Immediate ureterovaginal fistula secondary to oocyte
Transcrição
Immediate ureterovaginal fistula secondary to oocyte
CASE REPORT Immediate ureterovaginal fistula secondary to oocyte retrieval—a case report ^ Marcon D’Avila, M.D.,a,c Helena von Eye Corleta, M.D.,a,b,c Marcelo Moretto, M.D.,a Angela a,d and Milton Berger, M.D. a N ucleo de Reproduc x~ao Humana do Hospital Moinhos de Vento–Gerar; and b Department of Obstetrics and Gynecology, Postgraduate Program in Clinical Medicine, and d Department of Surgery, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil c Objective: To report a case of ureterovaginal fistula secondary to transvaginal oocyte retrieval (TVOR). Design: Case report. Setting: IVF Center IN a private hospital. Patient(s): A 31-year-old woman presented immediately after TVOR with right lower abdominal pain with irradiation to the suprapubic area and vaginal discharge. Intervention(s): Vaginal examination, creatinine dosage in plasma and vaginal discharge, excretory urography. A double-J catheter was inserted under general anesthesia. Main Outcome Measure(s): Clinical follow-up. Result(s): Vaginal leakage ceased a few hours after catheter insertion. Transfer of two embryos was performed 3 days after TVOR, but no pregnancy occurred. The double-J catheter was removed 21 days after its placement. Imaging studies done 6 weeks later demonstrated a normal urinary tract morphology. Conclusion(s): Given the elective nature of TVOR and IVF, patients should be informed about all potential complications, including ureterovaginal fistula. (Fertil Steril 2008;90:2006.e1–e3. 2008 by American Society for Reproductive Medicine.) Key Words: Transvaginal oocyte retrieval, ureteral injury, in vitro fertilization, infertility, complication, assisted reproductive technology Infertility is thought to affect 10 to 15% of couples. In European countries where assisted reproduction technologies (ART) are reported, 0.2% to 3.9% of all births are due to ART, such as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). More than 100,000 IVF cycles have been reported from 399 American centers in 2003, resulting in more than 48,000 births (1, 2). Described by Wickland et al. in 1985, transvaginal oocyte retrieval (TVOR) has become the technique of choice for obtaining oocytes for IVF, owing to its good oocyte retrieval yeld, minimal invasiveness, and light sedation required (3, 4). Less invasive than oocyte retrieval through laparoscopy, used in the early years of ART, TVOR should not be considered to be a risk-free procedure. Complications, such as bleeding from the vaginal wall or from pelvic vessels, pelvic abscess, and direct lesion to the bowel or ureter, have been reported (3, 5, 6). Received January 17, 2008; revised and accepted March 3, 2008. H.vE.C. has nothing to disclose. M.M. has nothing to disclose. A.M.d’A. has nothing to disclose. M.B. has nothing to disclose. Reprint requests: Dra. Helena von Eye Corleta, Rua Ramiro Barcelos, 910 conj. 905, CEP 90035-001, Porto Alegre, RS, Brazil (FAX: 0055 51 3311 6588; E-mail: [email protected]). 2006.e1 We describe a case of a right ureterovaginal fistula after TVOR in which symptoms developed immediately after the procedure. As far as we know, no case with such an early presentation has been previously reported. CASE REPORT A 31-year-old nulliparous woman with a 7-year history of infertility due to male factor (oligoasthenospermia) was planned to undergo TVOR with IVF. Pelvic anatomy was normal by laparoscopy 2 years before during infertility work-up. Ovarian stimulation was started with GnRH analogue in a short protocol with purified urinary gonadotropins and oocyte retrieval scheduled for 36 h after recombinant LH. The TVOR was performed with a 7.0-MHz ultrasound probe (GE-Adara Sonoline) fitted with the original manufacturer’s needle guide and 18-gauge double-lumen needle from Laboratoire CCD (France). Both ovaries were punctured and seven oocytes retrieved. Immediately after the procedure, the patient described right lower abdominal pain and right flank pain with irradiation to the suprapubic area. Opiods provided partial relief, and a pelvic and transvaginal ultrasonography did not show Fertility and Sterility Vol. 90, No. 5, November 2008 Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc. 0015-0282/08/$34.00 doi:10.1016/j.fertnstert.2008.03.005 FIGURE 1 (A) Excretory urography film showing a normal left ureter and contrast extravasation along distal third of the right ureter (a Foley catheter is present in the bladder). (B) Late film of excretory urography showing a fistulous tract from the right ureter to the vaginal apex. von Eye Corleta. Ureterovaginal fistula. Fertil Steril 2008. any pelvic abnormality. The patient was discharged to home with oral analgesics. Twelve hours after the procedure, the patient complained of a clear and odorless vaginal discharge and reported two episodes of pain similar to the first one. She was seen at the clinic, and a vaginal examination showed a small amount of clear watery fluid at the vaginal cul-de-sac. Curiously, the amount of fluid would increase or decrease depending on the movement of the vaginal speculum. The fluid was leaking from the area where the aspiration needle was inserted, just lateral to the cervix. The patient was admitted to the hospital. She was not febrile and had a normal complete blood count. Plasma and vaginal fluid creatinine were 1.03 mg/dL and 92.9 mg/dL, respectively, confirming the diagnosis of a urinary fistula to the vagina. A retrograde cystography was normal, and an excretory urography revealed leakage of contrast medium from the lower right ureter to the vaginal apex, clearly demonstrating a right ureterovaginal fistula (Fig. 1). A double-J catheter was inserted under general anesthesia. Intravenous cefazolin, 1 g t.i.d. was started, followed by oral cefuroxime, 500 mg b.i.d., for 14 days. Vaginal leakage ceased a few hours after catheter insertion. Transfer of two embryos was performed 3 days after TVOR, but no pregnancy occurred. The double-J catheter was removed 21 days after its placement. Imaging studies done 6 weeks later demonstrated a normal urinary tract morphology and further clinical course was uneventful. DISCUSSION Transvaginal oocyte retrieval is a safe technique (7–9). In large prospective and retrospective series of TVOR procedures, the most common complications are severe abdominal Fertility and Sterility pain (3%) (8) and minor vaginal bleeding (0.5%–7.5%)(8– 10). Severe or intra-abdominal bleeding occurs in 0–0.08% of the procedures. Pelvic infections or abscesses range from 0 to 0.6% (7–10). Injury to pelvic viscera, such as bowel, bladder, and large vessels, are exceedingly rare, with few reports in the literature (8). Given its anatomic position, ureteral injury after TVOR is surprisingly rare. Only one case is cited in a large series of TVOR procedures (8), and six case reports are found in the literature (3, 4, 6). Most of the cases were managed conservatively, with ureteral stenting (4, 6, 8, 11) or a nephrostomy tube (12), but two cases underwent ureterovesical reimplantation, either open or laparoscopic (13). In two cases, adhesions from endometriosis, laparoscopic pelvic surgery, or repeated ovarian punctures could have made more likely the ureteral trauma by reducing the mobility of nearby organs (12, 13). The present case had no previous pelvic or abdominal surgical procedures, except for a diagnostic laparoscopy that confirmed normal pelvic anatomy. The clinical presentation of a post-TVOR ureteral injury may include lower abdominal and flank pain, suprapubic pain, and irritative urinary symptoms, eventually accompanied by nausea and vomiting (3, 4, 6, 13) Fever may be a presenting sign (6, 13). Abdominal examination may reveal lower abdominal tenderness, involuntary guarding, and slight signs of peritoneal irritation (3, 4, 6, 13). The beginning of symptoms is variable, ranging from some hours to a few months (6, 12). The present patient presented immediate pain, suggestive of renal colic, probably due to the acute ureteral lesion. No signs of peritoneal irritation were found, which we attribute to the early drainage of urine to the vagina. 2006.e2 Imaging studies, like ultrasonography, computerized tomography, and magnetic resonance imaging, are extremely helpful in identifying pelvic collections, dilation of the urinary tract, and extravasations of contrast material to the retroperitoneum. We decided to do a retrograde cystography and an excretory urography, because the findings of the abdominal and transvaginal ultrasonography were normal and we already had the diagnosis of a urinary vaginal fistula because the creatinine measurement of the vaginal fluid was extremely high. We just needed to identify the exact point of extravasation and fistulization (bladder or ureter), which was clearly shown. This is the second case report of an ureterovaginal fistula secondary to TVOR and the first one with such a spontaneous and early presentation. The first case report was also a rightsided fistula presenting 5 days after the procedure and only occurring after surgical drainage of a vaginal tumescence (serohematic fluid collection) (3). Prevention of pelvic structure injury during TVOR could include improvements in imaging techniques, such as color Doppler ultrasound (4). Furthermore, it has been suggested that keeping the needle guide in a lateral position before puncture could avoid trauma to the important anterior structures (4). After transvaginal oocyte retrieval, abdominal, flank, and suprapubic pain, accompanied by irritative urinary symptoms and nausea/vomiting, should raise the suspicion of a ureteral injury. The differential diagnosis includes adnexal torsion, ovarian cyst rupture, bowel injury, pelvic vessel injury and hematoma formation, and pelvic infection or abscess (5, 7, 8). Given the elective nature of TVOR and IVF, patients should be informed about these potential, albeit rare, complications of the procedure. 2006.e3 von Eye Corleta et al. Ureterovaginal fistula REFERENCES 1. Nyboe Andersen A, Erb K. Register data on assisted reproductive technology (ART) in Europe including a detailed description of ART in Denmark. Int J Androl 2006;29:12–6. 2. Van Voorhis BJ. Clinical practice. In vitro fertilization. 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