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Urethrovaginal Fistula After Extruded Midurethral Sling Excision – Case Report

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Urethrovaginal Fistula After Extruded Midurethral Sling Excision – Case Report Urethrovaginal fistula after extruded midurethral sling excision – Case report R. Stoica 1,2, Madalina Vitan 2, V. Hurduc 1,2, R. Stoica 3, Daniela I. Teodorescu 2, C. Baston 1,2, C. Codoiu 1,2, I. Sinescu 1,2 1 University of Medicine and Pharmacy “Carol Davila” Bucharest, Romania ReportCase 2 Fundeni Clinical Institute, Bucharest, Romania 3 General Hospital CF2, Bucharest, Romania Keywords: midurethral sling, extrusion, urethrovaginal fistula, Martius flap. Introduction requires careful dissection and tension-free closure as Genitourinary fistulae represent a detrimental dis- well as reconstructive procedures.[6] The objective of order with a physical, psychological and lifelong social the present study is to report a case of urethrovaginal strain impact on patients. In developed countries, they fistula and to review the literature about this specific usually result from gynecologic surgery, prolonged ob- clinical condition. structed labor, pelvic pathology associated with trau- ma, fulguration therapy, radiation therapy or complex Case Report trauma injuries. [1] Genitourinary fistulae can be: vesi- A 57 years old female patient, menopausal, was ad- covaginal, urethrovaginal, vesicouterine, urethrocuta- mitted in June 2015 in an urological department with neous or combined (multiple) fistulae. [2] In the United stress urinary incontinence, for which she underwent States, the prevalence of urogenital fistula ranges from surgical repair with a transobturator midurethral sling. less than 0.5% after simple hysterectomy to 10% after One month later she was re-admitted for vaginal urine radical hysterectomy. [3] leakage. Extrusion of the mesh was identified and par- In underdeveloped countries, urogenital fistula is tial removal of the sling was performed. After the re- mainly caused by the lack of accessibility to obstetric moval of the Foley catheter, the patient complained of care. [4] World Health Organization evaluates that the the persistence of the urinary incontinence, and seek incidence of obstetric fistula is around 130.000/year further medical assistance in January 2016. (calculated from a presumption that fistula is likely to She addressed to our department complaining of occur in 2% of the 6.5 million cases of obstructed labor severe urinary incontinence, using more than five pads that occur in developing countries. [5] per day, recurrent urinary tract infection with pyuria The majority of this conditions require surgical and vaginal discharge. On physical examination an fis- treatment and it can be performed by a transvaginal, tulous tract at the anterior vaginal wall with continuous transabdominal or minimally invasive approach, de- urinary leakage was noted (Fig. 1). Urethroscopy helped pending on fistula type, scar tissue, radiation therapy to identify two urethrovaginal fistulous tracts, medio- history and surgeon experience. Proper surgical repair urethral and intrasphincterian, at 6 o’clock (Fig. 2). Corresponding Author: Vitan Madalina Urology Department Fundeni Clinical Institute Fundeni 258, Bucharest, Romania Phone: +40213038650 Email: [email protected] nr. 3 / 2020 • vol 19 Romanian Journal of Urology 39 Surgical Technique Our technique of transvaginal repair was performed with the patient in the dorsal lithotomy position, under regional anesthesia. We carefully examined the vagi- nal wall in order to evaluate scar tissue, to ensure that there is enough healthy surrounding tissue and to es- tablish that there was no additional vesicovaginal fistu- la present. A Foley catheter was placed in the bladder and we identified the orifices using curved instrument through the first large aperture (6 mm) and the smaller Case ReportCase Fig. 1. Catheter one (3 mm) (Fig. 4). exploring vaginal aspect of the main fistulous tract Fig. 4. Vaginal exploration of fistulous tracts Fig. 2. Ure- throscopy A U-shape inverted vaginal incision was performed image of intras- and the Lone-Star self-retaining retractor was set. phincterian Sharp dissection of fistulous tract was performed using catheter stay sutures and fistula hooks traction until complete Pressure flow study (PFS) revealed normal vesical isolations and excision of the fistula’s tracts (Fig. 5). sensations, normal compliance, normal flow (25mL/s), a Paraurethral space was explored but no further mesh functional bladder volume of 333 mL, Pdet@Qmax=16 extrusion or perforation was noticed (Fig. 6). cmH20, PVR=0 and severe stress incontinence (Fig. 3). After the proper treatment of the urinary tract infection and of the atrophic vaginitis with topical estrogens the patient underwent surgical repair. Fig. 3. Pressure-flow study: Stress incontinence during storage phase (starting from 60 mL fill), low pressure high flow voiding phase. Fig. 5. Main fistulous tract dissected 40 Romanian Journal of Urology nr. 3 / 2020 • vol 19 Case ReportCase Fig. 8. Martius flap transposed on vaginal incision Fig. 6. Paraurethral space dissected Considering the size of the urethral defect and the stress urinary incontinence that could require further surgery, a Martius modified labial fat pad flap was isolat- ed, mobilizing the distal end with the preservation of the internal pudendal artery (Fig. 7). The Martius graft was transposed at the vaginal incision an retracted the distal end away from the surgical area with a stay suture (Fig. 8). The urethral defects were further closed using a trans- verse tension-free separate suture with slow absorbable material (Fig. 9). The Martius flap was interposed from right to left and secured with two absorbable sutures (Fig. 10). The labial wound was closed in layers over a small suction drain and a pressure dressing was applied. In the postoperative period, the patient had a good re- Fig. 9. Transverse closure of urethral defects covery, with three days of antibiotic prophylaxis, the re- moval of the suction tube and betadine gauze the 2nd day and the Foley catheter on the 7th day. Fig. 7. Right side labial Martius flap isolation Fig. 10. Martius flap secured over the urethral sutures nr. 3 / 2020 • vol 19 Romanian Journal of Urology 41 At the three months follow-up, the patient present- tion of urethral function. ed with a healed vaginal incision, no fistula, light ure- In order to avoid a simultaneous reconstruction and thral mobility but with and no stress incontinence. She functional surgical procedures, and considering the rel- complained of nocturia (4-5 times/night) and urgency. ative immobile urethra after the initial sling placement The initial approach consisted of nocturnal fluid restric- and the rationale that the Martius flap applied trans- tion and anticholinergic therapy but with insufficient verse may act as an increase in urethral pressure and improve in patient’s symptoms. After six weeks, desmo- reduce de stress incontinence we presented opted for pressin was initiated with significant nocturia improve- this technique. We consider that in the case of per- ment (one nocturnal micturition). sistent stress incontinence after a successful fistula re- pair the Martius flap would also constitute the support Discussions for the urethra for further stress incontinence surgery. Case ReportCase As the transvaginal surgery for urinary incontinence became more common, the number of reported com- plication increases. Urethrovaginal fistula after sling ex- References trusion and sling extrusion surgery is usually reported by tertiary centers were these cases are being referred 1. Wong, M.J., et al., Urogenital fistula. Female Pelvic Med Re- constr Surg, 2012. 18(2): p. 71-8; quiz 78. as the management and surgical repair are challenging [7, 8] 2. Jozwik, M., M. Jozwik, and W. Lotocki, Vesicouterine fistu- for both the patients and the surgeon. la--an analysis of 24 cases from Poland. Int J Gynaecol Obstet, The transvaginal approach for urethrovaginal fistula 1997. 57(2): p. 169-72. repair is as well more suitable for an early repair as is less 3. Mann, W.J., et al., Ureteral injuries in an obstetrics and gyne- invasive, and has up to 90% success rate for the first at- cology training program: etiology and management. Obstet tempt an 92% [9], 98% [10] for the second attempt [6, 11]. Nev- Gynecol, 1988. 72(1): p. 82-5. ertheless the number of cases reported in the literature 4. Ekanem, E.I., et al., Review of obstetrics genito-urinary fistulae is small and reported by tertiary centers with certainly in the University of Calabar Teaching Hospital Calabar, Nigeria. [9, 12-15] Niger J Clin Pract, 2010. 13(3): p. 326-30. much experience in transvaginal approach 5. Wall, L.L., Obstetric vesicovaginal fistula as an international Preoperative urodynamics testing is mandatory for public-health problem. Lancet, 2006. 368(9542): p. 1201-9. patients management, as urogenital fistula usually co- 6. Hadley, H.R., Vesicovaginal fistula. Curr Urol Rep, 2002. 3(5): p. exist with dysfunctions as detrusor overactivity, intrin- 401-7. sic sphincter deficiency and/or bladder outlet obstruc- 7. Reisenauer, C., et al., Urethrovaginal fistulae associated with tion (approx. 50% of the patients with urethrovaginal tension-free vaginal tape procedures: a clinical challenge. Int fistulas present detrusor instability or concomitant uri- Urogynecol J, 2014. 25(3): p. 319-22. [16] 8. Scholler, D., S. Brucker, and C. Reisenauer, Management of nary incontinence). Urethral Lesions and Urethrovaginal Fistula Formation Follow- Timing of surgery: The reported time between sling ing Placement of a Tension-Free Suburethral Sling: Evaluation surgery and fistula diagnosis varies from one month to From a University Continence and Pelvic Floor Centre. Geburt- ten years. [7] In case of an early sling extrusion some ad- shilfe Frauenheilkd, 2018. 78(10): p. 991-998. vocate for immediate repair, while others consider that 9. Goodwin, W.E. and P.T. Scardino, Vesicovaginal and uret- at least 2 months should pass from the anterior inter- erovaginal fistulas: a summary of 25 years of experience. Trans vention. [17,18] In our reported case sufficient time passed Am Assoc Genitourin Surg, 1979. 71: p. 123-9. 10. Pushkar, D.Y., N.M. Sumerova, and G.R. Kasyan, Management of from previous surgery so the scar tissue was defined. urethrovaginal fistulae.
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