Vesicouterine fistula associated with placenta percreta

Pelvic Varices Mimnicking Placenta Percreta at Sonography

Abnormal placentation refers to pathologic adherence of the placenta to the uterus.1-3 Three subtypes are defined based on depth of myometrial invasion by nonneoplastic chorionic villi. Superficial, deep, and transmural involvement are termed placenta accreta, increta, and percreta, respectively. Of the three, placenta percreta is the rarest type, occurring with a frequency of only 1:33,000-90,000 deliveries.3 The antepartum diagnosis of placenta percreta is crucial because the associated vascular involvement of the myometrium and surrounding pelvic structures can result in massive blood loss, fetal demise, and maternal death at delivery. An imaging feature of placenta percreta is the sonographic demonstration of abnormal vascularity within the placenta, subplacental complex, and adjacent organs such as the bladder.1,2,4-8

Pelvic varices are dilated veins (T 5 mm) that can occur during pregnancy or in non pregnant women.9'-5 These enlarged veins commonly involve the broad ligaments and parametrium, and, as a result, they often abut or surround the uterus, lower uterine segment, and cervix. Although pelvic varices can be prominent, they rarely cause obstetrical complications (Gibbs R, personal communication).

We report a case of pelvic varices mimicking placenta percreta with bladder invasion. The antenatal diagnosis of placenta percreta radically altered the patient's management. Although only unusual pelvic varices were subsequently documented at cesarean hysterectomy, the extremely cautious care necessitated by the presumptive sonographic diagnosis of placenta percreta was warranted to avoid a potential obstetrical catastrophe.

A case of vesicouterine fistula: unwanted medical anomaly but consequentiality of most-wanted medical intervention 'caesarean section'

Vesicouterine fistula is a rare entity, with unique presentation of cyclical haematuria, amenorrhoea, absence of urinary incontinence (Youssef syndrome). A 35 year old female patient, P2L2 with 2 previous LSCS presented with cyclical haematuria, amenorrhoea, repeated UTI, dating from 11th day of last LSCS. Transabdominal sonography revealed communication between bladder & uterus, confirmed by cystoscopy. At laparotomy fistulous tract delineated and bladder separated from uterus. Hysterectomy and closure of bladder done. Continuous bladder drainage with suprapubic and perurethral foleys catheters maintained. Postoperative period was uneventful. Cystoscopy during followup revealed healthy scar. Vesicouterine fistula is an avoidable complication of LSCS which can be prevented by sound surgical technique.

Urogenital fistula in a Saudi Arabian referral center

PURPOSE

To review all cases of genitourinary fistula, their causes, management and outcome.

MATERIALS AND METHODS

A retrospective chart review of all fistula cases referred to the Urogynecology Department, King Fahad Medical City, Riyadh, Saudi Arabia, from January 2005 to December 2011.

RESULTS

Sixteen genitourinary fistula cases were identified; nine (56 %) cases of vesicovaginal fistula, four (25 %) cases of vesicouterine fistula, and three (19 %) cases of vesicocervical fistula. Mean age was 41 (29-61) and mean parity was 7.4 (2-15). Out of the 16 cases, 12 (75 %) had obstetrical surgical complications, of which 8 (50 %) had complications of cesarean sections. Twelve of 15 cases (80 %) were cured after primary surgical repair, 2 (13 %) after secondary repair and 1 after tertiary repair. One case was cured after conservative management.

CONCLUSION

Most of the genitourinary fistulae were of iatrogenic obstetric causes, mainly cesarean section with none of the cases due to obstructed labor unlike fistulae in developing countries or developed countries fistulae (iatrogenic gynecologic origin).

POST CAESAREAN VESICOUTERINE FISTULAE - YOUSSEF SYNDROME: OUR EXPERIENCE AND REVIEW OF PUBLISHED WORK

OBJECTIVE

To analyse the incidence, symptomatology, diagnosis and therapeutic aspects of Youssef syndrome (post caesarean vesicouterine fistula), and to review relevant published work.

METHODS

A retrospective study from the urosurgical unit of a tertiary care referral hospital was carried out. In a retrospective analysis of urogenital fistulae over 10 years, we identified 14 patients with uterovesical fistulae, resulting from caesarean section. All the patients were evaluated by history, physical examination, radiological tests and cystoscopy. All patients underwent transperitoneal repair of these fistulae with omental interposition. Results of surgery were evaluated by absence of cyclic haematuria, stoppage of urinary incontinence, and achievement of fertility.

RESULTS

A total of 12 patients who had minimum follow up was included in the present study. The results showed that 50% of the fistulae resulted from emergency caesarean operation with 58% of patients presenting after their second caesarean section. The mean age of the patients was 19 years (range 15-29) and mean duration of symptoms was 7 months (range 3-16). Menouria and amenorrhoea were predominant presenting symptoms. The results of surgical treatment were excellent with good continence and resolution of the cyclic haematuria. Three pregnancies (37.5%) which resulted in elective caesarean section were recorded.

CONCLUSION

Vesicouterine fistulae, despite being infrequent, are no longer a rare diagnosis and are most commonly secondary to lower segment caesarean section. With patient history and selected investigations diagnosis is relatively easy. The surgical repair of these fistulae is standard treatment, especially with delayed fistulae with achievement of total continence, and complete resolution of cyclic haematuria. Meticulous practice of obstetric and surgical principles during caesarean section can prevent the formation of these fistulae.

Vesicouterine fistula: a review of eight cases

Eight cases of vesicouterine fistula (VUF) (obstetrical etiology in six cases and inflammatory bowel disease in two) have been treated in the past 14 years. All six obstetrical cases were related to cesarean section. Both cases of colovesicouterine fistula presented acutely with watery vaginal discharge or fecaluria. Presenting complaints were vaginal urinary incontinence (five cases), hematuria (three), and vaginal discharge (two). Diagnosis was made with cystoscopy in seven cases and computed tomography in one. VUF usually was between posterior bladder and anterior uterine walls above the internal os. Of the initial treatments, six were surgical (three hysterectomies) with an abdominal (five) or transvaginal (one) approach. Mean follow up was 9 months (range, 2-24). Urinary incontinence resolved in all surgically treated patients. Two patients reporting cyclic hematuria were initially managed medically (medroxyprogesterone injections), with delayed surgical repair elsewhere. Surgical repair is the primary treatment for VUF. Successful pregnancy and cesarean delivery have been reported after VUF repair, without sequelae.

Placenta percreta--two cases and review of the literature

Two cases of placenta pecreta confirmed histologically were treated conservatively with retention of the uterus. Both later went on to have successful pregnancies.

Vesicouterine fistula: an updated review

To ascertain the condition of vesicouterine fistula, a search of the medical literature using the Ovid version (Ovid Technologies Inc., New York, USA) of Medline (1966-1997) was undertaken, using the keywords vesicouterine, vesico-uterine, uterovesico, and utero-vesico fistula. A search of the earlier medical literature was by cross-referencing and is likely to be less complete than the computerized database. Nonetheless, the authors believe the most relevant publications were cited. On reviewing the subject it was noticed that there had been a change in obstetric practice between the first and the latter half of this century, namely an increase in the incidence of cesarean deliveries. However, the literature contains relatively little information on pathophysiology, possibly owing to the relative rarity of the lesion. Emphasis has been given to the most recent 10 years (1987-1997) in order to update the etiology, diagnosis and management of this clinical condition.