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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 9  |  Issue : 3  |  Page : 199-201

Uterocutaneous fistula postabdominal myomectomy: Successful Repair – Case report and review of literature


1 Kingswill Specialist Hospital, Festac Town, Lagos, Nigeria
2 Departments of Obstetrics and Gynecology, Lagos University Teaching Hospital, Lagos, Nigeria

Date of Submission23-May-2021
Date of Acceptance09-Jul-2021
Date of Web Publication30-Nov-2021

Correspondence Address:
Dr. Aloy Okechukwu Ugwu
Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njecp.njecp_17_21

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  Abstract 


Uterocutaneous fistula (UCF) is a very clinical entity that occurs mostly following surgical injuries. We present a case of a 35-year-old nulliparous woman who developed UCF following openabdominal myomectomy. She was managed successfully using laparotomy with fistula tract excision and repair. Her symptoms resolved spontaneously after surgery,

Keywords: Abdominal myomectomy, Nigeria, uterocutaneous fistula


How to cite this article:
Nwogu CM, Ugwu AO, Soibi-Harry AP, Nwokocha SU. Uterocutaneous fistula postabdominal myomectomy: Successful Repair – Case report and review of literature. Niger J Exp Clin Biosci 2021;9:199-201

How to cite this URL:
Nwogu CM, Ugwu AO, Soibi-Harry AP, Nwokocha SU. Uterocutaneous fistula postabdominal myomectomy: Successful Repair – Case report and review of literature. Niger J Exp Clin Biosci [serial online] 2021 [cited 2022 Aug 14];9:199-201. Available from: https://www.njecbonline.org/text.asp?2021/9/3/199/331549




  Introduction Top


Myomectomy is a procedure for the removal of uterine fibroids, it is more commonly carried out in women who desire to retain their reproductive function, vis-a-vis, childbearing.[1] Although it is a common surgical procedure in our environment, it sometimes results in some complications, such as excessive bleeding, surgical site infection, inadvertent injury to contiguous structures, adhesion formation, wound dehiscence, enterocutaneous fistula, and rarely, uterocutaneous fistula (UCF).[1],[2],[3] Development of these complications sometimes depends on the uterine size prior to surgery, other associated comorbidities, such as obesity, history of prior abdominal surgeries, skill of the surgeon, and among other risks.[1]

A fistula is generally defined as an abnormal communication between two epithelial surfaces. There are several types of fistulas encountered in obstetrics and gynecological practice, ranging from ureterovaginal, vesicovaginal (such as juxta-urethral, mid-vaginal, juxta-cervical), vesicocervical or vesicouterine (including Youssef syndrome), rectovaginal, and very rarely UCF.[2],[3],[4] Uterine fistulas usually involve the cervix, bladder, or the rectum (uterocervical, vesicouterine, or uterocolonic) and occasionally, the skin.[1],[2] The etiology of these fistulas includes direct causes from obstetric injuries, following improper use of drains, incomplete closure of incisions, postoperative injuries, multiple abdominal surgeries, iatrogenic injury during difficult cesarean sections, following surgical techniques for postpartum hemorrhage, gynecological malignancies, genital tract tuberculosis, major gynecological surgeries, and postoperative wound infection or after septic abortion.[2],[3],[4],[5],[6]

There is no standardized protocol or guideline for the management of UCF owing to its rarity. However, many imaging modalities have been utilized in the diagnosis and treatment of women with UCF.[2],[4],[7] These imaging techniques such as ultrasonography, fistulogram, magnetic resonance imaging, and computed tomography scan have found various use in the management of UCF.[2],[3],[4] Currently, other modalities of management including exploratory laparotomy, laparoscopic and hysteroscopic excision, and repair the fistula tract have been utilized.[2],[4],[7],[8] Medical management using gonadotropin-releasing hormone agonists to induce pseudomenopause to allow for proper evaluation and management has also been utilized.[8],[9],[10]


  Case Report Top


A 35-year-old nulliparous woman was referred to our facility in 2019 with an inability to conceive and cyclical bleeding from abdominal scar of 8 years' duration. She was diagnosed with multiple uterine fibroids in 2011 following which she had open abdominal myomectomy at the referring facility. Her surgery was complicated by surgical site infection and wound breakdown, during which she had parenteral antibiotics and secondary wound closure thereafter. Two weeks later, her menses spontaneously returned partly through the vagina and partly through the surgical site. She was commenced on subcutaneous 3.6 mg of Goserelin monthly for 6 months, but the symptom returned following return of her menses. Physical examination revealed a hypertrophied midline subumbilical midline scar with two dimples and tenderness along the lower half of the scar. Pelvic ultrasonography revealed a uterus with a fundal defect and anterior surface adhered to the anterior abdominal wall with probe tenderness along the lower half of the scar, ultrasonography-guided uterine probe transcervically with an intra-uterine insemination catheter revealed probe beyond the uterus protruding through the fistulous tract on the anterior abdominal wall. A hysterosalpingography was done, during which an injected contrast was seen flowing through the abdominal incision site with no evidence of spill of filling of the  Fallopian tube More Detailss.

She also had a hysteroscopy done which revealed a 2 cm defect at the fundal region of the uterus, tubal ostia were not visualized. She subsequently had exploratory laparotomy with excision and repair of the fistula. She had a repeat HSG and hysteroscopy subsequently which revealed no defect. Her menstrual flow restarted vaginally with no flow through the surgical site.


  Discussion Top


A case of 35-year-old nulliparous woman with UCF has been presented. Although one of the very rare types of fistulae, with few cases reported globally, UFC is most times misdiagnosed as endometriosis, wound infection, or even as an abscess. It is because of this rare occurrence that its approach to diagnosis and treatment has not been standardized.[2],[3],[5]

Most cases of UCF reported are secondary to multiple abdominal surgeries, especially myomectomy and cesarean sections.[3],[4] However, other etiologies include UCF occurring post irradiation of the genital tract, tuberculosis, or even postB-lynch suturing for postpartum hemorrhage because of extensive uterine necrosis, postabdominal pregnancy, migration of intrauterine device, and secondary to congenital anomaly of the genital tract.[2],[6] Our patient was presented following abdominal myomectomy and failed medical therapy.

No standardized management approach exists currently, because of its rarity, few cases have been managed using medical therapy either to induce pseudomenopause or to relieve pain arising from other complications such as endometriosis.[8],[9] Majority of UCF are managed using surgical approach either laparotomy or laparoscopy.[7],[10] The extent of the surgery also depends on patients' desire and expertise of the surgeon.[1],[5] Our patient had laparotomy with fistula tract excision and repair. She was not fit for medical therapy because she presented after 8 years of the previous surgery, when the fistula tract had already undergone fibrosis and may not respond to medical treatment.


  Conclusion Top


UCF is a very rare complication of abdominal myomectomies, with different modalities of management. It can be prevented by meticulous surgical technique, use of potent antibiotics to prevent surgical site infection, and optimizing the patient prior to surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to thank all staff of medical records department and nurses of Kingswill Specialist Hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Eleje GU, Udigwe GU, Okeke MP, Nwokoro JM, Onyejiaku LC, Ezugwu CJ, et al. Post cesarean Uterocutaneous fistula with successful repair and successful outcome: A case report. J Preg Neonatal Med 2018;2:27-30.  Back to cited text no. 1
    
2.
Jindal A, Chaudhary H, Thakur M. Tubercular utero-cutaneous fistula after caesarean section: A case report. Case Rep Womens Health 2018;17:3-4.  Back to cited text no. 2
    
3.
Akkurt MÖ, Yavuz A, Tatar B, Özkaya MO, Ekici Eİ. Utero-cutaneous fistula after multiple abdominal myomectomies: A case report. Balkan Med J 2015;32:426-8.  Back to cited text no. 3
    
4.
Shah N, Changede P, More V. Laparoscopic management of post-cesarean section uterocutaneous fistula. J Obstet Gynaecol India 2019;69:380-2.  Back to cited text no. 4
    
5.
Hardy LE, Leung Y. Uterocutaneous fistula as the primary presentation of a gynaecological malignancy. BMJ Case Rep 2018;2018:100-14.  Back to cited text no. 5
    
6.
Thakur M, Rathore SS, Jindal A, Mahajan K. Uterocutaneous fistula following B-Lynch suture for primary postpartum haemorrhage. BMJ Case Rep 2018;2018:20-3.  Back to cited text no. 6
    
7.
Offiong RA, Adewole ND, Zakari MM, Okochi DO. Uterocutaneous fistula: A rare clinical entity. N Niger J Clin Res 2018;7:35-7.  Back to cited text no. 7
  [Full text]  
8.
Lawal IK, Suleiman AK, Ketare N, Obiokonkwo CA. Scar endometriosis as a complication of surgically treated utero-cutaneous fistula. Trop J Obstet Gynaecol 2020;37:213-5.  Back to cited text no. 8
  [Full text]  
9.
Seyhan A, Ata B, Sidal B, Urman B. Medical treatment of uterocutaneous fistula with gonadotropin-releasing hormone agonist administration. Obstet Gynecol 2008;111:526-8.  Back to cited text no. 9
    
10.
Taingson MC, Adze JA, Bature SB, Durosinlorun AM, Caleb M, Amina A. Utero-cutaneous fistula following cesarean section. Niger J Surg Res 2016;17:58-60.  Back to cited text no. 10
  [Full text]  




 

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