Vesicouterine fistula — an analysis of 24 cases from Poland

International

Journal

of Gynecology

& Obstetrics

57 (1997)

169-172

Article

Vesicouterine fistula - an analysis of 24 cases from Poland M. JSwik”, “Department

Received

M. J6iwikb*,

W. Lotocki”

of Gynecology and Septic Obstetrics, School of Medicine, bDepartment of Gynecology, School of Medicine, Bialystok, 18 September

1996; revised

20 December

1996; accepted

Bialystok, Poland 23 December

Poland

1996

Abstract Objective: This study wasundertakento evaluatewhat clinical eventsor situationsare currently associated with the occurrenceof vesicouterinefistula. Method: A retrospectiveinvestigationwascarried out on 24 patients treated in a tertiary referral center during a 1Zyear period. Clinical data were collected from the patients directly, the medical records, urographic and/or cystoscopicfindings before repair and intraoperative findings at repair. Results: All fistulaswere iatrogenic, and 21(87.5%) occurredfollowing cesareansectionor cesareanhysterectomy.Bladder injury occurred two times more often after repeat operationsthan after the primary. The proportion of repeat cesarean section resulting in a fistula was significantly increased(58.3% vs. 29.6%, P < 0.013) when compared to that previously reported. Conclusions: Cesareansectionsare currently the single major risk factor associatedwith the occurrence of vesicouterine fistulas. Repeat proceduresincreasethe risk of bladder injury and resultant fistulas. 0 1997International Journal of Gynecology and Obstetrics Keywords:

Cesareansection; Iatrogenic injury; Vesicouterinefistula

1. Introduction

Vesicouterine fistulas are abnormal passages between the lumen of the urinary bladder and

*Corresponding author. [email protected] 0020-7292/97/$17.00 PII SOO20-7292(97)

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that of the uterine cavity or cervical canal. Their occurrence is rare and usually presented as case reports. Few papers have described groups ranging from 5 to 19 patients [l-4]. The single largest review analyzed 88 casesand demonstrated 4 new patients [5]. Despite the increasing documentation of the occurrence of vesicouterine fistulas, still little is and Obstetrics

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et al. /International

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of Gynecology

Table 1 Types of genito-urinary fistulas observed in 110 women for the period 1983-1994 Type of fistula

Vesicovaginal Ureterovaginal Vesicouterine Combined Ureterocutaneous Total

Patients No.

%

56 19 18 15 2 110

50.9 17.3 16.4 13.6 1.8 100

known about the possible factors contributing to their development. This retrospective study was undertaken to assess what clinical events or situations are currently associated with this lesion. 2. Subjects and methods Between January 1983 and December 1994, 110 women with a variety of well-documented genito-urinary fistulas were seen in our institution (Table 1). In all, 24 simple or combined vesicouterine lesions comprised the present investigation (Table 2). The criteria for the fistula’s diagnosis have been previously presented when a part of this group was estimated for fertility after repair [4]. Those fistulas that involved the corpus uteri were labeled vesicocorporeal, and those referring to the cervix were labeled vesicocervical.

& Obstetrics

57 (1997) 169-172

Clinical data were collected directly from the patients by means of a structured questionnaire 141, from the medical records of the procedure resulting in a fistula, urographic and/or cystoscopic examinations before repair and intraoperative findings at repair. Clinical data reported here were compared to the data previously reported [5] using the SAS statistical program (Statistical Analyses System, SAS Institute Inc., Cary, NC). Logistic analysis of variance was applied. A P value of < 0.05 was considered as significant. 3. Results

Vesicouterine fistulas were the third most common type of genito-urinary fistulas (Table 1). Eighteen simple lesions and 6 combined were observed (Table 2). Three (12.5%) fistulas were manifest after gynecologic operations and 21 (87.5%) were associated with childbirth, secondary to low segment cesarean section or cesarean hysterectomy (Table 2). Gynecologic procedures resulting in a fistula were performed for benign conditions. Obstetric fistulas were seen after the first to sixth delivery, and after the first to fourth cesarean section. With respect to the 18 cesarean sections, 6 were primary and 12 repeated. All 3 cesarean hysterectomies (Table 2) were performed for major atonic

Table 2 Types and causes of vesicouterine fistulas Type of vesicouterine fistula

No. of patients

Cause

Simple vesicocorporeal Combined vesicocorporeal: - vesicocorporeal + urethrovaginal - vesicocorporeal + vesicovaginal - vesicocorporeal + ureter ligation Simple vesicocervical Combined vesicocervical: - vesicocervical + ureterovaginal - vesicocervical + vesicovaginal - vesicocervical + ileocervical

16

CS in 15 + anterior kolporrhaphy in I

Total

CS, cesarean section; CH, cesarean hysterectomy.

Forceps + CS cs cs CH in 1 + supravaginal hysterectomy in 1 1 1 1 24

CH Gertner cyst excision CH

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& Obstetrics

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Table 3 Contribution of primary and repeat cesarean sections to the development of fistula for two periods. For comparison with the present study, data from the review paper [5], for the period 1950-1985 only, were used Source of data

No. of patients

% of fistulas after CS

% of fistulas after primary CS

% of fistulas after repeat CS

Tamer [5] (years 1950-1985) Present study (years 1983-1994) P value

71 24

78.9% (56/71) 87.5% (21/24) NS _____

49.3% (35/71) 29.2% (7/24)

29.6% (21/71) 58.3% (14/24) = 0.0127 ---.--__

NS

___-

CS, cesarean section; NS, not significant.

postpartum hemorrhage as supravaginal hysterectomies, and the resulting lesions occurred at the level of the remaining cervix. These operations were modifications of one primary cesarean section and two repeat. The above proportions in primary to repeat surgery were compared with the literature, and a significant increase in the rate of repeat operations was found (Table 3). The location of the injury after cesarean sections varied. In 8 cases, the fistula was diagnosed on the left-hand side of the bladder and uterus. In 7 cases, it was located at the midline, in 2 on the right-hand side, and not specified in one. Thus, the probability of acquiring a fistula on the right side (2/17, i.e. 11.8%) was lower than that at other sites (47.1% and 41.2% on the left-hand side and at the midline, respectively). Of note, one instance of ureter ligation concomitant with a vesicocorporeal fistula and one instance of ureterovaginal fistula concomitant with a vesicocervical fistula (Table 21 were also found on the left-hand side. At repair, following cesarean section, three types of technical error were found. Firstly, in 9 patients, the urinary bladder was sutured too high onto the anterior uterine wall (after two primary cesarean sections and 7 repeat ones>. Secondly, in 2 patients, a vesical fold was sutured into the uterine incision. Finally, in 1 patient, the superior margin of the uterine wall was sutured to the bladder, i.e. a fragment of the bladder had been taken for a lower margin of the uterine wound, with the real margin remaining unsutured. This case followed a ruptured uterus and simultaneous hemorrhaging. The two largest apertures in the vesical wall were noted in two other patients. One case was

that of a ruptured uterus (15 mm in diameter), and the other of a bladder disruption during an extraction of a baby’s head (narrow, 4 cm long). The latter was the only one evident intraoperatively and repaired immediately. It was attributed to a full bladder. 4. Discussion

The direct or indirect causes of vesicouterine fistulas identified since 1950 are diverse. They include singular reports on dilatation and curettage for induced or incomplete abortion, forceps use, external cephalic version, degenerating myoma adherent to the bladder, craniotomy, septicemia, ruptured uterus, manual removal of placenta, pelvic tuberculosis, and intrauterine device perforation, the remainder being connected with cesarean section [5]. In addition, Kumar et al. [l] described two vesicouterine patients following pelvic trauma, and Golomb et al. [6] reported a fistula which developed after cervical cerclage. Our study confirmed that vesicouterine fistulas are currently iatrogenic rather than sequelae of pelvic disease, and that in recent decades low segment cesarean section has become an important cause of vesicouterine fistula. In fact, the occurrence due to obstetric causes was always secondary to cesarean section or cesarean hysterectomy, suggesting that the operation was the single largest risk factor. Bladder injury occurred two times more often after repeat operations than after the primary. The significant increase of fistulas following repeat interventions may justify the opinion that at present they create an additional risk of injury, at least in Poland. This is consistent with findings from other European

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countries [3,7] where the lesion manifested solely after repeat cesarean section. Yet, such observations may reflect the increased rate of repeat cesarean sections in recent decades, too. Mechanisms underlying the development of vesicouterine fistulas are not fully elucidated. It has been suggested that repeat cesarean sections produce progressive devitalization and scarring of the bladder base [8]. Moreover, fistula formation has been ascribed to altered pelvic anatomy during repeat cesarean section, too low transverse incision of the uterus, and insufficient caution in suturing the peritoneum covering the uterus [9]. In this report, we have identified three different types of technical errors. Interestingly, high anatomic displacement of the bladder onto the uterine wall was noted at repair in 9 women. It made no difference whether it was after a primary or repeat cesarean section. Thus, in primiparas, inadequate uterine incision and poor suturing are responsible, as displacement was a result. The latter certainly creates a risk of injury during the following interventions. This would help explain to some extent the observed high percentage (58.3%) of fistulas seen after repeat procedures. Three women with the vesical fold sutured into the uterine incision or taken for the lower margin of the uterine wall are evidence of the surgeon’s disorientation in the operating field. The potential association of obstetric emergencies, like ruptured uterus or atonic postpartum hemorrhage, with the mechanisms of fistula formation needs further clarification. Furthermore, this study draws attention to the neglected aspect of the fistula’s location. The probability of acquiring lesions on the left side of the body or at the midline was more common than on the right side. It is possible that physiological dextrorotation of the gravid uterus places the medial and left lateral uterine segments in the middle of the operating field. If the injury takes place, these segments are more likely to be involved. Similarly, the uterus rotation appears to aggravate the risk of damage to the left ureter, as evidenced in 2 of our patients, and in 3 patients reported by Thomas et al. [lo].

We report for the first time rupture of a full bladder during an extraction of a baby’s head in the course of a cesarean section as a cause of vesicouterine fistula. This instance demonstrates that not only inadequate surgical technique can lead to the lesion’s formation but that careful bladder emptying before operation is essential. In summary, an analysis of 24 cases of vesicouterine fistulas leads us to conclude that these fistulas are primarily associated with cesarean sections. They tend to occur on the left side of the body or at the midline. Several mechanisms may be involved in their formation. Repeat cesarean sections increase the risk of bladder injury and resultant fistulas. References

t11 Kumar A, Vaidyanathan S, Sharma SK, Sharma AK, Goswami AK. Management of vesico-uterine fistulae: a report of six cases. Int J Gynecol Obstet 1988; 26: 453-457.

La El Moussaoui A, Aboutaieb R, Bennani S, Elmrini M, Meziane F, Benjelloun S. Les fistules dsico-utbrines. Analyse de 19 dossiers. J Ural (Paris) 1994; 100: 143-146. [31 Furbetta A, Fagioli A, Cristini C, Michetti PM, Trucchi A, Signore S, et al. Vesicouterine fistulae as complications of repeated cesarean section. Int Urogynecol J 1994; 5: 240-246. M. Prognosis of fertility [41 Lotocki W, J&w& M, Jdtik after surgical closure of vesicouterine fistula. Eur J Obstet Gynecol Reprod Biol 1996; 64: 87-90. 151 Taxer ML. Vesicouterine fistula - a review. Obstet Gynecol Sure 1986; 41: 743-753. b51 Golomb J, Ben-Chaim J, Goldwasser B, Korach J, Mashiach S. Conservative treatment of a vesicocervical fistula resulting from Shirodkar cervical cerclage. J Urol 1993; 149: 833-834. t71 Kalis EG, Kokotas NS. Post-cesarean vesicouterine fistula. Int Urol Nephrol 1980; 12: 123-127. @I Editorial Comment. To: Furbetta A, Fagioli A, Cristini C, Michetti PM, Trucchi A, Signore S, et al. Vesicouterme fistulae as complications of repeated cesarean section. Int Urogynecol J 1994; 5’: 246. [91 Krakowski J. Injuries of the urinary organs during cesarean section. Int Urol Nephrol 1980; 12: 129-135. DOI Thomas DP, Burgess NA, Gower RL, Peeling WB. Ureteric injury at caesarean section. Br J Urol 1994; 74: 122-123.