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
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Vol. 90, No. 5, November 2008