V2-10: Vaginal approach to vesicouterine fistula
Vesicouterine fistula is a rare cause of genitourinary fistulas. Close relation between bladder and uterus predisposes to this lesion during many gynecological and obstetric procedures. This kind of complication is increasing due to the widespread of cesarian deliveries. The aim of this video is to highlight the technique of vesicouterine fistula repair using vaginal approach.
A 38-year-old female was admitted to hospital with ciclic hematuria, amenorrhea and no incontinence. She had three previous cesarian deliveries, last one with bladder trauma 3 months before admission. Magnetic Resonance has shown a vesicouterine fistula above cervix. Patient intended to have future pregnancies so a vaginal correction of the vesicouterine fistula without hysterectomy was performed. The patient was prepared and draped in a modified dorsal lithotomy position. Initially, cystoscopy was done with identification of the fistula tract at anterior bladder wall. Uterine cavity was inspected though fistula tract. Next, ureteral catheters were introduced for safety during the procedure. Methylene blue was injected into the bladder to demonstrate the localisation of the fistula in the vaginal wall. A Pozzi clamp was applied to the uterine cervix for good exposure. Next, a supracervical incision was made and dissection was carried out until fistulous tract was identified. A T-clamp was applied to the vaginal wall and the inked fistulous tract was identified and dissected. An Hegar bougie was introduced into the cervical canal facilitating the procedure. Then the bladder wall was dissected in order to allow a tension-free closure of the bladder defect. Both ureters were identified before the vaginal wall was closed. After the closure of the bladder, uterus was closed with interrupted sutures over the Hegar bougie. Finally, vaginal wall was closed and ureteral catheters are removed.
Patient was discharged home 1 day after surgery. Urethral catheter was maintained for 14 days. After four months, patient keeps without hematuria, neither incontinence and recovered her normal menstrual cycle.
Vesicouterine fistula is a dreaded complication after cesarian deliveries. Its correction is usually performed through abdominal approach, however, vaginal approach is feasible, safe and less invasive. It may always be considered, mainly if procedure is made early after delivery, when uterus is still movable.