OBSTETRIC FISTULA (Part three)

2 - The GOH’S System

A - the distal angle of the fistula >3.5 cm from the external urinary meatus.
B - the distal angle of the fistula 2.5-3.5 cm from the external urinary meatus.
C - the distal angle of the fistula 1.5-2.5 cm from the external urinary meatus.
D - the distal angle of the fistula <1.5 cm from the external urinary meatus.

1 - size <1.5 cm, in maximum diameter.
2 - size 1.5-3 cm, in maximum diameter.
3 - size >3 cm, in maximum diameter.

Nothing or single middle fibrosis, > 6cm normal capacity.

Moderate / severe fibrosis and reduced vaginal capacity and size.

Special condition, post-radiation, ureteric involvement, circumferential fistula, previous repair.

3 - The Waaldijk System

1. Surrounding mechanisms unaffected
2. Surrounding mechanisms affected
   a - without subtotal urethral involvement
     - without defects
     - circumferential
     - with defects
   b - with subtotal urethral involvement
     - without defects
     - circumferential
     - with defects
3. Ureteric fistula
   Based on size they are divided into:
     - Small <2 cm
     - Medium 2-3 cm
     - Large 4-5 cm
     - Very large <6 cm
   

Management of fistulas

1 - Conservative management

• early bladder catheterization
• vulvar dermatitis, irritation treated with zinc oxide.
• Foley catheter insertion, 16-18. If the catheter bypasses the fistula, it is excluded from treatment.
• Check after 24 hours
• Drink plenty of water but no more than 5 liters per day.
• Assessment after 4 weeks excludes closure failure.

Excluded from treatment:

• isolated rectovaginal fistula
• fistula from pelvic malignancy, radiotherapy, syphilitic infection
• women suffering from incontinence after treatment
• fistula between ureter and vagina

Treatment failure when:

• catheter in vagina
• lack of cooperation with the patient
• if the patient remains wet after 4 weeks
• catheter is removed after 4 weeks if the patient remains dry

2 - Surgical management

Juxtourethral, mid-vaginal fistulas are treated vaginally while juxtacervical fistulas are treated via vaginal or abdominal route.

The vaginal route has advantages: less bladder damage, less blood, less pain, fewer days in hospital and greater patient satisfaction.

The vaginal route is contraindicated when: there are damages in the vaginal tissue around the fistula, if the bladder has low capacity, low cooperation with the patient, presence of vaginal stenosis, involvement of other pelvic structures, when a ureteral reimplantation is required.

The abdominal route can be: intraperitoneal and extraperitoneal.

Antibiotic prophylaxis is done orally, single dose.

Preoperative preparation

• Perineum, washing and cleaning
• Increased fluids
• Enema
• Sedation, one night before and before surgery 10 mg midazolam or 100 mg phenobarbital
• Preoperative anesthetic assessment is done

Postoperative period

• Vital signs are assessed: BP, HR, Temperature
• Assessed for blood loss (vaginal / catheter) and for anemia.
• Fluid balance (intake and elimination) is monitored.
• The patient is kept with adequate anesthesia to stay calm.
• Should move as soon as possible to prevent thrombotic phenomena.
• Should take plenty of fluids to produce up to 2-3 liters of urine per day.
• The catheter is kept 5-21 days in simple cases and 21-42 days in complicated cases.
• Movement in simple cases is done within the day whereas in complicated cases (e.g., with ureteral implantation) more than 7 days rest is recommended.
• Psychotherapy exercises start the day after the operation.
• Non-absorbable sutures are removed when tissues heal.