3012 Lessons Learned from Ten Litigated Cases of Genitourinary and Gastrointestinal Fistulas Post Benign Gynecological Surgeries: A Multi-Center Case Series

Abstract

Listen

Translate article

Study Objective We aim to summarize all litigated cases of vesicovaginal, colovaginal and ureteric-vaginal fistulas from benign gynecological surgeries in Canada between 1997 to 2017. We outline the initial post-operative presentation, course of treatment and recovery, clinical and legal outcomes associated with each case. Design Retrospective case series of 10 genitourinary, gastrointestinal and enterocutaneous fistulas occurring post gynecological surgeries for benign indications. Setting Eight secondary and tertiary hospitals across Canada. Patients or Participants Ten women aged 18 years or older receiving laparoscopic, vaginal or open surgeries to treat benign gynecological conditions. Interventions Benign gynecological procedures including laparoscopic-assisted vaginal (1 case), vaginal (1 case) and open abdominal hysterectomies (3 cases), laparoscopic ovarian cystectomy (2 cases), laparoscopic cautery of endometriosis (2 cases) and operative hysteroscopy (1 case). Measurements and Main Results Median age at time of initial operation was 43 (range 39-55). The most common post-op presentation was fever, abdominal pain and tachycardia between post-op days (POD) 4-10. A bladder, small bowel or rectal injury was found on imaging at the time of presentation for 9 out of 10 cases, with one case diagnosed five weeks post op on outpatient serial CT scans. All patients required a laparotomy with involvement from a general surgeon or urologist, and five patients received second and third look laparotomies and bowel resections. 7 patients required ICU observation post-op. In all cases, the fistulas manifested as delayed presentations for unrecognized intra-operative bladder, bowel or ureteric injuries. One patient had ongoing fistulous drainage per vaginal at the time of case settlement. Most litigated cases were dismissed. Conclusion GU and GI fistulas are rare but morbid entities, which most often manifest after missed bladder or bowel injuries, post benign gynecological surgeries. Early detection and recognition of GI and GU injuries may be key for secondary prevention of fistula formation.