Delayed presentation of postcaesarean section vesicouterine fistula repaired robotically

Abstract

A premenopausal patient in her late forties presented with a 15-year history of urinary incontinence starting shortly after a caesarean section performed for her fourth delivery and more recently associated episodic light haematuria and passage of clots per vagina. The haematuria was intermittent over several months and associated with per-vaginal bleeding. She had symptomatic anaemia. Flexible cystoscopy and MRI showed a vesicouterine fistula. She underwent a robotic-assisted hysterectomy and multi-layered repair of the bladder with omental interposition. She remained in the hospital for 4 days, though recovered well and underwent catheter removal at 14 days following a normal cystogram. At 3 months, she was well with no incontinence or urinary symptoms. This case demonstrates the need for vigilance in assessing patients with persistent incontinence, particularly in the context of prior caesarean section. It highlights the feasibility of robotic surgery for correcting these defects in a society where minimally invasive surgery is becoming the norm, and cosmesis is a priority for patients.

Keywords: hematuria; incontinence; pregnancy; surgery; urological surgery.

Figure 1

Sagittal T2-weighted non-contrast MRI image. Fluid is seen in both bladder and uterus communicating via the fistulous tract (arrow).

Figure 2

A cystoscopic image of the fistulous tract (arrow) with surrounding erythematous mucosa.

Figure 3

Intraoperative image showing the bladder open and the endoscopically marked planned resection margin (arrow).

Figure 4

The uterus and fallopian tubes with arrow indicating the small section of bladder excised and fistulous tract.

Figure 5

The cystogram showing resolution of the fistula with no urine leak.