Vesicouterine fistulas following cesarean section Report on a case, review and update of the literature

Abstract

Herein we report on 1 more case of vesicouterine fistula followingcesarean section with review and update of the literature concerningthis unusual topic. The disease presented with vaginal urinary leakage,cyclic hematuria and amenorrhea. The fistula was successfully repairedby delayed surgery. Actually, all over the world the prevalence of thedisease is increasing for the frequent use of the cesarean section.Fistulas may develop immediately after a cesarean section, manifest inthe late puerperium or occur after repeated procedures. Spontaneoushealing is reported in 5% of cases. Vesicouterine fistulaspresent with vaginal urinary leakage, cyclic hematuira (menouria),amenorrhea, infertility, and first trimester abortions. The diagnosis isruled out by showing the fistulous track between bladder and uterus aswell as by excluding other more frequent urogenital fistulas. Thedisease treatment options include conservative treatment as well assurgical repair. Rarely, patients refuse any kind of treatment becauseof the benignity of symptoms and prognosis of the disease. Conservativemanagement by bladder catheterization for at least 4–8 weeks isindicated when the fistula is discovered just after delivery since thereis good chance for spontaneous closure of the fistulous track. Hormonalmanagement should be tried in women presenting with Youssef's syndrome.Surgery is the maninstay and definitive treatment of vesicouterinefistulas after cesarean section. Patients scheduled for surgery shouldundergo pretreatment of urinary tract infections. Surgical repair ofvesico-uterine fistulas are performed by different approaches whichinclude the vaginal, transvesical-retroperitoneal and transperitonealaccess which is considered the most effective with the lowest relapserate. Recently, laparoscopy has been proposed as a valid option forrepairing vesicouterine fistulas. The endoscopic treatment may beeffective in treating small vesicouterine fistulas. The pregnancy rateafter repair is 31.25% with a rate of term deliveries of25%. The disease may be prevented by emptying the bladder as wellas by carefully dissecting the lower uterine segment. It is advisablethat after vesicouterine fistula repair delivery should be performed byrepeating a cesarean section since the risk of fistula recurrence.Usually, vesicouterine fistulas are diagnosed postoperatively. As aresult, at least 95% of patients will undergo another operationfor repairing the fistula. In the meantime they are bothered by relatedsymptoms which impair their quality of life. As far as we are concernedintraoperative diagnosis is the gold standard in detecting vesicouterinefistulas for allowing immediate repair. We propose intraoperativesonography by the transvaginal (or transrectal) route for the Foleytransurethral catheter producing bloody urine, for suspecting bladderinjury while dissecting the uterine lower segment and for monitoringpatients who already had had vesicouterine fistula repair. As a resultpatients will avoid the familial and social problems related to thedisease as well another operation. Moreover, ultrasound Dopplerexamination may help in better investigating and understanding thepathophysiology of vesicouterine fistulas.