Selection Criteria
for VVF Surgery
Steve Arrowsmith, MD
World Fistula Fund
Mercy Ships
Pre-Test
This Child needs:
a) Land Reform
b)A Tractor and Plow
c) A Course in Agriculture
d)Food
e) All of the above
1
Pre-Test
This woman with VVF
needs:
a) Improved obstetrical
services
b) Empowerment
c) Safe Motherhood
Education
d) A Fistula Repair
e) All of the Above
Classification
►
J. Marion Simms, 1852:
1. Urethrovaginal
2. “Fistulae situated at the bladder neck or root
of the bladder, destroying the trigone”
3. Fistulae of the body and floor of the bladder
4. Uterovesical
2
Classification Systems
► Mahfouz
1930
► Thomas 1945
► Krishnan 1949
► McConnachie 1958
► Moir 1961
► Bird 1967
► Lawson 1968
► Hamlin 1969
► Goh 2005
Classification
►
Hamlin:
1.
2.
3.
4.
5.
6.
Simple VVF
Simple RVF
Simple urethrovaginal fistula
Difficult high RVF
Vesicouterine fistula
Difficult urinary fistula
3
Classification
► Other
Terminology
ƒ Descriptive:
►Circumferential
►“Lungu”
Lungu”:
around the corner
►“Unusual”
Unusual”: Bull horn, bullet
ƒ Etiologic:
►Infectious
►Malignant
Classification
►Each
of these systems are:
ƒ A composite of anatomic and
descriptive language
ƒ Subjective
ƒ Uncertain in purpose
4
Classification
►A
Descriptive Scheme:
ƒ Allows for communication
ƒ May aid selection of approach
►But,
does the system answer
the right questions?
Classification
► Better
questions?
ƒ Why is this a
nasty fistula?
ƒ Can I handle it?
ƒ How will the
patient do?
5
Classification
►How
can we do better?
ƒ Collect outcomes data
ƒ Observe which parameters matter
most in outcome
VVF Score
►Based
on 229 patients in
Jos, Nigeria
ƒ Outcome stratified simply as
“Wet” or “Dry”
►Dry
meaning successful repair
and no stress incontinence
6
VVF Score
► Parameters
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
considered:
Size of the fistula
Location of the fistula
Status of Urethra
Status of Bladder Neck
Degree of Scarring
Descriptive types (circumferential, etc.)
Presence of RVF
VVF Score
Score
Scarring
Urethral Status
None
0
Mild
1
Moderate
2
Severe
3
Intact
0
Partial Damage
2
Complete Destruction
3
7
VVF Score
Continence Rate vs. VVF Score
100
80
Continence Rate
(%)
60
Dry
40
Wet
20
0
Score 0,1
Score 2,3
Score >3
VVF Score
VVF Score
►Score
3 or less, and there is an 85%
chance the patient will be dry
►Score 4 or more, and the rate of
dryness is 41%
8
VVF Score
►Can
be used to:
ƒ Choose cases suitable for training
ƒ Counsel patients regarding hope for
success
ƒ Optimize patient selection for
working visits
Summary
►Tailor
Classification to Clinical
Questions
►Don’t be afraid to use data
►Don’t be afraid to use data
►Don’t be afraid to use data
9