoperable per vaginaype A: less than 1 cm diameterType B: over 1 but less than 2 cmype C: over 2 cmType D: any of above type with rectovaginal ÞstulaLawson (1968)i. Juxta-urethralii. Mid-vaginaliii. Juxta-cervicaliv. VaultMassive combination Þstulai. Simple vesico-vaginalii. Simple rectovaginaliii. Simple urethra-vaginal Þstula iv. Vesico-uterine ÞstulaDifÞcult high rectovaginal Þstulavi. DifÞcult urinary Þstula Ð complexi. Type 1 Þstula Ð not involve closing mechanismii. Type 2 Ð involve closing mechanismA) without (sub)total urethra involvementB) with (sub)total urethra involvementa) without circumferential defectb) with circumferential defectiii. Type 3 Ð ureter and other exceptional Þstula TabPrevious genito-anorectal classiÞcationClassiÞcation systemDescriptioni. Type 1: Total loss of perineal body with no other associated defectsii. Type 2: Fistula associated with loss of perineal bodyiii. Type 3: Fistula in lower third of vagina, intact or attenuated perineal bodyiv. Type 4: Fistula in middle third of vaginaype 5: Fistula in upper third of vagina J. T. W. Australian and New Zealand Journal of Obstetrics and Gynaecology2004; 502Ð504in women who have postradiation Þstulae or previous failedÞstula repairs is more likely fail).Genitourinary Þstula classiÞcationThe new classiÞcation divides genitourinary Þstulae into fourmain types, depending on the distance of the distal edge ofthe Þstula from the external urinary meatus. These four typesare further subclassiÞed by the size of the Þstula, extent ofassociated scarring, vaginal length or special considerations.ype 1: Distal edge of Þ�stula 3.5 cm from external urinarymeatusype 2: Distal edge of Þstula 2.5Ð3.5 cm from external urinarymeatusype 3: Distal edge of Þstula 1.5 2.5 cm from externalurinary meatusype 4: Distal edge of Þstula 1.5 cm from external urinarymeatus(a)Size 1.5 cm, in the largest diameter(b)Size 1.5Ð3 cm, in the largest diameter(c)&#x 85.;怀Size 3 cm, in the largest diameteri.None or only mild Þbrosis (around Þstula and/or vagina)and/or vag&#x 85.;怀inal length 6 cm, normal capacityModerate or severe Þbrosis (around Þstula and/or vagina)and/or reduced vaginal length and/or capacityiii.Special consideration e.g. postradiation, ureteric involve-ment, circumferential Þstula, previous repair.As an example, with this proposed classiÞcation in a Type2bi Þstula the ureteric oriÞce can be close to the Þstula edgeand it is recommended that ureteric oriÞces be identiÞedprior to or during surgery, whilst the woman with a Type 3aiiÞstula is probably at a higher risk of postoperative urinaryincontinence and requires followup.Genito-anorectal Fistula ClassiÞcationype 1: distal edge of Þ&#x 85.;怀stula 3.5 cm from hymenype 2: distal edge of Þstula 2.5Ð3.5 cm from hymenype 3: distal edge of Þstula 1.5Ð2.5 cm from hymenype 4: distal edge of Þstula 1.5 cm from hymen(a)Size 1.5 cm, in the largest diameter(b)Size 1.5Ð3 cm, in the largest diameter(c)&#x 85.;怀Size 3 cm, in the largest diameteri.No or mild Þbrosis around Þstula and/or vaginaii.Moderate or severe Þbrosisiii.Special consideration e.g. postradiation, inßammatorydisease, malignancy, previous repair.In this proposed classiÞcation, a woman with a Type 1ciiÞstula might require faecal diversion if there is ongoinginßammation or infection at the Þstula site. Type 3 or 4 Þstulaeare associated with a high risk of external anal sphincterinvolvement and might require concomitant sphincter repair.There is currently no accepted standardised method forgenital tract Þstula classiÞcation. Previously described ÞstulaclassiÞcations have been mainly based on subjective cate-gorisations. It is therefore difÞcult to compare and interpretresults from the literature using these older classiÞcations.The new proposed classiÞcation attempts to more objectivelyclassify the Þstulae by utilising a Þxed reference point andspeciÞc measurements and by taking into account possiblesurgical and postoperative sequelae.Acknowledgementsof this manuscript was presented at the InternationalUrogynaecological Association Annual ScientiÞc Meeting,December 2001 (Melbourne, Australia).etrie E. Urologic trauma in gynaecological surgery: diagnosisand management. Curr. Op Obstet Gynecol.1999; 495Ð498.Aronson MP, Bose TM. Urinary tract injury in pelvic surgery.Clin. Obstet Gynecol.2002; 428Ð438.Harkki-Siren P, Sjoberg J, Tiitinen A. Urinary tract injuriesafter hysterectomy. 1998; Goh JT, Krause HG. 1995 Brown Craig Travelling Fellowshipdestination: Ethiopia. Aust. NZ J. Obstet Gynaecol.1996; Goh JT. Genital tract Þstula repair on 116 women. Aust. NZJ. Obstet Gynaecol.1998; Margolis T, Mercer LJ. Vesicovaginal Þstula. Surv1994; : 840ÐGoh J. Vesico-vaginal Þstula: more than a hole in the bladder.Aust. Continence J.2000; : 20Ð21.Elkins TE. Surgery for obstetric vesicovaginal Þstula. A reviewof 100 operations in 82 patients. Am. J. Obstet Gynecol.1108Ð1120.Gray PH. Obstetric vesicovaginal Þstulas. Am. J. Obstet Gynecol.1970; 10Murray C, Goh J, Fynes M, Carey M. Continence outcomefollowing delayed primary obstetric genital Þstula repair at aÞstula hospital. 2002; 11Sims JM. On the treatment of vesico-vaginal Þstula. Am. J.Med. Sci.1852; : 59Ð82.12McConnachie ELF. Fistulae of the urinary tract in the femalea proposed classiÞcation. SA Med. J.1958; : 524Ð13Lawson JB. Birth-canal injuries. Proc. Roy Soc. Med.1968; 14Hamlin RH, Nicholson EC. Reconstruction of urethra totallydestroyed in labour. 1969; 15Waaldijk K. Surgical classiÞcation of obstetric Þstulas. Int. J.Gynecol. Obstet1995; 16Rosenshein NB, Genadry RR, Woodruff JD. An anatomicclassiÞcation of rectovaginal septal defects. Am. J. Obstet1980; 439Ð442.