Barbed Suture Causing Ureterovaginal Fistula Postconservative Surgery for Deep Infiltrating Endometriosis

Dear Editor, Barbed sutures have gained wide acceptance in minimally invasive gynecologic surgery due to their ability to eliminate knot tying and maintain uniform tension, thereby improving operative efficiency and surgical ergonomics. However, complications associated with their use continue to be reported and should be carefully considered in surgical planning. We discuss a rare case of ureterovaginal fistula resulting from a barbed suture following conservative laparoscopic surgery for deep infiltrating endometriosis. A 31-year-old female presented with chronic pelvic pain, progressive dysmenorrhea, and menstrual-exacerbated constipation. Pelvic magnetic resonance imaging revealed deep infiltrating endometriosis involving the rectovaginal septum, posterior uterine serosa, and anterior rectal wall, along with posterior wall adenomyoma. After inadequate response to medical therapy, she underwent laparoscopic excision of the disease [Figure 1], including adenomyomectomy, rectovaginal nodule excision, left ovarian endometriotic cystectomy, and rectal segmental resection with primary anastomosis. Specimen retrieval was performed through a posterior colpotomy, which was closed using a unidirectional barbed suture size 0 in a single layer and trimmed flushed with the vagina, and reverse stitches were not applied. The patient had an uneventful recovery and was discharged on postoperative day 5.Figure 1: (a) Intra-operative image showing the first laparoscopic view with rectosigmoid adherent to the posterior surface of the uterus. (b) Final endoscopic view showing the left ureter with intact vascularity with distance from the vault angle sutured using barbed sutureOn postoperative day 22, she developed continuous urinary leakage per vaginum. A computed tomography intravenous pyelogram revealed an ureterovaginal fistula between the distal left ureter and the left vaginal fornix. Laparoscopic re-exploration identified dehiscence at the colpotomy site [Figure 2], with the barbed suture tail protruding into the left ureter, forming the fistulous tract. DJ stent placement led to resolution, and the patient remained asymptomatic at follow-up after stent removal at 6 weeks.Figure 2: (a) Vault dehiscence noted during the second surgery. (b) Barbed suture seen protruding into the left ureterBarbed sutures have transformed laparoscopic surgery by providing a self-anchoring mechanism that distributes tension evenly and negates the need for knot tying, a step often challenging in laparoscopy. However, their increased use has also brought attention to potential risks, most notably small bowel obstruction due to exposed barbed ends.[1-3] In contrast, ureteric complications associated with barbed sutures have not been previously documented, to our knowledge. The causality was attributed to the barbed suture based on intraoperative findings during re-exploration, where the suture tail was seen protruding from the dehisced vault and entering the ureter at the fistula site. Unlike smooth sutures, barbed sutures possess unidirectional barbs that can cause tissue traction or microtrauma if exposed postoperatively. The pathophysiology in this case may involve gradual postoperative tissue contraction leading to exposure of the suture’s barbs, which due to the ureter’s peristaltic motion could result in frictional erosion and fistula formation. Although the barbed suture was trimmed flush with the vagina, manufacturer guidelines recommend two reverse stitches or burying the tail with clips or antiadhesive barriers to prevent exposure. Nonadherence to these measures may have contributed to the complication. The ureter’s proximity to the posterior vaginal fornix, especially in a distorted pelvis due to endometriosis, further increased vulnerability. While we do not claim barbed sutures are inherently unsafe, this rare occurrence highlights the importance of strict adherence to recommended techniques. Over the past 5 years, our center has performed 1131 laparoscopic gynecologic and gynecologic oncologic procedures utilizing barbed sutures, including colpotomy closure, myomectomy, and peritoneal closure. Only two major complications (0.17%) were encountered: the current ureterovaginal fistula and a prior case of small bowel obstruction postlaparoscopic sacrocolpopexy.[4] In cases with distorted anatomy, especially deep infiltrating endometriosis, it is essential to take additional precautions such as burying the suture tail, applying reverse sutures or securing with clips, or considering absorbable knotted sutures for vault closure when the ureter lies in close proximity. This case reinforces the importance of adhering to safe techniques when using barbed sutures, especially in anatomically complex or inflamed surgical fields. Surgeons should maintain a high index of suspicion for unusual complications and adopt a proactive approach when symptoms such as delayed urinary leakage emerge. While barbed sutures offer significant advantages, their use must be coupled with appropriate preventive strategies and rigorous intraoperative attention to detail. Ethics statement This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Author contributions All authors contributed to the study’s conception and design. Material preparation and data collection were performed by Ayush Heda and Mahan Gowda. The first draft of the manuscript was written by Ayush Heda, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Data availability statement Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.