31 Pessary incarceration complicated by vesicovaginal fistula requiring ureteroneocystostomy: A video case presentation

Abstract

This presentation discusses a rare case of pessary incarceration complicated by vesicovaginal fistula requiring ureteroneocystostomy. The patient is an 81-year-old who presented to the office with continuous leakage of urine. She had a history of pelvic organ prolapse that was treated with a Gellhorn pessary for the past 5 years, however, she was lost to follow-up 2 years ago. On physical examination and cystoscopy, the patient’s pessary was found to be eroded into the bladder near the trigone. Office removal of the pessary was not possible. The patient initially underwent pessary removal under anesthesia with repair of her vesicovaginal fistula. On cystoscopy prior to and after the procedure, no efflux of urine was seen from the left ureter. A CT urogram performed on post-operative day 1 demonstrated hydronephrosis with obstruction of the left ureter, so a left nephrostomy tube was placed. A second CT urogram several weeks later demonstrated recurrence of the vesicovaginal fistula. One month following the initial procedure, she underwent a robotic-assisted ureteroneocystostomy with psoas hitch and vesicovaginal fistula re-closure. A postoperative CT urogram demonstrated patency of both ureters without leakage. Three weeks post-operatively she had only minor complaints, and denied leakage of urine from the vagina. A plan was made to repeat the CT urogram in 3 weeks and hopefully remove the left ureteral stent placed during her second surgery. This video enforces the importance of regular pessary follow-up, and highlights a rare but serious complication that could develop. It also showcases careful technique for robotic-assisted ureteral re-implantation.