Vesicosalpingo Fistula: A Case Presentation And Review of The Literature

A 32-year-old otherwise healthy woman presented with a chief complaint of abdominal pain, distention, bloating, and persistent and continuous vaginal leakage. The patient had undergone hysterectomy for uterine fibroids 3 months prior. The hysterectomy was complicated with significant intraoperative pelvic bleeding in addition to a suspected bladder injury and was converted from laparoscopy to an open abdominal approach. Her ovaries and fallopian tube remnants remained in situ. In the perioperative period, the patient noted persistent urine leakage and presented to her gynecologist for repeat evaluation. A urinary catheter was placed by the performing surgeon, but this failed to resolve the leakage. The patient was then referred to urology for further assessment and management. Pelvic examination revealed a defect at the apex of the vagina which was consistent with a vesicovaginal fistula. Cystoscopy revealed 2 small defects near the midline of the posterior bladder trigone. The larger of the 2 defects was continuous with the vagina, whereas the smaller defect had no apparent vaginal communication. The findings were discussed, and an informed consent was obtained for abdominal fistula repair using robotically assisted laparoscopic technique. The patient was induced with general anesthetic and placed in the dorsal lithotomy position. Cystoscopy was repeated and cannulation of the larger of the 2 bladder defects with a ureteric catheter confirmed a 1-cm vesicovaginal fistula above the trigone. The smaller bladder defect was cannulated, and its catheter path was not evident. Fluoroscopy and retrograde fistulogram of this tract were performed, and the catheter appeared to sit within the peritoneum. Bilateral retrograde pyelogram showed no filling defects, hydronephrosis, or extravasation in the ureters or renal pelvises. Bilateral temporary ureteral catheters were placed to further identify the ureters during the surgical repair. Access to the peritoneum was achieved using open approach and the da Vinci (Sunnyvale, CA) robot was docked with port placement similar to abdominal sacrocolpopexy using a 12-mm periumbilical camera port; three 8-mm robot ports with left predominant spacing; and a 10-mm right-sided assistant port. Abdominal surveillance was performed, and the patient's right-sided fallopian tube was found adherent to the remnant of the vaginal cuff closure from her abdominal hysterectomy. The ureteral catheter which was placed into the smaller of the 2 bladder defects during our cystoscopic evaluation was visualized within the fistula tract and appeared to enter the right fallopian tube ( Fig. 1 ). The peritoneum overlying the posterior bladder was incised horizontally and divided. The bladder was elevated to define the vesicovaginal plane. The vesicovaginal plane was dissected using a combination of blunt and sharp dissection and a controlled cystotomy was performed. The vesicovaginal fistula was identified, entered, and the ureteric catheter within the fistula was traced back to its origin to visualize the tract in its entirety. The vesicovaginal fistula was widely exposed to achieve approximately 3 cm of healthy tissue on either side of the fistulous tract to ensure a tension-free repair. The bladder was completely mobilized away from the anterior surface of the vagina, whereas ureteral stents were in full view to ensure ureteral integrity. The ureteric catheter originating from the smaller bladder defect was seen exiting the bladder and entering the fallopian tube. The vesicosalpingo fistula was grasped and similarly divided and excised. The fallopian tube remnant was cauterized. Closure of the bladder was then performed in a horizontal running fashion with 3-0 polyglactin absorbable suture. This suture line was then imbricated with a second layer of 2-0 polyglactin suture. Water-tight closure was confirmed with a bladder backfill test using 300 mL of pigmented normal saline. The vaginal defect was then closed with a 2-0 polyglactin suture in a running locked fashion along its length. An omental flap was then interposed and anchored within the vesicovaginal plane with sutures. The patient's ureteral catheters were removed and an 18 Fr urinary catheter was left in situ for 2 weeks duration.

The first vesicosalpingo fistula in the literature was diagnosed by Rozin in 1954 while evaluating a 24-year-old woman for sterility of 5 years duration. Contrast dye was injected into the patient's right fallopian tube during hysterosalpingography and was observed entering a sac. In repeat imaging 1 hour later, the contrast medium had disappeared from the sac. The key difference was that the patient had urinated before the second film was taken, thus clearing her bladder of the contrast medium. The first diagnosis of a vesicosalpingo fistula was made. 6 More than 60 years have passed since then, and there have only been three additional vesicosalpingo fistulas case reports published in the literature. Previously reported vesicosalpingo fistulas have had etiologies which were either unknown, 6 secondary to a vaginal hysterectomy, 7 , 8 or from a tubo-ovarian abscess. 5 Vesicosalpingo fistulas may present with signs and symptoms, which include sterility, 6 lower abdominal pain, 5 , 7 , 8 dysuria, 7 fever, 5 recurrent urinary tract infections, 5 , 8 and vaginal urine leakage. Vesicosalpingo fistulas which form after a vaginal hysterectomy are likely caused by misdirected sutures joining the fallopian tube and bladder wall which are placed while tying the round ligament and fallopian tube shut. 7 Table 1 summarizes vesicosalpingo fistulas reported in the literature thus far. Sterility is a potential consequence of the vesicosalpingo fistula and was even a primary complaint in 1 case report. 6 Although prior studies did not evaluate for fertility on follow-up, one can infer that repair of a vesicosalpingo fistula would lead to the restoration of fertility as it has been shown to after the repair of vesicouterine and vesicocervical fistulas. 9 The diagnosis of a vesicosalpingo fistula was most commonly made through cystoscopy with fistulogram, 5 , 7 , 8 but was once made after hysterosalpingography. 6 An excretory urogram or cystogram may aid in diagnosing a vesicosalpingo fistula, but it occasionally is made during exploratory laparotomy. 7 Two of the 4 reported cases of vesicosalpingo fistulas were treated with salpingo-oophorectomy, 7 , 8 one was treated with fistulectomy and salpingostomy, 6 and one was treated by removing an intrauterine contraceptive device, which was suspected as the inciting cause of a tubo-ovarian abscess, and placement of a Foley catheter drainage with parenteral antibiotics for 11 days. 5 Conservative nonoperative management of a vesicosalpingo fistula with Foley catheter drainage, fistula tract irrigation, and antibiotics is usually only temporarily beneficial. 7 , 8 One case report does not quantify the amount of time at follow-up visit, so the duration of benefit that their patient received through non-operative management remains uncertain. 5 A recent case series described the robot-assisted laparoscopic repair of vesicovaginal fistula in detail and reports a 100% cure rate without fistula recurrence at a 2-year follow-up visit. 10 This is the first case report detailing the robotic-assisted laparoscopic repair of simultaneous vesicovaginal and vesicosalpingo fistulas with a uterus in situ. The vesicovaginal fistula is likely to present with constant urinary leakage from the vagina however the other forms of fistulas would have varying symptoms. It is imperative to perform preoperative cystoscopy with evaluation of the ureters in order to exclude the presence of multiple concurrent fistulas, such as urethrovaginal, vesicocervical, vesicouterine, vesicoureteral, or vesicosalpingo fistulas. If multiple fistula tracts or complex fistulas are present, authors strongly recommend abdominal approach over the transvaginal repair for wider dissection and accessibility to peritoneal cavity for exploration if needed and interposition of omentum or peritoneum in the vesicovaginal space. A recent randomized controlled trial by Barone et al has found that after repair of simple female genital fistulas, 7-day bladder catheterization is noninferior to 14 days and poses no increased risk of repair breakdown, urinary retention, or residual incontinence; however, the authors believe that in the presence of multiple fistulas, radiated filed, or a more comprehensive reconstructive repair a longer catheterization may be indicated which is usually followed by an imaging study such as a cystogram. If only the vesicovaginal fistula was repaired in the present case, the patient would likely have had persistent abdominal pain, urine leakage, and worsening of symptoms without resolution of the vesicosalpingo fistula. This shows a necessity to maintain a high suspicion for multiple fistula tracts communicating to various surrounding structures (such as the ureter, fallopian tubes, etc) and to thoroughly evaluate each fistula tract present. The combination of a detailed history and physical examination, complete preoperative and intraoperative evaluation of the fistula tracts including cystoscopy, retrograde pyelograms, ureteral and fistula tract catheterization, abdominal approach with tension-free cystotomy repair, omental interposition, and a follow-up with cystourethrogram all contributed to a successful robotic-assisted laparoscopic vesicovaginal and vesicosalpingo fistula repair and the avoidance of any future reoperations.

Total operative time was 110 minutes (including the endoscopic and fluoroscopic procedures). Robotic console time for this procedure was 80 minutes. The estimated blood loss was 50 mL. The patient was discharged on the first postoperative day. No intraoperative or perioperative complications were identified. The patient's Foley catheter was placed and left in situ for 14 days. A follow-up voiding cystourethrogram performed 2 weeks after the operation demonstrated no evidence of extravasation. There were no concerns of fistula formation or leak at the four month follow-up visit.