V08_No_2_Final.pdf Point of Technique 149Urology Journal Vol 8 No 2 Spring 2011 Laparoscopic Repair of Vesicouterine Fistula A Brief Report With Review of Literature Vishwajeet Singh,1 Pallavi Aga Mandhani,2 Seema Mehrotra,3 Rahul Janak Sinha1 Urol J. 2011;8:149-52. www.uj.unrc.ir Keywords: laparoscopy, fistula, uterus, urinary bladder 1Department of Urology, CSMMU (formerly KGMU), Lucknow, India 2Department of Radiodiagnosis, CSMMU (formerly KGMU), Lucknow, India 3Department of Obstetrics and Gynecology, Queen Mary Hospital, CSMMU (formerly KGMU), Lucknow, India Corresponding Author: Rahul Janak Sinha, MS, MCh Department of Urology, CSMMU (formerly KGMU), Lucknow, (U.P.), India Tel: +91 941 500 3051 E-mail: rahuljanaksinha@rediffmail.com Received June 2010 Accepted February 2011 INTRODUCTION Vesicouterine fistula (VUF) is a rare type of genitourinary fistula that accounts for 1% to 4% of all reported urogenital fistulas.(1) With the rising rate of lower segment cesarean section (LSCS) all over the world, the management of this entity becomes even more important, both from clinical as well as medico-legal points of view.(2) Herein, we report the laparoscopic management of a patient with VUF following LSCS. CASE REPORT A 34-year-old woman presented with history of recurrent suprapubic pain, secondary amenorrhea along with menouria following LSCS ten years earlier. She developed these complications one month after she underwent the LSCS. She had menouria and suprapubic pain at monthly intervals for 3 to 5 days. Apart from these symptoms, no other symptoms were reported. Physical examination of the abdomen and per-vagina were unremarkable. Ultrasonography of the kidney, ureter, and bladder and renal function tests were within normal limits. Intravenous urography was unremarkable. Cystoscopy revealed an opening of approximately 10 mm in the supratrigonal region (Figure 1). Cystoscopy was repeated after one week (at the the time she was having menouria) and showed blood clots emerging from a fistulous opening (Figure 2). A 6-F Figure 2. Cystoscopic view of the fistula in supratrigonal region with blood clots. Figure 1. Cystoscopy showing a round to oval 10-mm opening in the supratrigonal region. Laparoscopic Repair of Vesicouterine Fistula—Singh et al 150 Urology Journal Vol 8 No 2 Spring 2011 ureteral catheter over a J-tip guidewire (0.035”) (Terumo; glidewire) was inserted through this opening. With little manipulation, it entered the uterine cavity and coiled inside. In the same operative sitting, hysteroscopy was performed with the aid of a 7.5-F ureteroscope. It confirmed the position of the coiled ureteral catheter and the guidewire inside the uterine cavity. TECHNIQUE This patient was managed by laparoscopic surgery. In lithotomy position, bilateral ureteral orifices and the fistulous opening were catheterized with 6 F ureteral catheters. A 22-F Foley catheter was inserted inside the urinary bladder. Thereafter, the patient was placed in supine position with the head tilted down. Pneumoperitoneum was created and 3 ports were inserted; a 12-mm supraumbilical port for camera and two 5-mm para-rectal ports on either side laterally (halfway between the umbilicus and the anterior superior iliac spine). Dissection was started in the vesicouterine peritoneal fold. The bladder was densely adhered to the uterus. A plane between the bladder and uterus was created by sharp dissection. The fistulous tract was identified by the presence of the ureteral catheter entering the uterine cavity. A deliberate cystotomy was made (2 cm wide) in the posterior bladder wall, which was extended downwards to incorporate the fistulous opening in a circumferential manner and this was excised later on. The uterine fistulous opening was closed in interrupted fashion with 3-0 polyglactin suture. The ureteral catheter was pulled out just before the final knots were tied (Figure 3). The bladder was repaired in two layers in continuous manner with 3-0 polyglactin sutures (Figure 4). The bladder was then gently filled with normal saline to rule out any leak. The uterovesical fold of the peritoneum was mobilized and tucked onto the anterior wall of the uterus to cover the suture line. A 16-F tube drain was inserted in the uterovesical pouch and brought on the surface through the right para-rectal region. RESULTS The operation time was 180 minutes and the total blood loss was 50 mL. Postoperative course was uneventful and the patient was discharged after one week. Foley catheter was removed after 3 weeks. Micturating cysto-urethrogram was done following catheter removal and depicted normal bladder contour. Post-void film did not show any evidence of contrast extravasation. Now, the patient has started menstruating following the operation and is doing well at 6 months of follow- up period. DISCUSSION Cesarean section (CS) accounts for more than 75% of VUF(3,4) and menouria is the classical presentation following VUF after emergency CS. Our patient had menouria and secondary infertility for 10 years following CS. The Figure 3. Laparoscopic view of the intracorporeal suturing of the vesicouterine fistula. Figure 4. Laparoscopic view of the intracorporeal suturing of the cystotomy. Laparoscopic Repair of Vesicouterine Fistula—Singh et al 151Urology Journal Vol 8 No 2 Spring 2011 treatment of choice in such a case is VUF disconnection and closure of the bladder and uterine fistulous openings with interposition graft. Our patient was managed by laparoscopic transperitoneal fistula disconnection and closure of the bladder and uterine fistulous openings by intracorporeal suturing with the peritoneal fold as interposition graft. Depending on the menstrual flow, Jozwik divided VUF into 3 categories: Type I - with menouria; Type II - with menouria and vaginal flow; and Type III - with normal vaginal menses.(5) This condition is popularly known as Youssef syndrome and characterized by menouria with absence of urinary incontinence and vaginal bleeding.(6) For diagnosis, detailed history, vaginal examination, cystoscopy, cystography, and/ or hysterography are needed. In recent years, new diagnostic modalities, such as transvaginal ultrasonography (with or without Doppler study), contrast-enhanced computed tomography scan, and magnetic resonance imaging have been added to the armamentarium for rapid and clear diagnosis.(7-9) Conservative management, including continuous bladder drainage with antibiotics and anticholinergics are recommended if the patient is in early postpartum phase and has a small fistula. The success rate of conservative management is less than 5%.(10) Open surgical management also has good results.(10,11) The advantages of laparoscopic technique are quicker convalescence, shorter hospital stay, and better cosmetics with similar success rates to open surgery.(12-15) Technically, laparoscopy provides better visualization due to the magnification, but intracorporeal suturing is the difficult part of the operation (Table). This report points to following unique features not reported earlier in literature: (i) the patient had menouria and secondary infertily for a long duration (10 years); (ii) for the purpose of diagnosis, a ureteral catheter was passed in the uterine cavity under cystoscopic guidance and then with the help of a ureteroscope, hysteroscopy was performed to confirm the fistulous tract; and (iii) vesicouterine peritoneal fold was used as an interposition graft which has not been reported previously. CONFLICT OF INTEREST None declared. REFERENCES 1. Ramamurthy S, Vijayan P, Rajendran S. Sonographic diagnosis of a uterovesical fistula. J Ultrasound Med. 2002;21:817-9. 2. Alkatib M, Franco AV, Fynes MM. Vesicouterine fistula following Cesarean delivery--ultrasound diagnosis and surgical management. Ultrasound Obstet Gynecol. 2005;26:183-5. 3. Porcaro AB, Zicari M, Zecchini Antoniolli S, et al. Vesicouterine fistulas following cesarean section: report on a case, review and update of the literature. Int Urol Nephrol. 2002;34:335-44. 4. Rao MP, Dwivedi US, Datta B, et al. Post caesarean vesicouterine fistulae-- Youssef syndrome: our experience and review of published work. ANZ J Surg. 2006;76:243-5. 5. Jozwik M. Clinical classification of vesicouterine fistula. Int J Gynaecol Obstet. 2000;70:353-7. 6. Youssef AF. Menouria following lower segment cesarean section; a syndrome. Am J Obstet Gynecol. 1957;73:759-67. 7. Majeed HG, Christensen HB, Rasmussen KL. [Ultrasonically verified vesicouterine fistula]. Ugeskr Laeger. 2006;168:1037-8. 8. Kaaki B, Gyves M, Goldman H. Spontaneous intrapartum vesicouterine fistula. Obstet Gynecol. 2006;107:449-50. 9. Smayra T, Ghossain MA, Buy JN, Moukarzel M, Jacob D, Truc JB. Vesicouterine fistulas: imaging findings in First author (Year of Publication) No. of cases attempted No. of cases converted to open surgery No. of Successful cases by laparoscopic surgery Operation time, min Blood loss, mL Hemal(15) (2001) 2 1 1 140 <100 Das Mahapatra(13) (2007) 1 - 1 140 100 to 150 Chibber(12) (2005) 2 1 1 220 NR* Ramalingam(14) (2008) 1 - 1 140 50 Highlights of published reports on laparoscopic vesicouterine fistula repair. *NR indicates not reported. Laparoscopic Repair of Vesicouterine Fistula—Singh et al 152 Urology Journal Vol 8 No 2 Spring 2011 three cases. AJR Am J Roentgenol. 2005;184:139-42. 10. Hadzi-Djokic JB, Pejcic TP, Colovic VC. Vesico-uterine fistula: report of 14 cases. BJU Int. 2007;100:1361-3. 11. Drissi M, Karmouni T, Tazi K, et al. [Vesicouterine fistulas: an experience of 17 years]. Prog Urol. 2008;18:173-6. 12. Chibber PJ, Shah HN, Jain P. Laparoscopic O’Conor’s repair for vesico-vaginal and vesico-uterine fistulae. BJU Int. 2005;96:183-6. 13. Das Mahapatra P, Bhattacharyya P. Laparoscopic intraperitoneal repair of high-up urinary bladder fistula: a review of 12 cases. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18:635-9. 14. Ramalingam M, Senthil K, Pai M, Renukadevi R. Laparoscopic repair of vesicouterine fistula--a case report. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19:731-3. 15. Hemal AK, Kumar R, Nabi G. Post-cesarean cervicovesical fistula: technique of laparoscopic repair. J Urol. 2001;165:1167-8.