Ischemic Uretero-Vaginal Fistula After Manchester- Fothergill’s Surgery

Author Information

Gupta AS

(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 - Fothergill’s (MF) repair for prolapse is not reported. This case of uretero vaginal fistula that developed 3 weeks after surgery reflects the dangers involved if the surgeon deviates from the recommended surgical steps.

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 - Fothergill’s repair for prolapse 3 weeks back for uterovaginal descent.  On presentation with vaginal fluid leak, her pre-operative  and operative case record’s were reviewed. The pre- operative notes had a mention of her having a right sided unicornuate uterus but there was no confirmatory report supporting the same.  A notification regarding no desire for further child bearing was present in her discharge summary. Her general and systemic examination records were all within normal range.  Her local examination findings prior to surgery that were documented showed that she had a normal appearing vagina but presence of infra vaginal elongation of the cervix, though the cervix appeared normal. Uterus and cervix were central. No deviation was present. She had no cystocoele but rectocoele was present. Bimanual pelvic examination found a less than normal size, anteverted, anteflexed uterus, and normal fornices. Her documented utero-cervical length was  4” and of that the cervical length was 2 and a 1/2’’. The infravaginal portion of the cervix measured 1 and a 1/2”. Her biochemical, serological, radiological investigations were well within normal range. She underwent Manchester- Fothergill’s repair with posterior colpoperineorrhaphy in her proliferative phase of her menstrual cycle. Surgery  notes were reviewed. Surgery was  done under combined spinal and epidural anesthesia. The salient points of surgery were as follows. Pre operative uterocervical length was confirmed. Internal Os was dilated upto 6.5 Hegar dilator. Vagina was reflected circumferentially from the portiovaginal cervix. Pouch of 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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Citation

Gupta AS. Ischemic Uretero-Vaginal Fistula After Manchester- Fothergill’s Surgery JPGO 2015. Volume 3 No. 1. Available from: http://www.jpgo.org/2016/01/ischemic-uretero-vaginal-fistula-after.html