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Radiation-Induced Recurrent Vesicovaginal Fistula—Treatment International Journal of Environmental Research and Public Health Case Report Radiation-Induced Recurrent Vesicovaginal Fistula—Treatment with Adjuvant Platelet-Rich Plasma Injection and Martius Flap Placement—Case Report and Review of Literature Aleksandra Kołody ´nska 1,* , Dominika Streit-Cie´ckiewicz 1, Agata Kot 2,3, Iga Kuliniec 4 and Konrad Futyma 1 1 2nd Department of Gynecology, Medical University in Lublin, Jaczewskiego 8, 20-954 Lublin, Poland; [email protected] (D.S.-C.); [email protected] (K.F.) 2 Healthcare Centre of St. John of God Independent Public Provincial Hospital in Lublin, Biernackiego 9, 20-400 Lublin, Poland; [email protected] 3 Hospice of the Good Samaritan, Bernardy´nska11a, 20-109 Lublin, Poland 4 Department of Urology and Oncological Urology, Medical University in Lublin, Jaczewskiego 8, 20-954 Lublin, Poland; [email protected] * Correspondence: [email protected] Abstract: Vesicovaginal fistula is the non-physiological connection between the urinary bladder and vagina. This results in continuous urine leakage. In developed countries, the prevalence of this condition is low and affects (mainly) women with a history of gynaecological procedures Citation: Kołody´nska,A.; or radiotherapy. The aim of this study was to present the therapeutic process of a patient with Streit-Cie´ckiewicz,D.; Kot, A.; radiation-induced, recurrent vesicovaginal fistula. The thirty-eight-year-old patient underwent Kuliniec, I.; Futyma, K. Radiation-Induced Recurrent radical hysterectomy with follow-up radiotherapy due to cervical cancer. Five years after the therapy, Vesicovaginal Fistula—Treatment she was diagnosed with vesicovaginal fistula. After two unsuccessful Latzko procedures and two with Adjuvant Platelet-Rich Plasma adjuvant platelet-rich plasma injections, a third Latzko reconstructive surgery was performed with Injection and Martius Flap additional transposition of the Martius flap—with successful closure of the fistula. Placement—Case Report and Review of Literature. Int. J. Environ. Res. Keywords: vesicovaginal fistula; urogenital fistula; incontinence; radiation; Martius flap; platelet- Public Health 2021, 18, 4867. https:// rich plasma doi.org/10.3390/ijerph18094867 Academic Editors: Kazunori Nagasaka and Paul B. Tchounwou 1. Introduction Received: 24 March 2021 Vesicovaginal fistula (VVF) is the non-physiological connection between the urinary Accepted: 29 April 2021 bladder and vagina. This is a condition that results in continuous urine leakage. Compared Published: 3 May 2021 to developing countries, where it is a common problem due to poor perinatal care, resulting in obstetrical fistulas, in developed countries, the prevalence of this condition is low and Publisher’s Note: MDPI stays neutral affects, for the most part, women with a history of gynaecological procedures or radiother- with regard to jurisdictional claims in apy [1]. In the research of Härkki-Sirén et al., for example, a group of 62,379 hysterectomies published maps and institutional affil- was analysed, and the total incidence of vesicovaginal fistula was 0.8% [2]. According to iations. Härkki-Sirén et al., laparoscopic hysterectomies had the highest risk of this complication, as compared with no incidence of VVF after supracervical abdominal hysterectomy. Radiation-induced vesicovaginal fistulas, regardless of the size or localization, are classified as complex [3,4]. In 1997, Maier et al. analysed over 10,000 patients treated with Copyright: © 2021 by the authors. radiotherapy due to gynaecological malignancies. Urinary fistula was the second most Licensee MDPI, Basel, Switzerland. common urological complication, following irradiated bladder. The authors emphasized This article is an open access article that although the risk of fistula formation is relatively low (0.3%), it can severely affect the distributed under the terms and patient’s condition [5] and quality of life. conditions of the Creative Commons Among patients with radiation-induced VVF, it is widely favoured to prevent the Attribution (CC BY) license (https:// recurrence of the malignancy before they undergo therapeutic procedures [1]. creativecommons.org/licenses/by/ 4.0/). Int. J. Environ. Res. Public Health 2021, 18, 4867. https://doi.org/10.3390/ijerph18094867 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 2 of 7 Int. J. Environ. Res. Public Health 2021, 18, 4867Among patients with radiation-induced VVF, it is widely favoured to prevent2 of the 7 recurrence of the malignancy before they undergo therapeutic procedures [1]. 2. Case Report 2. Case Report AA thirty-eight-year-old thirty-eight-year-old womenwomen with a history history of of two two spontaneous spontaneous deliveries deliveries was was di- diagnosedagnosed with with planoepithelial planoepithelial cervical cervical can cancercer IB IB-1,-1, which which was, was, according according to to FIGO, FIGO, histo- his- tologicallylogically G G-3,-3, in in 2014 2014 [6]. [6]. Following surgical treatment,treatment, sheshe underwentunderwent aa Meigs Meigs radical radical hysterectomy.hysterectomy. Due Due to to metastatic metastatic disease disease in in the the left left iliac iliac lymphatic lymphatic nodes nodes and and advanced advanced abdominalabdominal adhesions adhesions (resulting (resulting in in right right ureter ureter occlusion), occlusion), she she qualified qualified for for percutaneous percutaneous nephrostomynephrostomy and and radiotherapy. radiotherapy. Ambulatory Ambulatory brachytherapy brachytherapy was was applied—two applied—two applica- applica- tionstions on on the the upper upper vaginal vaginal cuffcuff (1100(1100 cGy/g).cGy/g). Afterwards, Afterwards, the the patient patient developed developed postradi- postra- diationation symptoms, symptoms, including including mild mild dysur dysuricic symptoms symptoms,, for for a few a few days days after after the theprocedure. proce- dure.The Thefollow follow-up-up treatment treatment was was teletherapy teletherapy in inthe the pelvis pelvis area area withwith lymphaticlymphatic systemsystem (4500/4500(4500/4500 cGy)cGy) involvement—withinvolvement—with goodgood tolerance.tolerance. Moreover,Moreover, hormonehormone replacement replacement therapytherapy with with transdermal transdermal oestrogens oestrogens was was introduced introduced after after radiotherapy. radiotherapy. InIn January January 2015, 2015, due due to to increasing increasing right right hydronephrosis, hydronephrosis, psoas psoas hitch hitch and and Boari Boari flap flap ureterocystoneostomyureterocystoneostomy andand doubledouble J (DJ) (DJ),, catheter catheter placement placement was was performed. performed. During During the thefirst first 18 months 18 months postsurgery, postsurgery, the patient the patient contracted contracted several several urinary urinary tract infections tract infections (UTIs). (UTIs).Moreover, Moreover, right-side right-side hydronephrosis hydronephrosis re-occurred, re-occurred, which resulted which resulted in the need in the for need DJ cath- for DJeter catheter replacement replacement and repeated and repeated antibiotic antibiotic treatment. treatment. In July 2016, In July after 2016, another after ineffective another ineffectiveconservative conservative treatment, treatment, the patient the was patient schedul wased scheduled for right nephrectomy. for right nephrectomy. InIn January January 2018, 2018, the the patient patient presented presented acute acute left left kidney kidney injury injury (AKI) (AKI) with with left left postra- postra- diationdiation ureter ureter occlusion, occlusion, and, and, therefore, therefore, underwent underwent ureterorenoscopy ureterorenoscopy (URS) (URS) with with the the DJ DJ cathetercatheter left left until until December December 2018. 2018. In In May May 2019, 2019, she she was was hospitalized hospitalized due due to to a a moderate moderate depressivedepressive episode. episode. InIn July July 2019, 2019, duedue toto continuous urine urine leakage leakage from from the the vagina, vagina, the the patient patient was was exam- ex- aminedined for for the the vaginal vaginal location location of of cancer cancer recurrence. recurrence. Speculum Speculum examination examination revealed revealed a avesicovaginal vesicovaginal fistula fistula orifice orifice in in the the v vaginalaginal rag rag on on the the right right side side (Figure (Figure 1).1). Computed Computed to- tomographymography scan, scan, cystoscopy cystoscopy and and cystography cystography were were then then performed performed,, and and no no indication indication for foradditional additional histopathological histopathological examination examination was was found, found, but butthe thevesicovaginal vesicovaginal fistula fistula was wasconfirmed. confirmed. Figure 1. Vaginal orifice of the fistula. Figure 1. Vaginal orifice of the fistula. InIn October October 2019, 2019, the the patient patient was was admitted admitted to to our our tertiary tertiary urogynaecological urogynaecological depart- depart- ment,ment, and and Latzko Latzko vaginal vaginal reconstructive reconstructive surgery surgery was was performed. performed. A A Foley Foley catheter catheter was was keptkept in in placeplace for 18 18 days days after after the the surgery. surgery. A week A week after after catheter catheter removal, removal, the patient the patient again again presented a constant flow of urine from the vagina. A dye test with methylene blue indicated the recurrence of the fistula.
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