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Ureterovaginal fistula following spontaneous vaginal delivery, repaired by vaginal ureteroneocystostomy in a low resource setting

Ureterovaginal fistula following spontaneous vaginal delivery, repaired by vaginal... Ureterovaginal fistula commonly follows ureteric injury during pelvic surgery, and presents with continuous urinary incon- tinence in spite of normal micturition. Continuous urinary incontinence has significant impact on quality of life, thus requir- ing effective surgical intervention in order to restore health. We found no reported case of ureterovaginal fistula following spontaneous vaginal delivery with prolonged obstructed labour. Relevant history and simple diagnostic procedures were used for diagnosis and the patient had successful vaginal ureteroneocystostomy. This could be the first reported ureterova- ginal fistula following spontaneous vaginal delivery with prolonged obstructed labour. Vaginal ureteroneocystostomy though scarcely reported, is feasible in selected cases. INTRODUCTION Ureterovaginal fistula presents with constant incontinence of Ureterovaginal fistula is mainly iatrogenic, and commonly urine with devastating physical, social and mental consequences; complicates pelvic surgeries [1, 2]. Ureteral injuries occur in and significantly impacts the quality of life [4]. It is therefore 0.5–2.5% of gynaecological surgeries [1, 2]. Whereas studies imperative that women suffering from this devastating disease be offered immediate and effective care to alleviate their suffering. from low resource settings have reported a higher proportion of ureterovaginal fistula complicating caesarean deliveries [3], the The care offered to women with ureterovaginal fistula var- scenario in other countries reveal higher proportions following ies significantly depending on availability of resources. The hysterectomy [1, 3]. In a recent review of the aetiology of ure- medical literature offers different approaches to the diagno- sis of ureterovaginal fistula. Surgical options and preferences terovaginal fistula, only one case was associated with uterine rupture complicating vaginal delivery [1]. We found no case of also vary. This case emphasizes the scenario in low resource settings which are equally effective but scantly reported in ureterovaginal fistula following spontaneous vaginal delivery with prolonged obstructed labour in published literature. the medical literature. Received: May 27, 2017. Accepted: July 1, 2017 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2017. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 2 S.J. Lengmang et al. closure dye test was negative, so the vaginal wall was closed CASE with vicryl 2/0 in one layer (Fig. 3). A 20-year-old Para 1 woman presented with continuous urinary The patient had an uneventful recovery and post-operative incontinence in spite of normal micturition for one month. Her period, and the catheters were removed after 14 days. The symptoms followed an unsupervised spontaneous vaginal deliv- ery which lasted for more than 24 h, resulting in foetal demise. The pregnancy and delivery was not attended by a skilled birth attendant and there was no instrumentation during delivery. Direct dye test using 300 ml of dilute methylene blue instilled into the bladder showed no dye leak. However, a clear stream of urine was seen spilling from the left ureter (Fig. 1). The ureter was catheterized with a ureteral catheter for up to 6 cm. Furthermore, a three swab test confirmed ureterovaginal fistula as the swab near the cervix was soaked with urine but the other swabs were neither dye-stained nor soaked. The diagnosis of left ureterovaginal fistula was made and the patient was prepared for surgery. Her packed cell volume was 34%; HIV was non-react- ive; while urea and creatinine were within normal limits. The diagnosis and treatment options were discussed with the patient and she signed an informed consent for left ureter- oneocystostomy by vaginal approach. Ureteroneocystostomy was done via the vaginal route under spinal anaesthesia. An inverted ‘T’ shaped incision was made at the distal border of the left ureter, and the anterior vaginal wall was dissected, taking care to free the distal left ureter over the ureteral catheter. An artery clamp was passed through the urethra and used to pierce the bladder, creating a tiny bladder fistula around the distal margin of the left ureter through which the ureteral catheter was pulled through the bladder and out through the external urethral meatus. The ureter was then reimplanted into the bladder using 4/0 Vicryl at four quadrants by passing each suture from the serosal margin of the distal ureter exiting through the mucosa and then through the mucosa of the bladder exiting the bladder serosa. A second Figure 2: Bladder closed over left reimplanted ureter, with ureteral catheter layer of bladder serosa was closed over the reimplanted ureter exiting the external urethral meatus. using Vicryl 2/0 (Fig. 2). The urethra was catheterized and post Figure 1: Direct dye test: 300 ml methylene blue instilled into the bladder through Foley catheter shows no dye leak, but a clear stream of urine spilling Figure 3: Anterior vaginal wall closure with ureteral and urethral catheters exit- from the left ureter. ing from the external urethral meatus. Ureterovaginal fistula following spontaneous vaginal delivery 3 patient was completely continent of urine at discharge and Our patient had an uneventful post-operative period with remained continent at last follow up 2 years thereafter. the ureter and urethra catheterized for 2 weeks with a suc- The patient was therefore discharged from follow up after cessful outcome. Others have catheterized the ureter for repeated sessions of counselling for prenatal planning, ante- three weeks [3]. Shorter catheterization appears to offer sig- natal care and supervised delivery in a hospital to ensure safe nificant advantages in clinical care and programming. It subsequent deliveries. could reduce urine tract infection, increase turnover with opportunity for more patients to be operated especially when bed space is limited. DISCUSSION Since our patient’s first delivery had a poor outcome (ureter- Prolonged obstructed labour, home delivery and foetal loss are ovaginal fistula and foetal demise), it is important that subse- common findings in women with genital fistula in low- quent pregnancies be closely monitored, and deliveries be resource countries. Pressure necrosis often follows prolonged attended by trained healthcare providers. Furthermore, it is obstructed labour and results to fistula formation. The direct advisable that subsequent deliveries be by caeserean section, opening of the left ureter to the vagina in this case suggests as they often produce bigger babies which could further pressure necrosis and sloughing of the anterior vaginal wall as increase the risk of recurrent obstetric fistula. possible cause for the fistula. Spontaneous vaginal delivery does not exclude diagnosis The history of urinary incontinence in spite of intermittent of ureterovaginal fistula, as this case demonstrates that ure- normal voiding of urine suggested one ureter bypassing the terovaginal fistula could result from ureteric injury following bladder into the vagina while the other remains normally spontaneous vaginal delivery with prolonged obstructed placed in the bladder. The direct dye test supported the diagno- labour. Simple diagnostic procedures like direct dye and three sis of ureterovaginal fistula, since dye placed into the bladder swab tests are often sufficient for diagnosis of ureterovaginal did not leak to the vagina; implying normal integrity of the fistula in low resource settings. Vaginal ureteroneocystostomy bladder. Ureterovaginal fistula was confirmed when urine was is an effective minimally invasive extraperitoneal option in seen spilling directly from the ureter into the vagina. Further selected cases. confirmation was made with the three swab test. These steps appear to be sufficient for most diagnoses of ureterovaginal fis- tula in low resource settings, where most patients presenting CONFLICT OF INTEREST STATEMENT with urogenital fistula are indigent [3]. Most childbirth injuries None declared. in low resource settings affect the poorest of the poor who would otherwise endure the scourge of fistula for life, except if surgery was highly subsidized or offered at no cost to the patient. Conversely, abdominal ultrasound, CT scan, cystos- FUNDING copy, intravenous pyelography, retrogate pyelography, vagino- Fistula Foundation USA provides funding for patient care. gram, cystogram and voiding cystometry are commonly used in different combinations where resources are available [1]. Conservative minimal invasive treatment with JJ Stent for REFERENCES 6–8 weeks is possible [4], but Memokath stent with extended period offered a better outcome [3]. Failed ureteral stenting is 1. Murtaza B, Mahmood A, Niaz WA, Akmal M, Ahmad H, treated by ureteroneocystostomy by open, laparoscopic or Saeed S, et al. Ureterovaginal fistula—etiological factors and robotic abdominal approach [4]. outcome. J Pak Med Assoc 2012;62:999–1003. Ureterovaginal fistulae in low resource settings are com- 2. Al Otaibi K, Barakat A, El Darawany H, Sheikh A, Fadaak K, Al monly operated by open abdominal ureteric reimplantation. In Sowayan O, et al. Minimally invasive treatment of ureterova- our experience, reimplantation by the abdominal route is best ginal fistula: a review and report of a new technique. Arab J fit for women whose ureterovaginal fistula complicated pelvic Urol 2012;10:414–7. surgery where the ureter is often ligated along with bleeding 3. Randawa AJ, Khalid L, Abbas A. Diagnosis and management vessels. However, since this case followed a spontaneous vagi- of ureterovaginal fistula in a resource-constrained setting: nal delivery; the ureteral opening into the vagina could readily experience at a district hospital in Northern Nigeria. Libya be seen and catheterized for up to 6 cm, we offered ureteroneo- J Med 2009;4:41–3. cystostomy through the vaginal route as was the experience of 4. Boateng AA, Eltahawy EA, Mahdy A. Vaginal repair of ureter- others [4]. This approach has the advantage of being extraperi- ovaginal fistula may be suitable for selected cases. Int toneal, minimally invasive [4] and leaves no obvious scar. Urogynecol J 2013;24:921–4. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Ureterovaginal fistula following spontaneous vaginal delivery, repaired by vaginal ureteroneocystostomy in a low resource setting

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Publisher
Oxford University Press
Copyright
Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2017.
eISSN
2042-8812
DOI
10.1093/jscr/rjx143
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Abstract

Ureterovaginal fistula commonly follows ureteric injury during pelvic surgery, and presents with continuous urinary incon- tinence in spite of normal micturition. Continuous urinary incontinence has significant impact on quality of life, thus requir- ing effective surgical intervention in order to restore health. We found no reported case of ureterovaginal fistula following spontaneous vaginal delivery with prolonged obstructed labour. Relevant history and simple diagnostic procedures were used for diagnosis and the patient had successful vaginal ureteroneocystostomy. This could be the first reported ureterova- ginal fistula following spontaneous vaginal delivery with prolonged obstructed labour. Vaginal ureteroneocystostomy though scarcely reported, is feasible in selected cases. INTRODUCTION Ureterovaginal fistula presents with constant incontinence of Ureterovaginal fistula is mainly iatrogenic, and commonly urine with devastating physical, social and mental consequences; complicates pelvic surgeries [1, 2]. Ureteral injuries occur in and significantly impacts the quality of life [4]. It is therefore 0.5–2.5% of gynaecological surgeries [1, 2]. Whereas studies imperative that women suffering from this devastating disease be offered immediate and effective care to alleviate their suffering. from low resource settings have reported a higher proportion of ureterovaginal fistula complicating caesarean deliveries [3], the The care offered to women with ureterovaginal fistula var- scenario in other countries reveal higher proportions following ies significantly depending on availability of resources. The hysterectomy [1, 3]. In a recent review of the aetiology of ure- medical literature offers different approaches to the diagno- sis of ureterovaginal fistula. Surgical options and preferences terovaginal fistula, only one case was associated with uterine rupture complicating vaginal delivery [1]. We found no case of also vary. This case emphasizes the scenario in low resource settings which are equally effective but scantly reported in ureterovaginal fistula following spontaneous vaginal delivery with prolonged obstructed labour in published literature. the medical literature. Received: May 27, 2017. Accepted: July 1, 2017 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2017. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 2 S.J. Lengmang et al. closure dye test was negative, so the vaginal wall was closed CASE with vicryl 2/0 in one layer (Fig. 3). A 20-year-old Para 1 woman presented with continuous urinary The patient had an uneventful recovery and post-operative incontinence in spite of normal micturition for one month. Her period, and the catheters were removed after 14 days. The symptoms followed an unsupervised spontaneous vaginal deliv- ery which lasted for more than 24 h, resulting in foetal demise. The pregnancy and delivery was not attended by a skilled birth attendant and there was no instrumentation during delivery. Direct dye test using 300 ml of dilute methylene blue instilled into the bladder showed no dye leak. However, a clear stream of urine was seen spilling from the left ureter (Fig. 1). The ureter was catheterized with a ureteral catheter for up to 6 cm. Furthermore, a three swab test confirmed ureterovaginal fistula as the swab near the cervix was soaked with urine but the other swabs were neither dye-stained nor soaked. The diagnosis of left ureterovaginal fistula was made and the patient was prepared for surgery. Her packed cell volume was 34%; HIV was non-react- ive; while urea and creatinine were within normal limits. The diagnosis and treatment options were discussed with the patient and she signed an informed consent for left ureter- oneocystostomy by vaginal approach. Ureteroneocystostomy was done via the vaginal route under spinal anaesthesia. An inverted ‘T’ shaped incision was made at the distal border of the left ureter, and the anterior vaginal wall was dissected, taking care to free the distal left ureter over the ureteral catheter. An artery clamp was passed through the urethra and used to pierce the bladder, creating a tiny bladder fistula around the distal margin of the left ureter through which the ureteral catheter was pulled through the bladder and out through the external urethral meatus. The ureter was then reimplanted into the bladder using 4/0 Vicryl at four quadrants by passing each suture from the serosal margin of the distal ureter exiting through the mucosa and then through the mucosa of the bladder exiting the bladder serosa. A second Figure 2: Bladder closed over left reimplanted ureter, with ureteral catheter layer of bladder serosa was closed over the reimplanted ureter exiting the external urethral meatus. using Vicryl 2/0 (Fig. 2). The urethra was catheterized and post Figure 1: Direct dye test: 300 ml methylene blue instilled into the bladder through Foley catheter shows no dye leak, but a clear stream of urine spilling Figure 3: Anterior vaginal wall closure with ureteral and urethral catheters exit- from the left ureter. ing from the external urethral meatus. Ureterovaginal fistula following spontaneous vaginal delivery 3 patient was completely continent of urine at discharge and Our patient had an uneventful post-operative period with remained continent at last follow up 2 years thereafter. the ureter and urethra catheterized for 2 weeks with a suc- The patient was therefore discharged from follow up after cessful outcome. Others have catheterized the ureter for repeated sessions of counselling for prenatal planning, ante- three weeks [3]. Shorter catheterization appears to offer sig- natal care and supervised delivery in a hospital to ensure safe nificant advantages in clinical care and programming. It subsequent deliveries. could reduce urine tract infection, increase turnover with opportunity for more patients to be operated especially when bed space is limited. DISCUSSION Since our patient’s first delivery had a poor outcome (ureter- Prolonged obstructed labour, home delivery and foetal loss are ovaginal fistula and foetal demise), it is important that subse- common findings in women with genital fistula in low- quent pregnancies be closely monitored, and deliveries be resource countries. Pressure necrosis often follows prolonged attended by trained healthcare providers. Furthermore, it is obstructed labour and results to fistula formation. The direct advisable that subsequent deliveries be by caeserean section, opening of the left ureter to the vagina in this case suggests as they often produce bigger babies which could further pressure necrosis and sloughing of the anterior vaginal wall as increase the risk of recurrent obstetric fistula. possible cause for the fistula. Spontaneous vaginal delivery does not exclude diagnosis The history of urinary incontinence in spite of intermittent of ureterovaginal fistula, as this case demonstrates that ure- normal voiding of urine suggested one ureter bypassing the terovaginal fistula could result from ureteric injury following bladder into the vagina while the other remains normally spontaneous vaginal delivery with prolonged obstructed placed in the bladder. The direct dye test supported the diagno- labour. Simple diagnostic procedures like direct dye and three sis of ureterovaginal fistula, since dye placed into the bladder swab tests are often sufficient for diagnosis of ureterovaginal did not leak to the vagina; implying normal integrity of the fistula in low resource settings. Vaginal ureteroneocystostomy bladder. Ureterovaginal fistula was confirmed when urine was is an effective minimally invasive extraperitoneal option in seen spilling directly from the ureter into the vagina. Further selected cases. confirmation was made with the three swab test. These steps appear to be sufficient for most diagnoses of ureterovaginal fis- tula in low resource settings, where most patients presenting CONFLICT OF INTEREST STATEMENT with urogenital fistula are indigent [3]. Most childbirth injuries None declared. in low resource settings affect the poorest of the poor who would otherwise endure the scourge of fistula for life, except if surgery was highly subsidized or offered at no cost to the patient. Conversely, abdominal ultrasound, CT scan, cystos- FUNDING copy, intravenous pyelography, retrogate pyelography, vagino- Fistula Foundation USA provides funding for patient care. gram, cystogram and voiding cystometry are commonly used in different combinations where resources are available [1]. Conservative minimal invasive treatment with JJ Stent for REFERENCES 6–8 weeks is possible [4], but Memokath stent with extended period offered a better outcome [3]. Failed ureteral stenting is 1. Murtaza B, Mahmood A, Niaz WA, Akmal M, Ahmad H, treated by ureteroneocystostomy by open, laparoscopic or Saeed S, et al. Ureterovaginal fistula—etiological factors and robotic abdominal approach [4]. outcome. J Pak Med Assoc 2012;62:999–1003. Ureterovaginal fistulae in low resource settings are com- 2. Al Otaibi K, Barakat A, El Darawany H, Sheikh A, Fadaak K, Al monly operated by open abdominal ureteric reimplantation. In Sowayan O, et al. Minimally invasive treatment of ureterova- our experience, reimplantation by the abdominal route is best ginal fistula: a review and report of a new technique. Arab J fit for women whose ureterovaginal fistula complicated pelvic Urol 2012;10:414–7. surgery where the ureter is often ligated along with bleeding 3. Randawa AJ, Khalid L, Abbas A. Diagnosis and management vessels. However, since this case followed a spontaneous vagi- of ureterovaginal fistula in a resource-constrained setting: nal delivery; the ureteral opening into the vagina could readily experience at a district hospital in Northern Nigeria. Libya be seen and catheterized for up to 6 cm, we offered ureteroneo- J Med 2009;4:41–3. cystostomy through the vaginal route as was the experience of 4. Boateng AA, Eltahawy EA, Mahdy A. Vaginal repair of ureter- others [4]. This approach has the advantage of being extraperi- ovaginal fistula may be suitable for selected cases. Int toneal, minimally invasive [4] and leaves no obvious scar. Urogynecol J 2013;24:921–4.

Journal

Journal of Surgical Case ReportsOxford University Press

Published: Jul 31, 2017

There are no references for this article.