URETEROUTERINE AND VESICOURETEROVAGINAL FISTULAS AS A COMPLICATION OF CESAREAN SECTION

Abstract

Vesicouterine fistulas are complications of gynecological and obstetric surgery, occurring most commonly after cesarean section.1 Ureterouterine fistulas were first reported approximately 25 years ago as a complication of cesarean section, and fewer than 30 cases have been described.2 Ureterouterine fistula after cesarean section is associated with extending a low transverse uterine incision laterally, causing subsequent damage to the ureter. To our knowledge we report the first case of ureterouterine and vesicoureterovaginal fistulas after cesarean section. CASE REPORT A 32-year-old woman presented with copious leakage of blood tinged vaginal fluid. She had undergone an emergency low transverse cesarean section 1 month earlier at 37 weeks of gestation due to fetal distress. The patient had a bladder injury at that time, which was repaired primarily. She was completely soaking 8 to 10 pads per day and 3 pads per night at presentation. The patient had no history of urological abnormalities. Excretory urography (IVP) demonstrated a vesicovaginal fistula with no ureteral fistula or obstruction (fig. 1). Preoperative cystoscopy revealed scarring on the left side of the bladder in the area of the trigone, and the left ureteral orifice was unidentifiable. An abdominal approach was planned because a left ureteral reimplant was believed to be likely. An internal-external stent was placed through the kidney and down through the ureter, and was thought to be in the bladder as demonstrated on a film of the kidneys, ureters and bladder. Intraoperative cystoscopy was carried out and showed no obvious fistula site, and the internal-external stent was not identified in the bladder. On vaginal examination the stent was seen entering the vagina through the cervical os. The left ureter, which had fistulized to the uterus, was mobilized and transected through a midline abdominal incision. Methylene blue was instilled in the bladder and the vagina was packed with gauze. Blue dye was noted on the gauze lateral to the cervix and a fistula was identified in the left vaginal fornix. The fistulous tract was then catheterized using a 0.38 guidewire. The guidewire entered the bladder through the left ureteral orifice that previously had been unidentifiable (fig. 2). The fistula tract traveling from the left ureteral orifice to the vagina was excised via an intravesical approach, the left