• Users Online: 410
  • Print this page
  • Email this page


 
 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 242-245

Laparoscopic repair of post hysterectomy ureterovaginal fistula


1 EVE Women’s Hospital, Vadodara, Gujarat, India
2 Department of Obstetrics and Gynecology, MGM Medical College and Hospital, Navi Mumbai, Maharashtra, India

Date of Submission01-Apr-2022
Date of Acceptance02-Apr-2022
Date of Web Publication17-Jun-2022

Correspondence Address:
Dr. Nidhi Thumar
Department of Obstetrics and Gynecology, MGM Medical College and Hospital, Navi Mumbai 410209, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_38_22

Rights and Permissions
  Abstract 

The fistulas, following gynecologic, surgeries are not uncommon. Hysterectomy is one of the most common causes of lower urinary tract fistula in pelvic surgery. Higher incidences are associated with laparoscopic hysterectomy as compared to vaginal or abdominal hysterectomy. Early identification and management of ureterovaginal fistula (UVF) are of utmost importance. The laparoscopic approach in the management of UVF is preferred over open surgery as it reduces pain, hospital stay, and morbidity. However, the laparoscopic approach needs higher surgical dexterity, sound knowledge of pelvic anatomy, and has a higher learning curve. One such approach is discussed here.

Keywords: Laparoscopic ureteric reimplantation, ureteric injury, ureterovaginal fistula


How to cite this article:
Shah S, Thumar N, Kumar S. Laparoscopic repair of post hysterectomy ureterovaginal fistula. MGM J Med Sci 2022;9:242-5

How to cite this URL:
Shah S, Thumar N, Kumar S. Laparoscopic repair of post hysterectomy ureterovaginal fistula. MGM J Med Sci [serial online] 2022 [cited 2022 Jul 6];9:242-5. Available from: http://www.mgmjms.com/text.asp?2022/9/2/242/347692




  Introduction Top


Ureteric injury can occur during any abdominal or pelvic surgery, the most common being hysterectomy be it vaginal, abdominal, or laparoscopic.[1] The incidence of UVF occurring due to ureteric injury during gynecological surgery is 0.5%–2.5% when surgery is done for benign conditions and it increases to 5% for oncological conditions.[2] Approximately 30%–45% of ureteric injuries are identified and managed intra-operatively while the rest are diagnosed postoperatively.[3] It takes around 1–4 weeks for UVF to appear after ureteric injury and patients present with continuous leaking of urine per vagina and flank pain.[2] Repair of the ureterovaginal fistula (UVF) can be done by various methods depending on the site of the fistula, the nature of the disease, the presence of malignancy, or the history of radiotherapy.[4],[5] During the past decade, laparoscopic management of such fistula has emerged and has been considered a preferred option by some.[6],[7],[8],[9]


  Case report Top


A 45-year-old female, para 2 living 2 (previous 2 normal delivery) came to OPD with the complaints of a frank watery leak from the vagina and flank pain on a post-operative day 20 of laparoscopic hysterectomy. She had undergone laparoscopic hysterectomy 20 days back given multiple intramural fibroids with adenomyotic changes. There was no history of any other medical or surgical illness. The general condition was fair. There was no abnormality on physical examination. On per abdomen examination, there was no guarding, tenderness, or rigidity. Per speculum examination revealed pooling of watery discharge and indentation in the vault area. Serial investigations were performed. The creatinine level of the fluid collected from the P/S examination was 14 mg/dl. The fluid creatinine level was significantly higher than the serum creatinine level which confirmed that the fluid was urine. The dye test with methylene blue came negative ruling out VVF.

USG (Abdomen + Pelvis) was done which showed right-sided hydronephrosis. CT IVP was done which showed as shown in [Figure 1].
Figure 1: CT urogram showing hydronephrosis and hydroureter

Click here to view


  1. Right-sided mild hydroureteronephrosis.


  2. The distal-most ureter 0.8 cm proximal to a vesicouterine junction (VUJ) showed discontinuity with spillage of contrast. There was a thin tract of size 13 mm x 10 mm connecting it to the right side of the vaginal vault suggestive of the right UVF.


Laparoscopic repair of the UVF was planned for the 21st day. The patient was given a lithotomy position. Four ports were used: the supraumbilical 10-mm port for the telescope, one 5-mm port 2 cm above and medial to anterior superior iliac spine on the left side, and another 5-mm port between the left lower port and primary trocar. In addition, a 5-mm port between the junction of the upper 2/3rd and lower 1/3rd of the line joining an anterior superior iliac spine and the primary port was inserted. Initial inspection revealed a scarred and inflamed area lateral to the bladder above the external iliac vessel. Adhesiolysis was done. Retroperitoneal space was opened by putting an incision medial to the infundibulopelvic ligament up to the round ligament. The ureter was identified, dissected, and cut as distally as possible [Figure 2]. The bladder was filled with normal saline. Retzius space was identified, dissected and bladder mobilization was done. The anterolateral wall of the bladder was anchored to the psoas muscle (psoas hitch) using absorbable sutures [Figure 3]. The site of ureteric implantation was prepared on the anterolateral surface of the bladder by cutting the detrusor muscle to the mucosa. Cystotomy was done. Half the bladder drained. Ureteric spatulation was done to prevent ureteric stenosis post-implantation. Ureter approximated bladder mucosa by taking a stitch at the 6 o’clock position. A 5F double-J stent was passed into the ureter proximally and into the bladder distally [Figure 4]. Another four interrupted sutures using 4-0 polyglactin sutures were taken at 3 o’clock, 9 o’clock, and 12 o’clock positions. The detrusor muscle was approximated over the anastomosis, tunnel created and ureteric reimplantation done as shown in [Figure 5].
Figure 2: Ureteric dissection

Click here to view
Figure 3: Psoas hitch taken for urinary bladder

Click here to view
Figure 4: Ureteric stenting being done

Click here to view
Figure 5: Ureteric reimplantation into the bladder

Click here to view


An intraperitoneal drain was kept for 2 days, foley’s catheter was kept for 10 days and stent removal was done after 6 weeks. The patient was dry and had no further leakage. The patients remained asymptomatic during the postoperative follow-up period of 6 months.


  Discussion Top


Iatrogenic ureteric injury is an uncommon complication of obstetric and gynecological surgeries. The lower third ureter is the most common site to get injured.[10] Approximately 70% of the cases are unrecognized during surgery leading to fistula formation, fever, septicemia, urinoma or may impair renal function, increasing postoperative morbidity, and hence early identification and repair are necessary. Various investigations like methylene blue dye test, USG abdomen, intravenous urography, and CT urography can be done to confirm the diagnosis.[1] The treatment of UVF varies depending on the site, size, extent, location, patient’s condition, and the underlying etiology.[4],[5] The aim is to conserve renal function and to maintain the ureteric integrity by ureteroneocystostomy or by end-to-end anastomosis. DJ stenting is also helpful and can be removed after 6–12 weeks.[3],[11] The repair of the UVF can be done either by laparoscopic approach or via open surgery. The laparoscopic approach is better and preferred as it provides a better field for visualization, reduces bleeding, pain, discomfort, shortens the hospital stay, and provides speedy recovery.[6],[7],[8],[9] However, laparoscopic surgery needs more expertise and an expensive surgical setup.


  Conclusion Top


UVF causes significant discomfort and distress following any obstetric or gynecological surgery. Prompt identification and treatment of UVF are necessary to reduce further complications, hence improving the quality of life. The laparoscopic approach is the preferred modality as it is cosmetically better and it reduces post-operative discomfort, pain, bleeding, gives better healing, and decreases hospital stay.

Ethical consideration

Approval from the Institutional Ethics Committee was not required because of being a retrospective case report treated in a standard manner. However, the patient consent had been taken before surgery. The patient’s identification was not displayed anywhere in the case report

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Patil SB, Guru N, Kundargi VS, Patil BS, Patil N, Ranka K Posthysterectomy ureteric injuries: Presentation and outcome of management. Urol Ann 2017;9:4-8.  Back to cited text no. 1
    
2.
Al Otaibi K, Barakat AE, El Darawany H, Sheikh A, Fadaak K, Al Sowayan O, et al. Minimally invasive treatment of ureterovaginal fistula: A review and report of a new technique. Arab J Urol 2012;10:414-7.  Back to cited text no. 2
    
3.
Wijaya T, Lo TS, Jaili SB, Wu PY The diagnosis and management of ureteric injury after laparoscopy. Gynecol Minim Invasive Ther 2015;4:29-32.  Back to cited text no. 3
    
4.
Lee RA, Symmonds RE Ureterovaginal fistula. Am J Obstet Gynecol 1971;109:1032-5.  Back to cited text no. 4
    
5.
Onwudiegwu U, Makinde OO, Badejo OA, Okonofua FE, Ogunniyi SO Ureteric injuries associated with gynecologic surgery. Int J Gynaecol Obstet 1991;34:235-8.  Back to cited text no. 5
    
6.
Lakshmanan Y, Fung LC Laparoscopic extravesicular ureteral reimplantation for vesicoureteral reflux: Recent technical advances. J Endourol 2000;14:589-93; discussion 593-4.  Back to cited text no. 6
    
7.
Rafique M, Arif MH Management of iatrogenic ureteric injuries associated with gynecological surgery. Int Urol Nephrol 2002;34:31e35.  Back to cited text no. 7
    
8.
Sakellariou P, Protopapas AG, Voulgaris Z, Kyritsis N, Rodolakis A, Vlachos G, et al. Management of ureteric injuries during gynecological operations: 10 years experience. Eur J Obstet Gynecol Reprod Biol 2002;101:179-84.  Back to cited text no. 8
    
9.
Rassweiler JJ, Gözen AS, Erdogru T, Sugiono M, Teber D Ureteral reimplantation for management of ureteral strictures: A retrospective comparison of laparoscopic and open techniques. Eur Urol 2007;51:512-22; discussion 522-3.  Back to cited text no. 9
    
10.
Jha S, Coomarasamy A, Chan KK Ureteric injury in obstetric and gynecological surgery. RCOG Reviews the Obstetrician & Gynecologist 2004;6:203-8.  Back to cited text no. 10
    
11.
El Abd AS, El-Abd SA, El-Enen MA, Tawfik AM, Soliman MG, Abo-Farha M, et al. Immediate and late management of iatrogenic ureteric injuries: 28 years of experience. Arab J Urol 2015;13: 250-7.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed92    
    Printed2    
    Emailed0    
    PDF Downloaded18    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]