Keywords : Youssef’s syndrome, uteroversical fistula
Uterovesical fistula is rare. It could be the result of obstetric
trauma or surgical injury.
A 28 year old P2 L1 lady, presented with secondary amenorrhea of 13 months duration. She also complained of passing cyclical red colored urine. In her first pregnancy, she underwent emergency lower segment cesarean section for premature rupture of membranes. In her second pregnancy she had trial of labor for vaginal birth but underwent emergency laparotomy for scar rupture . A stil born fetus was lying in the peritoneal cavity. Scar repair was done.There was no urinary incontinence. Postoperatively, she developed deep vein thrombrosis and was treated with anticoagulants for 9 months. In the 10th postoperative month, she passed red colored urine and since then had cyclical hematuria for 5 days every month. History, hysterosalpingography (Figure 1), and cystoscopy confirmed the diagnosis of Youssef’s syndrome. On 12th January, 2003 she underwent laparoscopic repair of the uterovesical fistula which was situated in the supratrigonal region. Ureteric orifices were intact. The bladder was adherent to the lower segment and was released by sharp dissection. A fistulous opening in the posterior bladder wall (Figure 2) was closed by 2-0 vicryl. Omentum was interposed between the bladder and uterus. Foley’s catheter was removed on the 21st postoperative day. She had normal menses in February 2003 and there was no incontinence or cyclical hematuria.She is having regular cycles since then.
Nowadays uterovesical fistula is very rare because of
improved obstetric practice. Most of them are associated with
birth injury to or necrosis of the bladder wall directly over
the dehiscence of a lower segment cesarean section scar
1
.
Very rarely these fistulas occur due to instrumentation or
malignancy. When there is inadequate mobilization of the
bladder inferiorly or laterally the bladder may be injured with
delivery of a large fetal head or it may be accidentally included
in the suture used to close the uterine incision. Fistula forms
when sutures are absorbed
2
. A woman may experience
involuntary loss of urine or she may remain continent. She
may complain of cyclical hematuria and amenorrhea. This
symptom is called menuria of Youssef. Vaginal examination
fails to reveal a fistula though occassionaly trickling of urine
is seen through cervical os. Cystoscopy, cystogram and/or
hysterogram are useful in diagnosis. The vesical orifice of
the fistula is always in the supratrigonal location when viewed
through the cystoscope 3
. Although few small fistulas have
been reported to close either spontaneously or through
cystoscopic fulguration, most of them require surgery 3
. A
hysterectomy is not required for fistula repair
4
. Hysterectomy
may be done, if indicated for other reasons including the presence of large uterine defect. Laparoscopic surgery is
rapidly replacing laparotomy in many areas. The present case
appears to be the first ever reported laparoscopic repair of
uterovesical fistula.
