Vesico-vaginal fistula with ureteroureterostomy

Case contributed by Dr Ian Bickle

Presentation

Emergency C-section for PPH due to placenta percreta. Bladder dome injury at the time. Subsequent bladder repair, transurethteroureterostomy. Postoperative leak?

Patient Data

Age: 38
Gender: Female

Bladder filled to 150mls (maximum patient saiety).

IVU and CYSTOGRAM

Bilateral ureteric stents.

Right sided ureteroureterostomy.  No leak at this site.

Both kidneys concentrate and excrete normally.

CYSTOGRAM

Small volume bladder ( filled to 150mls of saiety )

Progressive contrast accumulation in a linear fashion with a more bulbous upper end posterior to the bladder in keeping with the vagina.

CT

The patient was treated conservatively for 5 months. Follow up CT-IVU undertaken.

CT-IVU

Bilateral ureteric stents.

Right sided ureteroureterostomy. 

Small amount of contrast accumulating in the dependent position of the upper vagina.  No contrast filled fistulous tract identified.

Fluoroscopy

Cystogram and CT-cystogram peformed 4 days later.

 CYSTOGRAM

Bladder filled to 150mls (maximum patient saiety).

Bilateral ureteric stents.  Right sided ureteroureterostomy. 

Progressive contrast accumulation in a linear fashion with a more bulbous upper end posterior to the bladder in keeping with the vagina.

Appearances unchanged from prior study.  The exact site of the fistulous tract is not identified.

CT PELVIS

Following cystogram.

4mm fistulous from the dome of the bladder to the vaginal vault.

The vagina is filled with a large volume of contrast.

Comment: High vesicovaginal fistula.

** the patient felt wet below at the time of the study clinically correlating with the above.

Annotated image

The CT CYSTOGRAM shows the exact site of the tract between the dome of the bladder and the vaginal vault.

It is illustrated with contrast and air within the fistulous tract.

B = bladder.   V = vagina

Case Discussion

The kind of case which makes you want to go to work.   

An example of 2 important concepts in imaging:

-  doing the right test for the clinical problem

-  the value of like for like imaging

-  the underestimated value of interval scanning

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Case information

rID: 48890
Case created: 29th Oct 2016
Last edited: 2nd Sep 2017
Inclusion in quiz mode: Included

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