Diagnostic problems as the cause of late diagnosis and treatment of postoperative urethrovaginal fistula . Case study

The fistula between the urinary tract and the female reproductive system are mostly due to iatrogenic disruptures. The most common is the vesicovaginal fistula (VVF) that constitutes a complications following 0,5-2% of surgeries within the area of the pelvis minor. Urethrovaginal fistula (UVF) is predominantly the effect of iatrogenic injury of the ureter that occurs during a surgical procedure within the pelvis minor. Statistically, gynecological and obstetric procedures prevail. The symptoms of UVF comprise permanent urine leakage from the vagina despite the preservation of normal miction, pain in the lumbar region, sometimes septic symptoms emerge. In the diagnostics of urine leakage immediately upon the gynecological surgery, a number of tests should be conducted in order to reveal the presence or concurrence of vesicovaginal fistula (cystoscopy with stain test, cystography) or scopy with stain test, cystography) or urethrovaginal fistula (urography, Uro-CT, ascending urethropyelography). Upon the exclusion of such complications, the suspicion of strain urine incontinence is confirmed by means of clinical examination (Boney trial) as well as delayed urodynamic examination. The treatment involves the restoration of the integrity of urinary passageways and in case of minor impairment – stenting with the double jointed ureteric catheter (DJ). The aim of the study was to present the late diagnosis of urethrovaginal fistula and its surgical treatment in a patient after hysterectomy due to cervical cancer, subsequently subjected to radiochemotherapy as well as brachytherapy. In the postoperative period, the first symptoms of urine leakage from the vagina emerged in the patient. After adjuvant radiochemotherapy the symptoms failed to aggravate. The assumption was made that this was due to strain urine incontinence (SUI). Eventually, the patient was referred for diagnostics to the Ward of Urology at the Regional Specialist Hospital in Rzeszow where, basing on the results of the test, urethrovaginal fistula was diagnosed. The patient underwent surgical treatment by grafting the right ureter onto the bladder by means of the Lich-Gregoire method with the deployment of a DJ catheter for splinting of the anastomosis. Immediate symptom discontinuation was achieved in the postoperative period. Urography performed within 3 months of the procedure indicated a normal picture of urinary passageways. The treatment of urethrovaginal fistula aims at the prevention of urosepsis and urine leakage as well as the restoration of the normal function and integrity of the urinary tract. There are many methods of surgical treatment, in an open method or by laparoscopy and in case of minor impairments endoscopic treatment is implemented that involves the catheterization with an ureteric catheter type DJ. Urine leakage requires the performance of full diagnostics upon a gynecological surgery in order to establish the reason. To be taken into consideration are vesicovaginal fistula, urethrovaginal fistula or their concurrence (occurs in 10-15%) as well as SUI. It is of special relevance if the symptoms are mildly intensive and the analgesia applied in the postoperative period masks the pain in the lumbar area. It is also to be borne in mind that SUI does not exclude a concurrent fistula.