Congenital urethrovaginal fistula associated with imperforate hymen causing fetal urinary ascites and abdominal cystic lesions: A case report and literature review

Robotic management of congenital urethra-vaginal fistula with transverse vaginal septum

Introduction:

The transverse vaginal septum (TVS) with congenital urethra-vaginal fistula (CUVF) is a rare anomaly of the mullerian duct (1 , 2 ). Incomplete channelling of the vaginal plate, or an abnormality in the fusion of the vaginal component of mullerian duct with the urogenital sinus results in TVS (1 , 3 , 4 ). High CUVF occurs due to the persistent communication between the urogenital sinus and utero-vaginal primordium at the tubercle sinus, whereas low CUVF is due to excessive apoptosis of the vaginal plate during channelling (5 ). The principles of management of CUVF with TVS include: 1) TVS resection, 2) Create a neovagina. We present a case of CUVF with TVS managed by robotic assistance.

Material and methods:

A 24-year-old female, married for 3 years, presented with cyclical hematuria since menarche, dyspareunia and primary infertility. Examination revealed blind ending vagina 4cm from the introitus. Magnetic resonance imaging revealed a fistulous communication between urethra and vagina, and TVS. Cystourethroscopy confirmed a proximal urethra-vaginal fistula. Urethroscopy guided puncture of the TVS was performed, tract dilated and a catheter was placed across it. Robotic assisted transvaginal approach was planned. Air docking of robot was performed. Traction on the catheter was given to identify the incised edges of the septum. Vaginal flaps were raised laterally, fistulous tract was excised. Proximal vagina mucosa was identified and vaginoplasty was performed.

Result:

Patient’s postoperative recovery was uneventful. Urethral catheter was removed after 5 days. She had normal voiding and menstruation. Vaginoscopy performed at 1st month follow-up, revealed an adequate vaginal lumen. Vaginal moulds were advised for 6 weeks during the night, following which she resumed her sexual activity. She conceived 6 months post-surgery, and delivered a child by caesarean section.

Conclusion:

We successfully managed this case by resection of septum, neovagina creation and thereby achieving normal menstruation and conception. The advantages of robotic approach were magnification, precision and manoeuvrability in a limited space, avoiding a vaginal release incision.

Best practice in management of paediatric and adolescent hydrosalpinges: a systematic review

BACKGROUND

Hydrosalpinx is a rare cause of abdominal pain in paediatric patients, though cases are documented in the literature. Its aetiology differs considerably from traditional hydrosalpinx due to ascending sexually transmitted infection. Hydrosalpinx can present mimicking an acute abdomen or can be asymptomatic. Management of paediatric hydrosalpinx varies, but often involves surgical removal of the affected tube.

METHODS

In June 2015, a literature search using relevant keywords was completed on MEDLINE and EMBASE databases to determine best management of paediatric hydrosalpinx.

RESULTS

We found 66 cases from 38 articles. Surgical intervention took place in 74% of cases (n=49). The most common surgical intervention was salpingectomy. In 3% of cases (n=2), nonsurgical medical management with hormonal therapy was utilized, with post-operative improvement in symptomology. In 23% of cases (n=15), conservative management was utilized: 2 of these cases torted, 4 cases persisted and 9 cases resolved.

CONCLUSION

Overall, the results of this review demonstrate that there are comparable outcomes between surgical, medical and conservative management. However, medical and conservative management was not often offered, and more research is needed on the subject.