Introduction/aim of the video

Vesicouterine fistula (VUF) is an abnormal communication between the uterus and the bladder. Although VUF accounts for only 1–4% of urogenital fistulas, its incidence is increasing [1]. It is usually related to an iatrogenic cause, mostly cesarean section. Risk factors include delivery in the second stage of labor, uterine rupture, placenta percreta, manual removal of the placenta, excessive intraoperative bleeding and previous cesarean section [2]. Clinical presentation may vary. VUFs above the internal uterine orifice may be associated with cyclic hematuria, amenorrhea and lack of urinary leakage, referred as Youssef’s triad. On the contrary, VUFs involving the uterine cervix may be characterized by continuous urinary leakage, without menstrual anomalies [3]. However, regardless of their presentation, VUFs can negatively affect quality of life and are associated with severe psychosocial burden.

Diagnosis can be challenging and is based on the identification of the presence and topography of a fistulous tract. Filling the bladder with a dye solution (e.g. dilute methylene blue) or sterile infant feeding formula is a useful test to detect a genitourinary fistula. Retrograde cystography and cystoscopy can define the characteristics of the fistulous tract. Additional procedures such as vaginal ultrasonography, contrast-enhanced CT and MRI can complete the diagnostic assessment. In particular, MRI shows 100% sensitivity for the diagnosis of VUF and should be considered part of the work-up [4]. Nonsurgical approaches include prolonged bladder catheterization plus antibiotics and hormonal therapy. Spontaneous healing following conservative management has been reported in only 5% of patients [5]. Fulguration followed by continuous bladder drainage is another feasible option for small VUFs [2].

Surgical repair remains the method of choice for the treatment of VUFs. There are typically two timings for surgical treatment: early repair is performed within 48 h of cesarean section, while delayed repair is postponed until after 2–3 months. Various surgical techniques have been described. Routes include transvaginal, transvesical–retroperitoneal and transperitoneal approaches. Laparoscopic and robot-assisted procedures have also been proposed [6]. Interposition of tissue (omentum, graft) between the bladder and uterus may be an option [7]. The aim of this video is to present a case report of a delayed transvaginal layered repair of a high VUF after cesarean section with manual removal of a morbidly adherent placenta (placenta percreta) to provide a tutorial on the surgical technique.

Method

A 43-year-old woman was referred to our unit for continuous urinary leakage 3 months after undergoing a cesarean section with manual removal of a morbidly adherent placenta. She had one previous cesarean section in her obstetric history. Her postoperative course was complicated by anemia, the need for uterine artery embolization and fever. A methylene blue test showed leakage of dye solution from a cervical external uterine orifice, confirming the existence of a VUF. Retrograde cystography and MRI defined the characteristics of the fistulous tract that started from the right side of the posterior bladder wall and ended in the supracervical portion of the anterior uterine wall. Diagnostic cystoscopy confirmed the presence of a 1-cm (0.4-in.) bladder opening in the posterior bladder wall.

In consideration of the desire of the woman to preserve her uterus for childbearing reasons and the presence of a stage 1 anterior and central apical prolapse, she was scheduled for a transvaginal layered repair of the VUF without hysterectomy. Bowel preparation was performed and broad-spectrum endovenous antibiotic prophylaxis administrated. In the operating theater, the woman was placed in the lithotomy position. The procedure was performed 3 months after the cesarean section by an experienced urogynecological surgeon (R.M.). The surgical repair consisted of the following steps, as shown in the video:

  1. 1.

    Diagnostic cystoscopy is repeated to identify the fistula opening. The bladder is then emptied by placing an indwelling catheter.

  2. 2.

    An anterior transverse colpotomy is performed to access the vesicouterine space.

  3. 3.

    The vesicouterine space is carefully dissected until the uterus and bladder are completely detached. Proper preparation of an adequate extension of the bladder wall and uterine wall surrounding the fistula openings is mandatory. The uterine and bladder fistula openings are identified with Hegar cone dilators.

  4. 4.

    The uterine wall is sutured with interrupted sutures. A second layer of introverting interrupted sutures is placed to reinforce the uterine isthmus. The second layer is performed in a transverse fashion without overlying sutures.

  5. 5.

    Fulguration of the bladder opening is followed by suturing of the bladder wall with interrupted sutures. To achieve a symmetrical reconstruction, sutures are first placed as landmarks on the edges, followed by the intermediate sutures.

  6. 6.

    A second layer of introverting interrupted sutures is placed on the bladder wall. Again, sutures are first placed on the edges.

  7. 7.

    A running colporrhaphy completes the procedure.

Results

The featured procedure was performed in 120 min and blood loss was less 200 ml. Broad-spectrum antibiotics were continued for 3 days and the urethral catheter was left in place for 2 weeks. No surgical complications were observed postoperatively. At 2 months, the fistula had not recurred and the patient reported no urinary leakage.

Discussion

Surgical management is considered the mainstay of the treatment of VUF after cesarean section [5]. The first attempt to repair the fistula is the most likely to succeed [7]. It is usually recommended that treatment be delayed for at least 3 months so that surgery can be performed on an involuted uterus and less inflamed tissues, thus reducing complications [7]. Hysterectomy is not mandatory, and thus should be reserved for multiparous women nearing menopause or for women with significant uterine pathologies such as fibroids or endometrial dysfunction [3]. Different surgical approaches have been described, including transvaginal, transvesical and transabdominal (open, laparoscopic or robot-assisted) procedures [7]. However, due to the low incidence of VUF, only case reports and small series are available. As a consequence, it is difficult to identify the most promising approach.

Conclusion

Transvaginal layered primary repair of VUF was shown to be a safe and effective procedure for restoring the anatomy. However, genital fistula repair via the vaginal route should only be performed by experienced vaginal surgeons.