Recurrent vesico-cervical fistula: our experience.

Abstract

Vesico-cervical (VCxF) is an uncommon entity among the gamut of genitourinary fistulas. The common causes include prolonged labor, previous lower-segment cesarean sections (LSCS), difficult vaginal deliveries, and traumatic injuries. A 31-year-old woman presented with a history of LSCS for prolonged labor 4 years ago followed by a failed robotic repair for diagnosed VCxF and vesico-uterine fistula (VUtF) 1 year ago. The patient developed a recurrence 4 weeks after catheter removal. The patient underwent cystoscopic fulguration 6 months after the robotic surgery, but this failed after 2 weeks. Now, the patient presented with continuous urine leakage through the vagina for 6 months. On evaluation, she was diagnosed with recurrent VCxF and a repeat transabdominal repair was planned. On cystovaginoscopy, there was difficulty in negotiating the fistulous tract from either end. With great difficulty, we placed the guidewire from the vaginal end, which reached a false paracervical passage. Although in the false tract, the guidewire helped with localization of the intraoperative fistula site. After docking, port placement, and localization of the fistula site (tug on the guide wire), a mini cystostomy was performed. A plane was created between the bladder and cervicovaginal layer and dissected up to 1 cm beyond the fistula. The cervicovaginal layer was closed. An omental tissue interposition was followed by cystotomy closure and drain placement. The postoperative period was uneventful, and the patient was discharged on the 2nd day after drain removal. The catheter was removed after 3 weeks and the patient is doing fine under regular follow-up for 6 months. It is challenging to diagnose and repair VCxF. Transabdominal repair is better than transvaginal repair owing to its location. Patients can opt for open or minimally invasive (laparoscopic/robotic) surgery, with better postoperative outcomes in minimally invasive techniques.