Int Urogynecol J DOI 10.1007/s00192-014-2374-1
CASE REPORT
Vesico-cutaneous fistula: unusual complication after transobturator mid-urethral sling Fulya Dokmeci & Tuncay Yuce & Serife Esra Cetinkaya
Received: 19 January 2014 / Accepted: 10 March 2014 # The International Urogynecological Association 2014
Abstract The transobturator tape (TOT) procedure was described in 2001 as the safest sling technique for the treatment of stress urinary incontinence (SUI). Although routine intraoperative cystoscopy to detect bladder and urethra injuries after the TOT procedure is not usually advocated, when such perforations do occur, there is potential for further patient morbidity. We present a case report of a vesico-cutaneous fistula detected after placement of a TOT sling in a 44-year old woman, 3 months postoperatively. Cystoscopic evaluation after mid-urethral sling procedures, especially in high-risk situations such as patients with cystocele, previous pelvic floor surgery or during the learning curve of the procedure, may avoid such complications associated with unrecognized lower urinary tract injuries.
complications such as voiding difficulty, infection, rejection or erosion of sling materials, most of which depend upon the route or materials used for the sling as well as unnecessary tape tension or inappropriate placement. Although early reports emphasize that the TOT procedure is the safest sling technique in which cystoscopy is not mandatory to eliminate bladder and urethral injuries, complications have been recently described, including bladder perforation, urethral injury, and vesico-vaginal fistula [2–4]. To our knowledge, this is the first report of a case with a vesico-cutaneous fistula secondary to unrecognized bladder perforation during the TOT procedure.
Case report Keywords Stress urinary incontinence . Transobturator mid-urethral sling . Vesico-cutaneous fistula
Introduction After the introduction of the tension-free vaginal tape (TVT) procedure for anti-incontinence surgery in 1996 by Ulmsten et al. [1], a variety of mid-urethral slings including transobturator tape (TOT) have been marketed as minimally invasive surgical techniques for women with stress urinary incontinence (SUI) and have recently become widely accepted for all types of SUI because of their significant cure rates. However, there are also many reports focusing on the serious complications of these procedures, which are related to blind trocar passage. These operations are also associated with F. Dokmeci : T. Yuce : S. E. Cetinkaya (*) Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey e-mail: [email protected]
A 44-year-old woman with a history of a previous TOT procedure for urinary incontinence performed at another institution presented to the urogynecology unit of the Ankara University Hospital with complaints of overactive bladder symptoms and minimal wetness of her underwear from the right groin intermittently. Upon review of her operative report, no intraoperative evaluation with cystoscopy was noted. Her history revealed that she had presented with an intermittently discharging cutaneous opening in the right groin at the trocar insertion scar and had undergone secondary suturing at the same institution. The patient underwent the routine urogynecological evaluation at our urogynecology unit including physical examination, 3-day voiding diary, symptom and quality of life questionnaires, urinalysis, urine culture, and post-void residual urine measurement. On pelvic examination, the stress test was negative and grade 2 anterior vaginal wall prolapse was observed. A 2×3mm area of granulation tissue with a serous discharge was found in the right groin. As the patient with a history of a TOT
Int Urogynecol J
procedure had complaints of intermittent wetting through the cutaneous opening on the scar of trocar entry site and recurrent urinary infections with persisting overactive bladder symptoms, we strongly suspected a fistulous tract. An insemination catheter was introduced through the cutaneous opening, which could be advanced for 4 to 5 cm. A methylene blue test was performed. After instillation of the bladder with 400 mL of methylene blue, the patient was asked to perform her routine daily activities. One hour later, there was no visualized leakage from the right groin. Because of the high scores of overactive bladder symptoms, confirmation of frequency and nocturia from 3-day voiding diary, and positive urine culture, the patient was treated with antibiotics and scheduled for further investigations to figure out a possible very tiny fistulous tract that could not be demonstrated using the methylene blue test. The fistulography, which could be carried out only with an insemination catheter inserted from the opening in the right groin, revealed a vesico-cutaneous fistulous tract between the bladder and the right groin (Fig. 1). During cystoscopic evaluation, we observed a piece of mesh making a free bridge with one entry and one exit site on the right lateral bladder wall. Concurrently, the tip of the insemination catheter inserted through the cutaneous opening of the fistula was seen at the same entry point of one of the mesh sites in the bladder (Fig. 2). The bladder was approached intraperitoneally and opened through a vertical incision in the anterior bladder wall. The mesh passing through the bladder was excised and the proximal segment of the mesh was pulled out from the bladder wall. The proximal part of the fistulous tract was dissected off from the bladder and all the mucosal defects were repaired. The defect in the bladder wall was closed in two layers. The distal portion of the fistulous tract was dissected out from the groin. Two weeks after the operation the indwelling Foley catheter was removed. The patient was symptom free at the follow-up visits 3 months and 1 year after the repair procedure. Evaluation with a voiding cystourethrography also showed no communication between the bladder and the right groin.
Fig. 1 Fistulography revealing vesico-cutaneous fistulous tract between the bladder and the right groin
Fig. 2 Cystoscopy revealing mesh bridges on the right lateral bladder wall and the tip of the insemination catheter inserted through the cutaneous opening of the fistula
Discussion Pelvic irradiation, radical pelvic surgery, and severe trauma with pelvic fractures are the common causes of vesicocutaneous fistula. After a search of the literature we could not find any reported cases of vesico-cutaneous fistula following a TOT procedure. As far as we know, there is only one case report of vesico-cutaneous fistula with formation of a vesical stone following a gauze-hammock sling operation, with the fistula tract appearing on the skin at the laparotomy scar [5]. Although mid-urethral sling operations have a very high success rate, they are also associated with voiding difficulties, infections, rejection or erosion of synthetic sling materials and intra-operative bladder or urethral injuries. Most of these complications depend upon unnecessary tape tension or inappropriate placement [2–4]. Patients who have undergone mid-urethral sling operations, presenting with persisting lower urinary tract complaints or nonspecific irritative bladder symptoms require a thorough clinical approach with a high index of suspicion. To manage the complications successfully with less morbidity, early intraoperative recognition is mandatory. The development of the vesico-cutaneous fistula in this patient may have been due to the lack of clinical experience of trocar passage and to undetected bladder perforation with placement of the mesh inside the bladder. As a piece of free mesh bridge with one entry and one exit site was observed inside the bladder, this complication probably occurred because of an intraoperative bladder perforation rather than erosion over time. We may suggest that intraoperative cystoscopic evaluation should be performed, even after the TOT procedure, particularly in high-risk situations such as patients with anterior vaginal wall prolapse, previous pelvic floor surgery or during the learning curve of the procedure. This may avoid the complications as presented in this case.
Int Urogynecol J Consent Written informed consent of the patient was obtained before attempting to publish this paper Conflicts of interest None.
References 1. Ulmsten U, Henriksson L, Johnson P, Varhos G (1996) An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence. Int Urogynecol J 7:81–85
2. Smith PP, Appell RA (2007) Transobturator tape, bladder perforation, and paravaginal defect: a case report. Int Urogynecol J Pelvic Floor Dysfunct 18:99–101 3. Starkman JS, Meints L, Scarpero HM, Dmochowski RR (2007) Vesicovaginal fistula following a transobturator midurethral sling procedure. Int Urogynecol J Pelvic Floor Dysfunct 18: 113–115 4. Ashok K, Petri E (2012) Failures and complications in pelvic floor surgery. World J Urol 30:487–494 5. Danso D, Thein K, Haloob R (1998) Vesico-cutaneous fistula with a valvular stone: an unusual complication following gauze-hammock sling operation. J Obstet Gynaecol 133:292– 294
CASE REPORT
Vesico-cutaneous fistula: unusual complication after transobturator mid-urethral sling Fulya Dokmeci & Tuncay Yuce & Serife Esra Cetinkaya
Received: 19 January 2014 / Accepted: 10 March 2014 # The International Urogynecological Association 2014
Abstract The transobturator tape (TOT) procedure was described in 2001 as the safest sling technique for the treatment of stress urinary incontinence (SUI). Although routine intraoperative cystoscopy to detect bladder and urethra injuries after the TOT procedure is not usually advocated, when such perforations do occur, there is potential for further patient morbidity. We present a case report of a vesico-cutaneous fistula detected after placement of a TOT sling in a 44-year old woman, 3 months postoperatively. Cystoscopic evaluation after mid-urethral sling procedures, especially in high-risk situations such as patients with cystocele, previous pelvic floor surgery or during the learning curve of the procedure, may avoid such complications associated with unrecognized lower urinary tract injuries.
complications such as voiding difficulty, infection, rejection or erosion of sling materials, most of which depend upon the route or materials used for the sling as well as unnecessary tape tension or inappropriate placement. Although early reports emphasize that the TOT procedure is the safest sling technique in which cystoscopy is not mandatory to eliminate bladder and urethral injuries, complications have been recently described, including bladder perforation, urethral injury, and vesico-vaginal fistula [2–4]. To our knowledge, this is the first report of a case with a vesico-cutaneous fistula secondary to unrecognized bladder perforation during the TOT procedure.
Case report Keywords Stress urinary incontinence . Transobturator mid-urethral sling . Vesico-cutaneous fistula
Introduction After the introduction of the tension-free vaginal tape (TVT) procedure for anti-incontinence surgery in 1996 by Ulmsten et al. [1], a variety of mid-urethral slings including transobturator tape (TOT) have been marketed as minimally invasive surgical techniques for women with stress urinary incontinence (SUI) and have recently become widely accepted for all types of SUI because of their significant cure rates. However, there are also many reports focusing on the serious complications of these procedures, which are related to blind trocar passage. These operations are also associated with F. Dokmeci : T. Yuce : S. E. Cetinkaya (*) Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey e-mail: [email protected]
A 44-year-old woman with a history of a previous TOT procedure for urinary incontinence performed at another institution presented to the urogynecology unit of the Ankara University Hospital with complaints of overactive bladder symptoms and minimal wetness of her underwear from the right groin intermittently. Upon review of her operative report, no intraoperative evaluation with cystoscopy was noted. Her history revealed that she had presented with an intermittently discharging cutaneous opening in the right groin at the trocar insertion scar and had undergone secondary suturing at the same institution. The patient underwent the routine urogynecological evaluation at our urogynecology unit including physical examination, 3-day voiding diary, symptom and quality of life questionnaires, urinalysis, urine culture, and post-void residual urine measurement. On pelvic examination, the stress test was negative and grade 2 anterior vaginal wall prolapse was observed. A 2×3mm area of granulation tissue with a serous discharge was found in the right groin. As the patient with a history of a TOT
Int Urogynecol J
procedure had complaints of intermittent wetting through the cutaneous opening on the scar of trocar entry site and recurrent urinary infections with persisting overactive bladder symptoms, we strongly suspected a fistulous tract. An insemination catheter was introduced through the cutaneous opening, which could be advanced for 4 to 5 cm. A methylene blue test was performed. After instillation of the bladder with 400 mL of methylene blue, the patient was asked to perform her routine daily activities. One hour later, there was no visualized leakage from the right groin. Because of the high scores of overactive bladder symptoms, confirmation of frequency and nocturia from 3-day voiding diary, and positive urine culture, the patient was treated with antibiotics and scheduled for further investigations to figure out a possible very tiny fistulous tract that could not be demonstrated using the methylene blue test. The fistulography, which could be carried out only with an insemination catheter inserted from the opening in the right groin, revealed a vesico-cutaneous fistulous tract between the bladder and the right groin (Fig. 1). During cystoscopic evaluation, we observed a piece of mesh making a free bridge with one entry and one exit site on the right lateral bladder wall. Concurrently, the tip of the insemination catheter inserted through the cutaneous opening of the fistula was seen at the same entry point of one of the mesh sites in the bladder (Fig. 2). The bladder was approached intraperitoneally and opened through a vertical incision in the anterior bladder wall. The mesh passing through the bladder was excised and the proximal segment of the mesh was pulled out from the bladder wall. The proximal part of the fistulous tract was dissected off from the bladder and all the mucosal defects were repaired. The defect in the bladder wall was closed in two layers. The distal portion of the fistulous tract was dissected out from the groin. Two weeks after the operation the indwelling Foley catheter was removed. The patient was symptom free at the follow-up visits 3 months and 1 year after the repair procedure. Evaluation with a voiding cystourethrography also showed no communication between the bladder and the right groin.
Fig. 1 Fistulography revealing vesico-cutaneous fistulous tract between the bladder and the right groin
Fig. 2 Cystoscopy revealing mesh bridges on the right lateral bladder wall and the tip of the insemination catheter inserted through the cutaneous opening of the fistula
Discussion Pelvic irradiation, radical pelvic surgery, and severe trauma with pelvic fractures are the common causes of vesicocutaneous fistula. After a search of the literature we could not find any reported cases of vesico-cutaneous fistula following a TOT procedure. As far as we know, there is only one case report of vesico-cutaneous fistula with formation of a vesical stone following a gauze-hammock sling operation, with the fistula tract appearing on the skin at the laparotomy scar [5]. Although mid-urethral sling operations have a very high success rate, they are also associated with voiding difficulties, infections, rejection or erosion of synthetic sling materials and intra-operative bladder or urethral injuries. Most of these complications depend upon unnecessary tape tension or inappropriate placement [2–4]. Patients who have undergone mid-urethral sling operations, presenting with persisting lower urinary tract complaints or nonspecific irritative bladder symptoms require a thorough clinical approach with a high index of suspicion. To manage the complications successfully with less morbidity, early intraoperative recognition is mandatory. The development of the vesico-cutaneous fistula in this patient may have been due to the lack of clinical experience of trocar passage and to undetected bladder perforation with placement of the mesh inside the bladder. As a piece of free mesh bridge with one entry and one exit site was observed inside the bladder, this complication probably occurred because of an intraoperative bladder perforation rather than erosion over time. We may suggest that intraoperative cystoscopic evaluation should be performed, even after the TOT procedure, particularly in high-risk situations such as patients with anterior vaginal wall prolapse, previous pelvic floor surgery or during the learning curve of the procedure. This may avoid the complications as presented in this case.
Int Urogynecol J Consent Written informed consent of the patient was obtained before attempting to publish this paper Conflicts of interest None.
References 1. Ulmsten U, Henriksson L, Johnson P, Varhos G (1996) An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence. Int Urogynecol J 7:81–85
2. Smith PP, Appell RA (2007) Transobturator tape, bladder perforation, and paravaginal defect: a case report. Int Urogynecol J Pelvic Floor Dysfunct 18:99–101 3. Starkman JS, Meints L, Scarpero HM, Dmochowski RR (2007) Vesicovaginal fistula following a transobturator midurethral sling procedure. Int Urogynecol J Pelvic Floor Dysfunct 18: 113–115 4. Ashok K, Petri E (2012) Failures and complications in pelvic floor surgery. World J Urol 30:487–494 5. Danso D, Thein K, Haloob R (1998) Vesico-cutaneous fistula with a valvular stone: an unusual complication following gauze-hammock sling operation. J Obstet Gynaecol 133:292– 294
