Complex circumferential obstetric fistula-a urologist's worst nightmare.

INTRODUCTION AND HYPOTHESIS: Circumferential vesicourethrovaginal fistula is a severe form of obstetric injury that is challenging to repair and carries a poor prognosis related to eventual continence. Here, we report the successful repair of a circumferential vesicovaginal fistula associated with near total loss of the urethra. The use the anterior bladder flap technique along with an autologous rectus sheath sling resulted in the creation of an effective continence unit. METHODS: A 31-year-old woman had a history of obstructed labor resulting in intrauterine death followed by trans-abdominal hysterectomy for postpartum hemorrhage. Since then she had had total urinary incontinence. She had an attempted repair through the vaginal route, which had failed. Physical examination and endoscopic evaluation revealed a large vesicourethrovaginal fistula with near total loss of the urethra leaving only the meatus. Intraoperatively, we found that it was a large circumferential defect in the infratrigonal region with no anterior bladder wall left at the site of the fistula. RESULTS: We performed an anterior bladder flap procedure as described by Tanagho along with an autologous rectus sheath sling for additional support. Postoperatively, the patient was completely continent. CONCLUSIONS: The anterior bladder onlay flap technique, which has been used extensively for female urethral reconstruction in developed countries, along with an autologous rectus sheath sling is an effective technique for management of circumferential fistulas allowing good continence. Incorporation of this technique into the armamentarium of surgeons managing fistulas in developing countries will go a long way toward helping this unfortunate group of women with this morbid complication of obstructed labor.

Organization of urological care for patients with iatrogenic ureteral injury.

OBJECTIVE: Introduction: We conducted a retrospective assessment of diagnostic and therapeutic approaches in patients with iatrogenic ureteral injury, who were treated in a specialized medical center. The aim: The aim of the research was to determine the optimal treatment method for correction of iatrogenic ureteral defects. PATIENTS AND METHODS: Materials and methods: The study included 73 patients with iatrogenic ureteral injury. In 70 cases ureteral reconstruction was carried out with the help of Boari bladder flap. The effectiveness of this approach was assessed retrospectively by analysis of the complications and long-term results of the treatment. RESULTS: Results: The length of the bladder flap varied from 3 to 21 cm and averaged 9.8 ± 1.4 cm. In 6 (8.2%) cases a successful reconstructive surgery of the ureter up to the level of its upper third was performed. The overall frequency of intraoperative complications did not exceed 12.9%. The total frequency of early postoperative complications was high (75.8%), however, they were not severe and required surgical correction only in one (1.4%) case. The total number of positive long-term results (good + satisfactory) amounted to 91.5%. Nephrectomy was required only in 2 (2.3%) cases. CONCLUSION: Conclusions: The Boari bladder flap operation should be considered as the basis of the algorithm for providing medical care to patients with iatrogenic ureteral injury. This type of surgery makes it possible to completely replace the damaged or having doubtful blood supply portion of the ureter even with the defects extending to its upper third. The main advantages of this surgery technique are good blood supply of tubularized bladder flap and a high level of positive long-term results.

Urinary symptoms after bladder flap at the time of primary cesarean delivery: a randomized controlled trial (RTC).

INTRODUCTION AND HYPOTHESIS: The aim of this study was to evaluate urinary symptoms in the postpartum period after omission of the bladder flap at the time of primary cesarean delivery. METHODS: This was a single-blind parallel-group randomized comparison (bladder flap, no bladder flap) in women scheduled for a primary cesarean delivery at 37 weeks gestation or later. The primary outcome was urinary symptom scores at 6-8 weeks postpartum. Secondary outcomes included comparisons of preoperative and postoperative pelvic floor symptom scores and the proportions of symptom bother responses between the study groups. RESULTS: A total 43 women were available for analysis. Randomization was as follows: omission of the bladder flap (n = 22) and bladder flap (n = 21). Demographic characteristics and baseline pelvic floor symptom scores were similar between the groups. The primary outcome, urinary symptom scores at 6-8 weeks postpartum, did not differ significantly between the groups, but urinary symptom bother was significantly higher in women who received a bladder flap. Pelvic floor symptom scores improved significantly following delivery. CONCLUSIONS: Urinary symptom scores as measured by the UDI-6 did not differ between women randomized to bladder flap or omission of the bladder flap, but the proportion of women with urinary symptom bother was significantly higher among those who received a bladder flap.

Omission of a Bladder Flap during Cesarean Birth in Primiparous Women.

AIMS: Creation of a bladder flap has traditionally been an integral surgical step of Cesarean birth, and the practicality of such a procedure to create a bladder flap is still highly debated. METHODS: A total of 208 patients undergoing a primary cesarean birth were randomized. Group 1 (bladder flap) had 101 patients and group 2 (omission of a bladder flap) had 100 patients. The primary outcome was the total operating time and secondary outcomes were postoperative urinary symptoms, bladder injury, postoperative urinary retention, and postoperative residual urine volume. RESULTS: No significant differences were found among groups in terms of mean total operating time and mean skin incision-to-delivery time. No bladder injury occurred in either group. Postoperative urine retention observed in the bladder flap group was 2%. The postoperative residual urine volume was significantly more in the bladder flap group compared to the non-bladder flap group (24.5 ± 2.8 vs. 16.2 ± 1.4 mL). The number of patients with dysuria was significantly higher in the bladder flap group (42 vs. 13%). CONCLUSIONS: The creation of a bladder flap during cesarean birth does not have an effect on intraoperative results and operation time, but it is associated with short-term urinary complaints, such as postoperative urinary retention and dysuria.

Ureterocystoneostomy in complex oncological cases with an "Uebelhoer" modified Boari bladder flap.

PURPOSE: The study aims to describe the technique and analyze the outcome of an arcuated bladder incision with building of a triangular flap, first described by Uebelhoer (UBBF), as a modification of the classical rectangular Boari bladder flap (BBF), that is often viable, but can present difficulties, such as reduced flap vascularization and mobility in pretreated patients. METHODS: Twelve consecutive patients with distal or mid ureteral leakage or stenosis, that underwent UBBF, were retrospectively analyzed. We assessed postoperative morbidity using Clavien-Dindo classification. Short- and long-term functional outcomes were assessed using glomerular filtration rate (GFR), ultrasound, and renal scintigraphy. RESULTS: Patients underwent UBBF during initial oncological surgery in five cases and due to ureteral defects following oncological surgery or radiotherapy in seven cases. Median patient age was 57 (interquartile range (IQR) 46-72), defect length was 7.5 cm (IQR 5-8 cm), and median follow-up period was 41 (IQR 36-48) months. In short-term follow-up, 11/13 postoperative morbidities were Clavien-Dindo level I-II complications, mostly infections. Two level IIIa complications occurred. One anastomotic leakage was treated sufficiently with temporarily ureteral stenting and one voiding disorder needed intervention. In the long-term follow-up, 84% of patients had improved or constant GFR. In the one-year renal scintigraphy, no urodynamically relevant voiding disorder occurred. CONCLUSIONS: The UBBF is a reliable procedure to reconstruct ureteral trauma even in complex oncological, pretreated patients suffering from distal or mid ureteral defects. It can be performed easily by a modified arcuate incision and provides good long-term functional outcomes.

Repair of complex vesicovaginal fistulas by combining a rotational bladder flap and full thick vascular peritoneal interposition.

PURPOSE: To present the experience of repairing iatrogenic vesicovaginal fistulas (VVFs) using a rotational bladder flap and peritoneal interposition technique. METHODS: Between January 2009 and June 2014, a total of 18 patients (mean age, 44.0 years; age range, 29-51 years) with VVFs were treated using a transperitoneal approach. All VVFs were complications of gynecologic procedures. Twelve patients experienced recurrent VVFs and one patient had a concomitant rectovaginal fistula after radiotherapy. The fistula was approached transabdominally. The peritoneum covering the bladder was isolated to expose the bladder and prepare for the interposition. The bladder was opened along the sagittal plane to the fistula and a bladder flap was rotated downward to fill the fistula defect. The vaginal defect was closed, then a flap using the isolated peritoneum was interposed and fixed between the vagina and bladder. A ureteral re-implantation was performed in one patient. All VVF procedures were performed by one urologist (SW). Repair of the rectovaginal fistula was performed by a general surgeon at the same time. RESULTS: Seventeen patients (success rate = 94% [100% for primary cases and 92% for recurrent cases]) had no evidence of recurrent VVF at a mean follow-up of 20 months (range, 6-36 months). The only patient who had previously undergone a repair procedure failed. CONCLUSIONS: A transperitoneal approach with the use of a rotational bladder flap and peritoneal interposition might be a feasible and reliable procedure for surgical management of iatrogenic VVFs, especially in complicated cases. Neurourol. Urodynam. 35:934-938, 2016. © 2015 Wiley Periodicals, Inc.

Large bladder flap haematoma following a caesarean section associated with right hydroureteronephrosis: A case report and a mini­review of the literature.

Post-caesarean section bladder flap haematoma is a rare postpartum complication. There are currently no specific treatment protocols, at least to the best of our knowledge. In general, the failure of conservative treatment with antibiotics requires the re-operation and surgical drainage of the haematoma. The present study describes the case of a primiparous pregnant woman who, at 40 weeks of pregnancy, delivered by caesarean section. On the 3rd post-operative day, the puerperant, haemodynamically stable, developed febrile infection. During the evaluation, the presence of bladder flap haematoma associated with moderate right hydroureteronephrosis was found. The failure of conservative management led to the decision to perform a re-laparotomy 1 week later. During the surgery, a large bladder flap haematoma was found with a retroperitoneal extension into the right parametrium. The surgical drainage of the haematoma and thorough haemostasis in the area of the vesicouterine pouch was performed. The patient was discharged from the clinic on the 5th post-operative day following the re-operation. After 2 weeks, an ultrasound revealed the complete repair of the lesions in the vesicouterine pouch and the right kidney. In the present study, a brief review of literature is also provided regarding the diagnostic and therapeutic management of patients with post-caesarean section bladder flap hematoma.

The bladder-flap ureteral augmentation: An original solution in case of complex distal stricture.

An original surgical solution for complex stenosis of the distal ureter is presented. A young, single-kidney male patient developed a stricture of the pelvic ureter after ureteroscopy and laser lithotripsy. Surgical repair was planned after the failure of conservative management. The ureter was sectioned prevesically and spatulated; a bladder flap with the same dimensions of the ureteral plate was taken from the anterior wall, and used to augment the ureter; finally an omental flap was wrapped around the reconstructed tract. Further radiological and ureteroscopic controls showed a largely patent reconstructed ureter, and follow up proved a regularly maintained kidney function.

A Contemporary Case Series of Complex Surgical Repair of Surgical/Endoscopic Injuries to the Abdominal Ureter.

BACKGROUND: Iatrogenic ureteral injuries are devastating complications potentially resulting in irreversible impairment of renal function and/or infectious sequelae. Only few data are available on the management of such injuries to the abdominal ureter. OBJECTIVE: To report the etiology, perioperative outcomes, and treatment failure rate of different reconstructive surgical interventions for iatrogenic injuries to the abdominal ureter in a contemporary case series. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively analyzed consecutive patients who underwent reconstructive surgery for iatrogenic injuries to the abdominal ureter at our academic centers between July 2013 and April 2019. All interventions were performed via either an open or a robot-assisted approach by a single expert surgeon. SURGICAL PROCEDURE: Different surgical reconstructive procedures, such as Boari bladder flap, ureteroureterostomy, ileal replacement, and pyeloureteroplasty, have been adopted. MEASUREMENTS: Outcome measures were the etiology of iatrogenic injuries, rate of postoperative complications, and rate of treatment failure, defined as upper urinary tract obstruction requiring permanent urinary drainage. RESULTS AND LIMITATIONS: Nineteen patients were included. Injuries were consequent to endourological procedures in nine (47.4%), gynecological procedures in two (10.5%), colonic surgery in two (10.5%), vascular surgery in two (10.5%), and other surgeries in four (21.1%) cases. Boari bladder flap was performed in 12 (63.2%), ureteroureterostomy in two (10.5%), ileal substitution in two (10.5%), and pyeloureteroplasty in three (15.8%) cases. Only four (21.1%) procedures were performed robotically. Major postoperative complications were recorded in three (15.8%) patients. After a median follow-up of 16 (interquartile range 12-24) mo, treatment failure was observed in two (15.8%) cases. We accept the limitations of a small retrospective single-surgeon series with preference-based management choice. CONCLUSIONS: In our series, endourological procedures were the most frequent cause of iatrogenic injuries to the abdominal ureter requiring reconstructive surgery. A Boari bladder flap was the preferred option to bridge extensive ureteral defects. Despite the complexity of such procedures, major postoperative complications were infrequent and treatment failure rate was low. PATIENT SUMMARY: We report on a contemporary series of patients with disparate iatrogenic injuries to the abdominal ureter requiring complex reconstructive surgery. Despite the difficulty of such procedures, we found that major postoperative complications were infrequent and treatment failure rate was low.

Postnatal diagnosis of an occult uterine scar dehiscence after three uncomplicated vaginal births after Caesarean section: A case report.

INTRODUCTION: The incidence of Caesarean sections has been increasing in the United Kingdom. Obstetricians have become more inclined to offer a trial of a vaginal birth to women following a single uncomplicated Caesarean section due to growing recognition of the high morbidity associated with repeat abdominal surgeries, and the relative rarity of a Caesarean scar defect causing complications at subsequent vaginal deliveries. The diagnosis of a Caesarean scar defect such as a uterine scar dehiscence in the postnatal period still remains elusive due to its vague presentation. An incorrect diagnosis or a delay in diagnosis can lead to unnecessary interventions or delay the management of patient symptoms. CASE PRESENTATION: A 35-year-old woman with a single Caesarean section and three subsequent uncomplicated vaginal deliveries was diagnosed with an occult scar dehiscence two weeks postnatally. She initially complained of persistent vaginal bleeding and underwent a suction evacuation for suspected retained placental tissue. Her symptoms did not improve, and a CT scan was requested to rule out a uterine perforation following the surgical procedure. The CT scan suggested a uterine dehiscence at the level of the previous scar. As the patient remained clinically well, her symptoms were managed conservatively. She underwent a laparoscopic sterilisation six months later and was discharged as the scar defect had fully resolved. CONCLUSION: Clinicians should remain vigilant about the possibility of an occult scar defect in women with a previous Caesarean section who present with persistent vaginal bleeding and pain in the postnatal period.

An alternate surgical approach to reduce hemorrhage and complications during cesarean hysterectomy for adherent placenta.

BACKGROUND: Cesarean hysterectomy for adherent placenta is associated with increased maternal morbidity due to massive hemorrhage requiring large volume blood transfusion, bladder or ureteric injury, intensive care unit (ICU) admission and prolonged hospital stay. There is an ongoing effort to improve the outcome of these women and measures to reduce blood loss. OBJECTIVE: The purpose of the present study was to develop an alternate surgical approach for performing a Cesarean hysterectomy in women with adherent placenta in order to reduce hemorrhage and urinary tract injuries, and thereby improve the maternal outcome. STUDY DESIGN: A prospective observational study in a tertiary care hospital in North India. The surgical approach described in the present study was practiced in 12 women who underwent Cesarean hysterectomy for adherent placenta previa. In this approach, dissection of the bladder flap as close as to the cervix was made prior uterine incision and delivery of the baby. During dissection of the bladder flap, the blood vessels traversing between uterus and bladder were ligated and divided. RESULT: These 12 women underwent Cesarean hysterectomy under general anesthesia. The interval from induction of anesthesia to delivery of the baby ranged from 40 to 79 min, and none of the babies had birth asphyxia. No woman had bladder or ureteric injury. All women had histopathological proven adherent placenta, 5 had placenta percreta, one had placenta increta and 6 had placenta accreta. The average blood loss was 1.46 l and the mean number of blood transfusions was 2.1 units. None of the women required post-operative ventilatory support or ICU admission, and all women were discharged from hospital between 4 to 7 days following Cesarean hysterectomy CONCLUSION: The present series describes an alternate surgical approach for Cesarean hysterectomy in adherent placenta. Dissection of the bladder flap prior to delivery of the baby followed by hysterectomy reduced the hemorrhage and there was no bladder or ureteric injury. This surgical approach requires no additional resources and may easily be followed in a low-resource setting.

Comparing Formation or Non-Formation of Bladder Flap at Cesarean Section on Perioperative and Postoperative Complications: Double-Blind Clinical Trial.

Objective: To investigating formation or non-formation of bladder flap at Cesarean section on the complications during and after surgery. Materials and methods: This is a double-blind clinical trial study conducted during February 2014 to May 2015 on 64 pregnant women with gestational age of 36 weeks or more who were delivered by Cesarean section for the first time. They were randomly divided into two groups (intervention group: non-formation of bladder flap; control group: formation of bladder flap). The time to cut out the baby by Cesarean section, total duration of operation, bladder injury, intraoperative bleeding, hematocrit changes expected prior to during and following operation, postoperative pain, macroscopic and microscopic hematuria, postoperative complications and duration of hospitalization were compared between two groups. The data were analyzed with SPSS version 16 using and statistics tests. p < 0.05 was considered significant. Results: Time to cut out the baby for the intervention group (124.9 ± 40.5 seconds and for control group 155.1 ± 42.9 seconds) and total duration of the operation (intervention group: 27.7 ± 5.2 min and control group: 34 ± 4.73 min) were significantly different (p = 0.000). Number of gauze consumption during operation and postoperative hematocrit drop in the intervention group was significantly lower in the intervention group compared the control group (p = 0.000). The postoperative pain score in the intervention group (4.8 ± 1.1) and in control group (6.3 ± 0.9) were significantly different (p = 0.000). Conclusion: Omission of the bladder flap at Cesarean section leads to short-term benefits such as reducing the time to cut out the fetus, duration of surgery, decreasing postoperative bleeding and lowering pain.

Could Revision of the Embryology Influence Our Cesarean Delivery Technique: Towards an Optimized Cesarean Delivery for Universal Use.

Until today, there is no standardized Cesarean Section method and many variations exist. The main variations concern the type of abdominal incision, usage of abdominal packs, suturing the uterus in one or two layers, and suturing the peritoneal layers or leaving them open. One of the questions is the optimal location of opening the uterus. Recently, omission of the bladder flap was recommended. The anatomy and histology as results from the embryological knowledge might help to solve this question. The working thesis is that the higher the incision is done, the more damage to muscle tissue can take place contrary to incision in the lower segment, where fibrous tissue prevails. In this perspective, a call for participation in a two-armed prospective study is included, which could result in an optimal, evidence-based Cesarean Section for universal use.

Tratamiento con drenaje percutáneo ecoguiado de hematomas vesicouterinos postcesárea complicados. Experiencia en 4 casos / Treatment with ultrasound-guided percutaneous drainage of complicated post-cesarean vesicouterine hematomas. Experience in 4 cases

Resumen ANTECEDENTES: Los hematomas vesicouterinos sobreinfectados son una rara complicación de la histerotomía segmentaria transversa. La acumulación de sangre entre la pared posterior de la vejiga y el segmento uterino facilita la proliferación de microorganismos patógenos. Cuando el tratamiento antibiótico falla deben plantearse técnicas invasivas para su resolución, entre las que destaca el drenaje percutáneo ecoguiado. CASOS CLÍNICOS: Se exponen 4 casos de mujeres que, después de la cesárea, iniciaron con descenso del hematocrito, fiebre (3 casos) y cuadro pseudooclusivo (1 caso). Con base en la ecografía se estableció el diagnóstico de hematoma vesicouterino sobreinfectado. Después de la falla del tratamiento con antibióticos se propuso el drenaje percutáneo ecoguiado. Se observó mejoría clínica en todos los casos de forma significativa. El cultivo del material drenado orientó al tratamiento antibiótico específico. La evolución de las pacientes fue satisfactoria. CONCLUSIONES: El drenaje percutáneo ecoguiado permite evacuar el contenido hemático, obtener suficiente muestra para el cultivo y aportar información del microorganismo patógeno concreto. Además, es una técnica efectiva, menos invasiva que la cirugía y se asocia con escasas complicaciones.

Abstract BACKGROUND: Infected bladder-flap hematomas are a rare complication after a lower uterine segment caesarean section. This blood collection located in the space between the posterior bladder wall and the lower uterine segment allows microorganism proliferation. When the treatment with antibiotics fails, invasive techniques are considered, such as ultrasound percutaneous drainage. CLINICAL CASE: We present 4 cases of women whom, after the performance of a cesarean section, began with a decrease in hemoglobin levels, spiking fevers in 3 cases and pseudo-occlusive symptoms in the other one. With an ultrasound examination, the diagnosis of infected bladder-flap hematomas were achieved. After the failure of the antibiotics treatment, an ultrasound percutaneous drainage was performed. As a result of the evacuation of the collection, the clinical situation improved significantly. Culture of the sample obtained permitted to establish a more effective antibiotic treatment. CONCLUSIONS: Ultrasound percutaneous drainage allows not only the evacuation of the blood collection to obtain a sample for culture, but also provides information about the presence of a specific microorganism. Moreover, it is a highly efficient technique, less invasive than surgery which presents few complications.

Omission of the bladder flap at caesarean section reduces delivery time without increased morbidity: a meta-analysis of randomised controlled trials.

Caesarean section (CS) is the most common major surgical procedure performed worldwide. Traditionally, creation of a bladder flap (BF) has been a routine surgical step at CS although recent randomised controlled trials (RCTs) have begun to question its value. We performed a meta-analysis of RCTs examining the benefits of BF formation at CS. Pubmed, Medline, Embase, CINAHL Plus(®), Web of Science Reference and Cochrane Databases online were searched in March 2012 using combinations of the terms "c(a)esarean", "bladder", "flap" and "technique". Citations identified in the primary search were screened for eligibility. Online clinical registries (www.clinicaltrials.gov, www.controlled-trials.com and www.ukcrc.org.) were also searched. The primary outcome was bladder injury. Secondary outcomes were skin incision-delivery interval, total operating time, blood loss and duration of hospitalisation. Pooled outcome measures (odds ratio [OR] and weighted mean difference [WMD]) were calculated using a random effects model. Three published RCTs and one unpublished trial identified from an online trial registry were included (n=581 women). All four trials excluded very preterm and emergency CS. Omission of the BF step at CS reduced the skin incision-delivery interval (WMD 1.27min; p=0.0001). No differences were found for bladder injury (pooled OR 0.96), total operating time (WMD 3.5min), blood loss (WMD 42ml) or duration of hospitalisation (WMD 0.07 days). Omission of the BF at elective CS does not appear to increase the rate of peri-operative complications and improves the skin incision-delivery interval. The role of BF formation in very preterm procedures and emergency intrapartum CS needs further study.

Strategies for open reconstruction of upper ureteral strictures.

This article presents a review of the literature regarding surgical techniques and outcomes for reconstruction of strictures involving the upper ureter. The preoperative assessment for proximal ureteral stricture is briefly reviewed, followed by a discussion of ureteroureterostomy, transureteroureterostomy, ureterocalicostomy, bladder flaps, downward nephropexy, bowel interposition grafts, onlay or tubular grafting, renal autotransplantation, and nephrectomy. The future direction for reconstruction of the proximal ureter is proposed.