|Year : 2022 | Volume
| Issue : 2 | Page : 242-245
Laparoscopic repair of post hysterectomy ureterovaginal fistula
Siddharth Shah1, Nidhi Thumar2, Sushil Kumar2
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 Submission||01-Apr-2022|
|Date of Acceptance||02-Apr-2022|
|Date of Web Publication||17-Jun-2022|
Dr. Nidhi Thumar
Department of Obstetrics and Gynecology, MGM Medical College and Hospital, Navi Mumbai 410209, Maharashtra
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
Ureteric injury can occur during any abdominal or pelvic surgery, the most common being hysterectomy be it vaginal, abdominal, or laparoscopic. 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. Approximately 30%–45% of ureteric injuries are identified and managed intra-operatively while the rest are diagnosed postoperatively. 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. 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., During the past decade, laparoscopic management of such fistula has emerged and has been considered a preferred option by some.,,,
| Case report|| |
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].
- Right-sided mild hydroureteronephrosis.
- 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].
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|| |
Iatrogenic ureteric injury is an uncommon complication of obstetric and gynecological surgeries. The lower third ureter is the most common site to get injured. 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. The treatment of UVF varies depending on the site, size, extent, location, patient’s condition, and the underlying etiology., 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., 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.,,, However, laparoscopic surgery needs more expertise and an expensive surgical setup.
| Conclusion|| |
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.
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
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]