Author Information
(Professor, Department
of Obstetrics and Gynecology, Seth GS Medical
College & KEM Hospital , Mumbai ,
India
Abstract
Urinary tract
complications after various gynecology surgeries mainly hysterectomy are well
documented. However, uretero vaginal fistula after Manchester
Introduction
Manchester- Fothergill
surgery is a conservative surgery for
uterine prolapse . It comprises
of amputation of the elongated cervix , shortening of the uterosacral
mackenrodt’s liagments by their anterior fixation to the cervical stump,
creation and dilatation of the neo cervix, anterior colporrhapy and posterior
colpoperineorrhapy.[1] Iatrogenic
ureterovaginal fistulas have been reported in various gynecological surgeries.
Hysterectomy mainly abdominal and
cesarean sections are the leading gynecology and obstetric reasons for these
uretero vaginal fistulas. An incidence of 0.4 to 2.5% of ureterovaginal
fistuals has been reported for gynecology surgeries that were performed for
benign conditions.[2]
Case Report
A 35 year old G3P1L1A2,
resident of Mumbai , presented to our OPD with vaginal discharge of fluid since
a couple of days. She had undergone a Manchester Douglas
peritoneum was opened. Bilateral uterosacral, mackenrodt’s ligament complex was
ligated and detached from the cervix. Bilateral descending cervical arteries
were ligated. Suture material used was Polyglactin 910 throughout the
surgery. A sufficient portion of the
portiovaginal part of the cervix was amputated.
Three Fothergill stitches were taken. The interesting part of the
surgery was the performance of the Sturmdoff suture. Four Sturmdoff sutures
were taken to refashion the cervix. One anterior, one posterior and two
lateral, one on the left and one on the right. The patient was examined in the
dorsal position with adequate light. Speculum examination showed the presence
of the four Sturmdoff sutures. One anterior, one posterior and two lateral, one
on the left and one on the right as mentioned by the surgeon. A trickle of
fluid was seen from underneath the suture in the right fornix.
Figure 1. The post MF
neocervix. The yellow arrow marks the external Os and the 3 gray arrows mark
the right , posterior and the left dimples of the sturmdoff sutures.
Figure 2. The post MF
neocervix. The artery points the uretero vaginal fistula and the leak.
Figure 3. The post MF
neocervix. The artery has lifted the suture end of the right sturmdoff suture
to show the fistula and leak coming from underneath the suture (yellow arrow).
It was odorless. There
was no perineal excoriation or urine smell. The portiovaginal cervix was not
even 1 cm in length. The cervix appeared flushed to the vagina. On redirect
questioning patient had normal voiding sensation and she was passing adequate
amount of urine through the urethra. A three swab methylene blue test was
performed. None of the swabs turned blue. Upper most swab was found to be
moist. The patient was admitted and evaluated for suspected uretero-vaginal
fistula. An intravenous pyelography (IVP) was done. The left kidney and ureter
were normal. There was right sided hydronephrosis and hydroureter. The right
dilated ureter in its terminal portion before entering into the bladder had its
continuity interrupted and there was presence of small quantity of radio opaque
dye in the vagina, suggestive of right sided uretero vaginal fistula.
Figure 4. The 20 minute
IVP. It shows the right hyrdoureter, hydro nephrosis, The terminal hydro ureter
is marked by the yellow arrow and the pink arrow marks the dye in the vagina.
Figure 5. The 45 minute IVP Film (Oblique film). The
yellow arrows show the entry of the ureter in the bladder. Left yellow arrow
shows entry of left normal ureter and the right arrow shows the dilated ureter
that is not entering the urinary bladder (red hollow arrow).
Figure 6. The 1 hour IVP
Film.
Figure 7. The Post IVP
Film
The patient was seen by
a urologist and a cystoscopy was done. An attempt at cannulating the right
ureter was unsuccessful. She subsequently underwent an implantation of the
right ureter (neoureterocystostomy) in the bladder 10 weeks after her primary
surgery and a DJ stent was placed for 3 months. The DJ stent was removed after
12 weeks and there was no leak after the stent removal.
Discussion
Manchester- Fothergill
surgery is a conservative surgery for young patients of utero vaginal prolapse
who desire to retain their menstrual function. It is not the best surgery for
women desiring child birth. A pubmed,
medline and a google search failed to bring up any reported ureterovaginal
fistula following a Manchester- Fothergill surgery for uterine descent in
english literature. Literature search highlighted the causes of uretero vaginal
fistuals to be hysterectomy, post cesarean section, and obstructed labor. Occurrence of ureterovaginal fistula was
maximum after abdominal rather than with laparoscopic or vaginal
hysterectomy. It was least after vaginal
hysterectomies. [3,4,5,6,7,8]
Various studies have
evaluated the complications associated with this surgery. Alkis et al has studied 49 cases who underwent Manchester-
Fothergill surgery over a period of 5 years. Of these 49 one patient had bladder injury, one
patient developed recurrent prolapse and
one patient had post operative urinary retention.[9] Ayhan et al analyzed the
data of 204 women who had Manchester-
Fothergill surgery performed on them. He studied women operated between 1985 to
2004, a period of 19 years. None of them had any urological injuries. Urinary
retention, cervical stenosis were the main complications.[10] Eighty one
patients of MF were evaluated by De Boer, urinary retention was the commonest
complication. There were no cases of urological injuries in their reported
series.[11] Ninety eight patients studied by Thys and colleagues also reported
no urological tract injuries.[12] All the above authors after analyzing data
from over 450 patients have not reported a single uro vaginal fistula. There
was only one patient with bladder injury. All the above studies concluded that
the MF procedure for uterine prolapse is low on morbidity and mortality.
MF procedure consists of
amputation of the elongated cervix , shortening of the uterosacral mackenrodt’s
liagments by their anterior fixation to the cervical stump, creation and
dilatation of the neo cervix, anterior colporrhapy and posterior colpoperineorrhapy.
The neo amputated cervix is covered with sturmdoff sutures. Two sturmdoff
sutures, one covering the anterior and another covering the posterior lip of
the cervix is the norm. The surgery notes documented that four instead of two
sturmdoff sutures were placed. One anterior, one posterior and two lateral. I
believe that the right lateral sturmdoff suture went through the right ureter
and caused ischemic necrosis resulting in the uretero-vaginal fistula. The original cervical length was 2 and a 1/2’’
and the infravaginal portion of the cervix measured 1 and a 1/2”. It was
observed that the portio vaginalis cervix was almost flushed to the fornix and
barely 1 cm in length. The post surgery utero cervical length was 2”. This
suggests that only half an inch of the cervix was left behind, excising the
entire infra vaginal and half the supra vaginal portion of the cervix. The
distance between the external and the internal Os was only half an inch. The ureter that goes about 1 and a 1/2 cm
below and lateral to the uterine artery at the level of the isthmus would now
be directly susceptible to trauma in the lateral fornix. So while passing the
lateral sturmdoff suture through the cervical canal and bringing it out
laterally at the right lateral angle of the vagina, the surgeon possibly
injured the ureter at this point due to generous amputation of the cervix. It
is also possible to injure the uterine vessels and cause a retroperitoneal
hemorrhage. Prior to performing the IVP, the possibility of an aberrant course
of the right ureter being the cause for this trauma was entertained as one of
her old papers mentioned a right unicornuate uterus. But after the IVP the
normal course of the ureter was seen ruling out developmental reason for the
ureteric trauma.
Surgeons, when they
deviate from the recommended steps have
to realize that they expose the patients to morbidity and subject them to
prolonged surgical, medical treatment, immense emotional and financial burdens.
A procedure with inherently low rate of serious complication was converted into
a highly morbid condition.
References
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