21: A posterior uteroperitoneal fistula: AN unexpected finding

Abstract

This video shows the surgical evaluation of a posterior uteroperitoneal defect resulting in excision of a fistula tract and repair in multiple layers. Uteroperitoneal fistulas are rare and when discovered are typically anterior in the location of a uterine scar. We present a unique case of a spontaneous posterior uteroperitoneal fistula in a patient who presented for evaluation of pelvic pain, dysmenorrhea and secondary infertility. She had a prior history of one uncomplicated cesarean section. During evaluation of her secondary infertility, imaging was performed that revealed findings suggestive of a fistula. The patient underwent robotic-assisted operative laparoscopy that revealed a four-centimeter mass on the right posterior aspect of the uterus independent from her adnexa. Concomitant hysteroscopy revealed normal endometrium and no evidence of a fistula. During chromopertubation, extravasation was seen into the peritoneal cavity from this mass. The mass and fistula tract were excised to the level of the endometrium without a connection found from her cesarean scar. Reconstruction was performed in multiple layers. She also had endometriotic lesions intraperitoneally in locations distant from the mass. The patient had significant improvement in her symptoms postoperatively. We present a unique case of a suspected spontaneous posterior uteroperitoneal fistula in the presence of endometriosis without evidence of a connection to her prior hysterotomy scar. Possible etiologies of this include an undiagnosed hysterotomy extension that went unrepaired or a result of chronic inflammation from deep infiltrating endometriosis. As in our case, successful treatment of symptoms resulting from an uteroperitoneal fistula requires removal of the fistula tract. The constellation of pelvic pain, dysmenorrhea, post-menstrual bleeding, and infertility should raise suspicion for an uteroperitoneal fistula.