A rare case of iatrogenic vesicovaginal fistula arising from a forgotten gauze strip during Caesarean section.

The incidence of iatrogenic vesicovaginal fistulas in women after gynecological surgery is 82%, as hysterectomy being the most common cause for them - 88%. We presented a rare case of iatrogenic vesicovaginal fistula resulting from a series of errors and forgotten gauze strip in a 26-years-old woman after a third Caesarean section.

Introduction

According to the literature, the main causes of iatrogenic vesicovaginal fistulas in women are gynecological surgeries, obstetric interventions, radiation therapy, injuries or burns. Of all gynecological operations, hysterectomy is the most common cause of vesicovaginal fistulas. When the hysterectomy is performed with abdominal access, the expectation of iatrogenic bladder injury is increased 3 times. The incidence of bladder injury during abdominal hysterectomy is 1.0%, and vesicovaginal fistulas are formed in 0.1–0.2% of cases, which are usually associated with unrecognized intraoperative trauma and incorrect suturing.

Case report

We present a rare case of iatrogenic vesicular fistula in a 26-year-old woman after a third Caesarean section, as a result of a series of errors that occurred in an emergency. At 34 weeks of gestation, the patient was admitted to the maternity ward with regular uterine contractions and bleeding from the genitals. Due to the previous two operative abdominal deliveries and ultrasound diagnosed placenta previa, a third emergency Caesarean section was undertaken. After extraction of the fetus, it was found that the placenta was tightly adherent to the uterine musculature - placenta previa percreta. Due to the impossibility of complete removal of the placenta, hypotension of the uterus and massive intraoperative blood loss, hysterectomy was undertaken. The solid adhesions in the pelvis, caused by the previous two Caesarean sections, are the cause of iatrogenic damage to the entirety of the bladder wall. Operators repair the defect by stitching the bladder wall in two floors. Stitching performed by a gynecological team without calling a urologist (error 1), and both bladder floors having a running stitch without knowing if there is a urinary infection (error 2). After the final hemostasis was completed, the abdominal wall is restored. Before the abdominal wall was closed there was no leak test (error 3) and the straps were not listed correctly (error 4). The patient was discharged from the hospital in good condition, without complaint with a urethral catheter for 1 month,. Three months later, the woman reported subfebrile fever and dysuric disorders. Despite antibiotic treatment, the symptoms persisted. There was also a leakage of urine through the vagina, accompanied by an unpleasant smell. In a microbiological testing E. coli, S. aureus and Enterococcus spp. were isolated. A CT scan and cystoscopy diagnosed the presence of a foreign body (probably a gauze strip) located in the bladder and vagina, as well as an existing vesicovaginal fistula. Fig. 1 It is decided to extract the gauze strip through the vagina under X-ray and cystoscopic control and to place a urethral catheter. Fig. 2, Fig. 3 The patient was planed for a plastic surgery to repair the bladder wall and vagina after four months.

Fig. 1

CT-scan of the abdomen showing the presence of a foreign body (probably a gauze strip) located in the bladder and vagina, as well as an existing vesicovaginal fistula.

Fig. 2

Showing the removing of a gauze strip from the vagina.

Fig. 3

Showing the removed gauze strip.

Discussion

According to most authors, the main causes of iatrogenic vesicovaginal fistulas in women are gynecological surgeries - 82%, obstetric interventions - 8%, radiation therapy - 6% and injuries or burns - 4%. Of all gynecological surgeries, hysterectomy is the most common cause of vesicovaginal fistulas - 88%. When it is performed with abdominal access, the probability of iatrogenic bladder injury is increased 3 times. The incidence of bladder injury during abdominal hysterectomy is 0.5–1.5%, and vesicovaginal fistulas are formed in 0.1–0.2% of cases. In pelvic surgery, the risk of developing vesicovaginal fistulas is as follows: 0.22 for laparoscopic hysterectomy, 0.1% for abdominal hysterectomy and 0.02% for vaginal hysterectomy. Obstetric fistulas are usually larger than post-hysterectomic fistulas and are more distal. Performing hysterectomy during Caesarean section due to placenta previa percreta further increases the risk of injury to adjacent organs. In our opinion, the occurrence of this fistula is the series of errors already mentioned that, due to a possible infection, led to the inability to properly heal the bladder and subsequently the emergence of leakage of urine and fistula despite the prolonged stay of the urethral catheter. They occur as a complication of gynecological surgery and are a consequence of a serious mistake by the entire operating team. After gynecologic surgery, leakage of urine from the vagina usually occurs after removal of the urinary catheter. Cystoscopy and vaginal examination are the main diagnostic methods. Instillation of methylene blue solution in the bladder is helpful in diagnosing of small fistulas. A CT scan with cystography in lateral position is needed to detect the position of the fistula and exclude ureterovaginal fistula.

Conclusion

Massive intraoperative bleeding, adhesions, altered anatomy from previous surgery, and the urgency of the situation increase the risk of injury to adjacent organs and complications. Lack of consultation with a urologist, improper stitching, lack of a leak test, and forgotten tape are the main causes that lead to the appearance of a vesico-vaginal fistula. Of the whole series of errors, the key to us is the decision not to seek a consultation with a urologist who would eliminate some of the causes and probably prevent this serious complication. This case demonstrates the responsibility of each member of the operations team and demonstrates the importance of an interdisciplinary approach in conducting operational interventions.