- Email: [email protected]
Vesicouterine fistula after manual removal of placenta in a woman with previous cesarean section
European Journal of Obstetrics & Gynecology and Reproductive Biology 84 (1999) 75–76
Original Article
Vesicouterine fistula after manual removal of placenta in a woman with previous cesarean section Antonio Setubal*, Nuno Clode, J.L. Bruno-Paiva, Irene Roncon, Luis M. Grac¸a Maternal-Fetal Unit, Department of Obstetrics and Gynecology, Department of Urology, Santa Maria University Hospital, Lisbon, Portugal Received 6 August 1998; received in revised form 29 October 1998; accepted 13 November 1998
Abstract Vesicouterine fistula is one of the less common acquired urogenital fistula and a rare event in obstetrics. We report a case which occurred after a vaginal delivery followed by manual removal of placenta in a woman who had a previous cesarean section. The fistula was successfully repaired 5 weeks after delivery. 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Manual removal of placenta; Vaginal delivery; Vesicouterine fistula
1. Introduction Vesicouterine fistula is the least common acquired urogenital fistula and is a rare event in obstetrics usually occurring after a low uterine segment cesarean section. Few cases have been reported after vaginal birth; we report a case which occurred after a vaginal delivery followed by manual removal of the placenta in a woman who had a previous cesarean section. The fistula was successfully repaired 5 weeks after delivery.
2. Case report A 28-year-old woman, gravida 2, para 1, was admitted at 41 weeks estimated gestational age for labor induction. Her family and medical history was unremarkable: she had an uncomplicated cesarean delivery for secondary arrest of labor 5 years earlier, the baby weighing 3800 g. Since then she had no urinary or gynecologic complaints. Labor was induced with intracervical application of 0.5 mg Dinoprostone gel and, 3 h later, with intravenous oxytocin (2.5 mU / min). Labor progressed without compli*Corresponding author. Tel.: 1351-1-7275276
cations and 5 h after the beginning of induction a 3350 g fetus was delivered vaginally. One hour later, because the placenta was not delivered spontaneously, a manual removal of the anterior situated placenta was performed under general anesthesia. The placenta was intact and a surgical curettage was unnecessary. Digital exploration of the low uterine segment was not performed. In the following 24 h the patient complained of hematuria and continuous urine leakage. A Foley catheter was inserted and methylene blue dye instilled. A vesicouterine fistula was diagnosed by observation of the dye coming from the cervical os. The patient was settled in bed with continuous bladder drainage and prophylactic antibiotic therapy. Cystoscopy revealed a defect in the posterior wall, above the trigone and close to the left ureteral opening; an i.v. pyelogram confirmed bilateral ureteral patency. Computerized axial tomography performed 4 weeks after delivery showed the patency of the fistula. Because spontaneous closure of the fistula could not be anticipated, 5 weeks after delivery she underwent reparative surgery. As the patient had spontaneous ablactation a continuous contraceptive pill was started for a faster uterine involution. At laparotomy a fistulous tract (4 cm in length and 1.5 cm diameter) could be seen between the bladder trigone and the anterior wall of the transition
0301-2115 / 99 / $ – see front matter 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S0301-2115( 98 )00305-4
76
A. Setubal et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 84 (1999) 75 – 76
between the uterine isthmus and the cervix. After opening the bladder, two double J ureteral catheters were inserted. Then excision of the fistulous tract was performed and the bladder was closed in two layers with 0 chromic suture and the uterine wall in three layers with 00 Vycril. The operation was completed with interposition of Interceed (Johnson & Johnson) between the bladder and the uterus. Fourteen days after surgery the Foley catheter was removed and the patient had spontaneous micturition. One month after surgery the double J catheters were removed and cystoscopy revealed a well healed bladder mucosa and histerography showed a uterine cavity with a normal triangular shape.
3. Comments Vesicouterine fistula is a rare event in obstetrics. The great majority occur after low segment cesarean section following direct injury of the bladder which has been not recognized, or inclusion of a bladder flap in the suture closure of the uterine incision [1]. In vaginal deliveries the fistula can result either from direct injury caused by high forceps operations or from tissue compression due to neglected obstructed labor. In 1986, Tancer [1], reviewing the 88 cases reported until then, reported only one case occurring after manual removal of the placenta. The vesicouterine fistula we describe appeared after a normal labor and spontaneous vaginal delivery complicated by a retained placenta in a woman with a previous cesarean section. Although deficient healing of the low uterine segment could not be excluded as a cause for the etiology of the fistula, the manual removal of the placenta located on a thin low uterine segment could be the stressful event causing the vesicouterine fistula.
The diagnosis of post-partum vesicouterine fistula is not difficult, but the treatment options and the appropriate timing for surgery are controversial issues. Spontaneous closure of the fistula with conservative measures such as bed rest, continuous bladder drainage and antibiotics is not common unless the defect is small and recognized early [2]; this option implies patient compliance and carries obvious limitations for her daily life. Surgery seems to be the most appropriate treatment. It is consensual that the transperitoneal approach is the best option and, in the young woman, surgery should be as conservative as possible in order to preserve fertility. Many authors propose that surgery must be delayed for 3 months waiting for uterine involution and allowing spontaneous closure of the fistula. But, in the puerperal woman, it seems reasonable to act earlier avoiding social and familiar limitations that conservative measures imply. In our case, surgery was performed after 5 weeks of delivery with excellent results and we believe, following the opinion of Rivas del Fresno [3], that a good surgical technique with the total removal of the fistulous tract, and correct closure of the wall defects of the uterus and bladder with interposal of biological material—omentum, Interceed (Johnson & Johnson)— between them will present results as good as delayed surgery.
References [1] Tancer ML. Vesicouterine fistula—a review. Obstet Gynecol Surv 1986;41:743–53. ´ S, Gergely I. Successful pregnancy after surgical repair of [2] Kottasz vesicouterine fistula. Int Urol Nephrol 1986;18:289–98. [3] Rivas del Fresno M, Fernandez VM, Sejas FJR, et al. Fistula vesico-uterina: a proposito de dos nuevos casos. Actas Urol Esp 1992;16:740–2.
Original Article
Vesicouterine fistula after manual removal of placenta in a woman with previous cesarean section Antonio Setubal*, Nuno Clode, J.L. Bruno-Paiva, Irene Roncon, Luis M. Grac¸a Maternal-Fetal Unit, Department of Obstetrics and Gynecology, Department of Urology, Santa Maria University Hospital, Lisbon, Portugal Received 6 August 1998; received in revised form 29 October 1998; accepted 13 November 1998
Abstract Vesicouterine fistula is one of the less common acquired urogenital fistula and a rare event in obstetrics. We report a case which occurred after a vaginal delivery followed by manual removal of placenta in a woman who had a previous cesarean section. The fistula was successfully repaired 5 weeks after delivery. 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Manual removal of placenta; Vaginal delivery; Vesicouterine fistula
1. Introduction Vesicouterine fistula is the least common acquired urogenital fistula and is a rare event in obstetrics usually occurring after a low uterine segment cesarean section. Few cases have been reported after vaginal birth; we report a case which occurred after a vaginal delivery followed by manual removal of the placenta in a woman who had a previous cesarean section. The fistula was successfully repaired 5 weeks after delivery.
2. Case report A 28-year-old woman, gravida 2, para 1, was admitted at 41 weeks estimated gestational age for labor induction. Her family and medical history was unremarkable: she had an uncomplicated cesarean delivery for secondary arrest of labor 5 years earlier, the baby weighing 3800 g. Since then she had no urinary or gynecologic complaints. Labor was induced with intracervical application of 0.5 mg Dinoprostone gel and, 3 h later, with intravenous oxytocin (2.5 mU / min). Labor progressed without compli*Corresponding author. Tel.: 1351-1-7275276
cations and 5 h after the beginning of induction a 3350 g fetus was delivered vaginally. One hour later, because the placenta was not delivered spontaneously, a manual removal of the anterior situated placenta was performed under general anesthesia. The placenta was intact and a surgical curettage was unnecessary. Digital exploration of the low uterine segment was not performed. In the following 24 h the patient complained of hematuria and continuous urine leakage. A Foley catheter was inserted and methylene blue dye instilled. A vesicouterine fistula was diagnosed by observation of the dye coming from the cervical os. The patient was settled in bed with continuous bladder drainage and prophylactic antibiotic therapy. Cystoscopy revealed a defect in the posterior wall, above the trigone and close to the left ureteral opening; an i.v. pyelogram confirmed bilateral ureteral patency. Computerized axial tomography performed 4 weeks after delivery showed the patency of the fistula. Because spontaneous closure of the fistula could not be anticipated, 5 weeks after delivery she underwent reparative surgery. As the patient had spontaneous ablactation a continuous contraceptive pill was started for a faster uterine involution. At laparotomy a fistulous tract (4 cm in length and 1.5 cm diameter) could be seen between the bladder trigone and the anterior wall of the transition
0301-2115 / 99 / $ – see front matter 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S0301-2115( 98 )00305-4
76
A. Setubal et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 84 (1999) 75 – 76
between the uterine isthmus and the cervix. After opening the bladder, two double J ureteral catheters were inserted. Then excision of the fistulous tract was performed and the bladder was closed in two layers with 0 chromic suture and the uterine wall in three layers with 00 Vycril. The operation was completed with interposition of Interceed (Johnson & Johnson) between the bladder and the uterus. Fourteen days after surgery the Foley catheter was removed and the patient had spontaneous micturition. One month after surgery the double J catheters were removed and cystoscopy revealed a well healed bladder mucosa and histerography showed a uterine cavity with a normal triangular shape.
3. Comments Vesicouterine fistula is a rare event in obstetrics. The great majority occur after low segment cesarean section following direct injury of the bladder which has been not recognized, or inclusion of a bladder flap in the suture closure of the uterine incision [1]. In vaginal deliveries the fistula can result either from direct injury caused by high forceps operations or from tissue compression due to neglected obstructed labor. In 1986, Tancer [1], reviewing the 88 cases reported until then, reported only one case occurring after manual removal of the placenta. The vesicouterine fistula we describe appeared after a normal labor and spontaneous vaginal delivery complicated by a retained placenta in a woman with a previous cesarean section. Although deficient healing of the low uterine segment could not be excluded as a cause for the etiology of the fistula, the manual removal of the placenta located on a thin low uterine segment could be the stressful event causing the vesicouterine fistula.
The diagnosis of post-partum vesicouterine fistula is not difficult, but the treatment options and the appropriate timing for surgery are controversial issues. Spontaneous closure of the fistula with conservative measures such as bed rest, continuous bladder drainage and antibiotics is not common unless the defect is small and recognized early [2]; this option implies patient compliance and carries obvious limitations for her daily life. Surgery seems to be the most appropriate treatment. It is consensual that the transperitoneal approach is the best option and, in the young woman, surgery should be as conservative as possible in order to preserve fertility. Many authors propose that surgery must be delayed for 3 months waiting for uterine involution and allowing spontaneous closure of the fistula. But, in the puerperal woman, it seems reasonable to act earlier avoiding social and familiar limitations that conservative measures imply. In our case, surgery was performed after 5 weeks of delivery with excellent results and we believe, following the opinion of Rivas del Fresno [3], that a good surgical technique with the total removal of the fistulous tract, and correct closure of the wall defects of the uterus and bladder with interposal of biological material—omentum, Interceed (Johnson & Johnson)— between them will present results as good as delayed surgery.
References [1] Tancer ML. Vesicouterine fistula—a review. Obstet Gynecol Surv 1986;41:743–53. ´ S, Gergely I. Successful pregnancy after surgical repair of [2] Kottasz vesicouterine fistula. Int Urol Nephrol 1986;18:289–98. [3] Rivas del Fresno M, Fernandez VM, Sejas FJR, et al. Fistula vesico-uterina: a proposito de dos nuevos casos. Actas Urol Esp 1992;16:740–2.