Vesicouterine fistula after a previous low vertical cesarean section (DeLee incision)

Abstract

Vesicouterine listulas are the rarest urogenital tistulas. Patients present with urinary incontinence with or without cyclic hematuria. We present a 28year-old patient, para III. At her second delivery in 199 1, she underwent a low vertical cesarean section @Lee incision) for premature breech delivery. The third pregnancy ended in a ventouse extraction. An indwelling Foley’s catheter was removed after 24 h despite blood-stained urine, and she was discharged from hospital. Afterwards she developed a bloody vaginal discharge smelling of urine. A urologist diagnosed a vesicovaginal fistula and prescribed ampicillin and an indwelling catheter, which was removed 2 weeks later without improvement. The patient presented at Ring Khalid University Hospital in Riyadh, 8 weeks after delivery. An intravenous pyelogram showed contrast in the uterine cavity (Fig. 1A and B). Cystoscopy revealed a 3cm fistula in the posterior wall, communicating with the uterine cavity. Three months after delivery, the patient was admitted for repair. Ureteric catheters were inserted bilaterally. The transabdominal supravesical approach was used. The uterus was dissected from the bladder, the edges of the uterine opening freshened and closed in two layers. The bladder rent was repaired in two layers. An omental flap was interposed between the posterior bladder wall and the uterus. An indwelling and a suprapubic catheter were left in situ. On the 14th day, a cystogram revealed no evidence of leakage (Fig. 2). The catheters were removed, the patient regained the desire to void and has remained continent since.