121. Urinary Tract Fistulae **PART 1** скачать в хорошем качестве

121. Urinary Tract Fistulae **PART 1**

Goh Classification of Vesicovaginal Fistula (VVF) 🔹 The Goh classification is used to describe and assess VVF based on **three key factors**: 📍 1. Location (Distance from External Urethral Orifice - EUO): • Type 1: More than 3.5 cm (no urethral involvement) • Type 2: 2.5–3.5 cm • Type 3: 1.5–2.5 cm • Type 4: Less than 1.5 cm 📏 2. Size of Fistula: • a: Less than 1.5 cm • b: 1.5–3 cm • c: More than 3 cm 🌟 3. Degree of Scarring: • Grade I: No or mild fibrosis (vaginal length more than 6 cm) • Grade II: Moderate to severe fibrosis (reduced vaginal capacity) • Grade III: Special cases (circumferential fistula[Complete separation of bladder from urethra], ureteric involvement) 📌 Example Classification: ➡️ Goh type 3bII = fistula 1.5–2.5 cm from EUO [Measured through vagina], size 1.5–3 cm, moderate/severe scarring. ✅ Ideal for preoperative planning and outcome prediction, especially in obstetric fistulas. ----------------------------------------------------------------------------------------------------------------------------------- 🖼️Waaldijk Classification of Vesicovaginal Fistula (VVF)🖼️📀🎼🕺🏻💃🏼 A widely used system for classifying obstetric VVF, focusing on involvement of the urethral closing mechanism and fistula size. 🚪🔑🚪🔑1.Closing mechanism 🚪🔑🚪🔑 Type I: Fistula not involving the urethral closing mechanism (more than 5 cm from the external urethral meatus) Type II: Fistula involving the urethral closing mechanism (within 5 cm of the external urethral meatus) • IIA: Without subtotal or total involvement of the urethra • a: Without circumferential defect • b: With circumferential defect • IIB: With subtotal or total involvement of the urethra • a: Without circumferential defect • b: With circumferential defect Type III: Miscellaneous fistulas (for example, ureteric or other exceptional locations) Size 📏categories: • Small: Less than 2 cm • Medium: 2 to 3 cm • Large: 4 to 5 cm • Extensive: More than 6 cm [m+: S,M,L,XL] [SECOND----siX] Notes📝: • The closing mechanism includes the urethra and bladder neck. Its involvement is important for continence outcomes after repair. • This system is helpful for standardizing reporting and surgical planning in obstetric fistula ------------------------------------------------------------------ Immature VVF VS Mature VVF Immature VVF • Appearance: The opening and margins are usually inflamed, erythematous (red), and often display granulation tissue. The surrounding vaginal mucosa is swollen and may show bullous edema. • Features: • Edematous, friable tissue • May be tender or bleed on contact • Unhealed, active inflammatory process • Timing: Typically identified shortly after the initial injury (e.g., recent surgery, trauma, or childbirth). • Clinical Approach: Surgical repair is usually postponed until the inflammation subsides and tissue becomes healthier, reducing the risk of surgical failure. Mature VVF • Appearance: The fistulous tract and surrounding tissue have progressed to a chronic, more stable state. The margins are smooth with evidence of fibrosis and scarring of the bladder and vaginal wall. • Features: • Well-defined, non-inflamed edges • Minimal or no granulation tissue • Surrounding mucosa appears healthy but shows fibrotic changes • Timing: Usually present weeks after the initial injury, once acute inflammatory changes have resolved. • Clinical Approach: Definitive surgical repair is typically performed at this stage, as mature tissue heals more predictably and reduces recurrence risk ---------------------------------------------------------------------------------------------------------------------------------------------- The Oxford grading scale—commonly known as the Modified Oxford Scale—is a widely used, subjective system for assessing pelvic floor muscle strength via internal examination. It helps clinicians communicate the degree of pelvic floor contraction felt during a digital (finger) vaginal or anal assessment. The grading is as follows: • Grade 0: No contraction • Grade 1: Flicker (barely discernible contraction) • Grade 2: Weak contraction—without any lift • Grade 3: Moderate contraction—with some lift of examiner’s finger • Grade 4: Good contraction—clear lift of finger(s) • Grade 5: Strong contraction—firm squeeze and lift with resistance ------------------------------------------------------------------------------------------------------------ HUTCH CRITERIAS to prevent fistula formation: 1. Immediate identification 2.Watertight closure 3.Extraperitoneal drain 4. Prolonged catheterization[mnemonic m+: I WE Pee] ----------------------------------