The work presents a rare case of spontaneous migration of an 11-week fetus from the uterine cavity into the urinary bladder cavity through the long-standing vesicouterine fistula

Dmytro Shchukin

Inessa Safonova

Karyna Didenkova

Maria Lisova

Roman Safonov

Vladimir Lesovoy

Yuryi Parashchuk

Case Reports in Medicine

The work presents a rare case of spontaneous migration of an 11-week fetus from the uterine cavity into the urinary bladder cavity through the long-standing vesicouterine fistula.</jats:p

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Case ReportFetus in the Bladder: Rare Complication of Vesicouterine FistulaVladimir Lesovoy,1,2 Yuryi Parashchuk,1 Dmytro Shchukin,1,2 Roman Safonov,3Karyna Didenkova,2 Maria Lisova,1 and Inessa Safonova41Kharkiv National Medical University, 4 Nauky Avenue, Kharkiv 61022, Ukraine2V.I. Shapoval Regional Clinical Center of Urology and Nephrology, 195 Moskovskyy Avenue, Kharkiv 61037, Ukraine3Regional Clinical Hospital, Center of Emergency Medical Care and Disaster Medicine, 13 Pravdy Avenue, Kharkiv 61022, Ukraine4Kharkiv Medical Academy of Postgraduate Education, 58 Amosova Street, Kharkiv 61176, UkraineCorrespondence should be addressed to Dmytro Shchukin; shukindv@gmail.comReceived 29 July 2016; Revised 8 December 2016; Accepted 8 December 2016Academic Editor: Raoul OrvietoCopyright © 2016 Vladimir Lesovoy et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.The work presents a rare case of spontaneous migration of an 11-week fetus from the uterine cavity into the urinary bladder cavitythrough the long-standing vesicouterine fistula.1. IntroductionVesicouterine fistula is an abnormal passageway between thecavities of the bladder and uterus. This condition is very rareand accounts for 1% to 4% of all urogenital fistulas, includingvesicovaginal fistula, ureterovaginal fistula, and urethrovagi-nal fistula [1, 2].Themost common causes of this problem areconsidered to be iatrogenic injuries resulting from Cesareansection, use of vaginal forceps, as well as cervical dilation anduterine cavity curettage abortion [3–5]. The more rare causesof this type of fistulas include embolization of uterine arteries,vaginal birth after previous Cesarean section, migration ofintrauterine devices, placenta percreta, and endometriosis.The literature also describes anecdotal cases of spontaneousdevelopment of vesicouterine fistulas, as well as cases of theirformation as a result of necrosis of uterine fibroids, chronicinflammation, or radiotherapy [6–8].Clinical presentations of vesicouterine fistulas may beearly or late and are mostly represented by amenorrhea, uri-nary incontinence, and macroscopic hematuria during men-struation (menouria) [2, 9].Although there are reports in the literature about preg-nancy in the presence of vesicouterine fistula, cases of move-ment of the fetus through the fistulous tract are extremely rare[10–12]. We present a survey of spontaneous migration of an11-week fetus from the uterine cavity into the urinary bladderthrough the long-term vesicouterine fistula.2. Case ReportPatient K., a 39-year-old female was admitted to a generalhospital in Severodonetsk (Ukraine) on 14 December 2015with complaints of severe lower abdominal pain radiating tothe lumbar region, as well as difficulty urinating.She had a history of Cesarean sections in 2003 and 2005,respectively.The latest Cesarean section ended up with iatro-genic injury to the apex of the bladder. The defects of thebladder and uterus were repaired separately. The patient wasin satisfactory condition when discharged from the depart-ment of obstetrics.However, after three months the patient developed severeabdominal pain at the end of urination associated withscanty periods accompanied by hematuria. On the basis ofcharacteristic symptoms vesicouterine fistula was suspected.This diagnosis was confirmed by cystoscopy. The patientwas offered surgery, which she refused. Subsequently, due toresolution of symptoms the patient stopped seeking medicalattention, although she periodically suffered from urinaryincontinence, menouria, and recurrent infection of lowerurinary tract.Hindawi Publishing CorporationCase Reports in MedicineVolume 2016, Article ID 5750710, 4 pageshttp://dx.doi.org/10.1155/2016/57507102 Case Reports in Medicine(a) (b)Figure 1: Ultrasound images demonstrate (a) a fetus in the mother’s bladder and (b) the fistulous tract between the cavities of the uterus andbladder.(a) (b)(c)Figure 2: Images obtained at cystoscopy. ((a) and (b)) a dead fetus in the bladder cavity and the fetus’ arms are visualized (arrows). (c) Amouth of fistula from the bladder side.After examination the patient was diagnosed with missedabortion of ectopic pregnancy at 11 weeks of gestationlocalized in the bladder. The fetus in the cavity of the urinarybladder was detected at ultrasound examination (Figure 1).The vesicouterine fistula was also well visualized. For furtherexamination the patient was referred to Kharkiv RegionalClinical Perinatal Center and afterwards was transferred fortreatment toRegional ClinicalHospital, Center of EmergencyMedical Care and Disaster Medicine, Kharkiv Regional Peri-natal Center.On 15 December 2015 the patient underwent cystoscopy,which revealed in the cavity of the urinary bladder a deadfetus, embryonic vesicle, and fragments of the umbilical cord(Figure 2). On the posterosuperior wall of the bladder adeck-edged mouth of fistula 2.0 cm in diameter was visual-ized.On 17December 2015 a joint teamof urologists and obste-trician-gynecologists performed the following surgical treat-ment: laparotomy, vesicouterine fistula excision, removal ofthe fetus from the bladder cavity, bladder defect closure, andCase Reports in Medicine 3(a) (b)Figure 3: (a) The stage of fetal removal from the bladder cavity. (b) The dead fetus with signs of autolysis.(a)Uterus(b)Figure 4: Intraoperative images. (a) View of the fistulous tract from the side of the bladder (arrow). (b) Separation of the bladder (whitearrow) from the fistulous tract (black arrow).supravaginal amputation of uteruswith removal of both fallo-pian tubes.In the course of the operation some severe adhesionswerefound between the bladder, uterine body, and the parietalperitoneum. The uterus measured 11.0 × 9.5 × 10.0 cm, withpale pink color, softish consistency, and smooth outer surface.The uterus had limited mobility due to adhesions. Using themethod of sharp dissection the bladder was separated fromthe anterior surface of the uterus toward the level of thefistulous tract. The bladder was opened. The body of macer-ated fetus was removed from the bladder cavity along withfetal membranes with clear signs of autolysis (Figure 3). Thebladder was circumferentially dissected away from the uterusaround the fistulous tract (O’Connor’s technique) (Figure 4).The bladder was closed with Vicryl locking sutures, and Foleycatheter was inserted into the bladder cavity through theurethra. Finally, supracervical hysterectomy was performed.The postoperative period was uneventful. Patient wasdischarged from the hospital at the 8th day. The urethralcatheter was removed 14 days after surgery.3. DiscussionAmong all types of urogenital fistulas the vesicouterine fistulais considered to be the most rare one. However, there arequite a number of reports available addressing this subject[1–9]. It is established that vesicouterine fistulas occur mostoften in patients who previously underwent several Cesareansections. Concerning the diagnostic aspects of this typeof fistulas, it should be noted that they are accompaniedby a characteristic clinical picture, including incontinence,menouria, and menstrual disorders [2, 9]. The diagnosis canbe easily established by cystoscopy and roentgenologic exam-ination (cystography, hysterography), as well as by modernmethods of visualization (ultrasonography, MDCT, or MRI).Scientific publications have presented some clinical casesof pregnancy accompanied by vesicouterine fistula; however,only three cases of embryonic or fetal migration into thebladder cavity have been reported so far. Guruvare S. andcoauthors reported a case of a patient with macrohematuriaand blood clots in the bladder, who had undergone Cesareansection 18 months earlier [10]. At ultrasonography a largemass in the bladder was suspected, though histological exam-ination revealed a blood clot, which contained fragments ofan embryo.Thefirst case of finding a fetus in the bladderwas reportedby Banale and coauthors [11]. A patient, who previously hadhad twoCesarean sections, presentedwith complaints of painin the abdomen and macrohematuria. A day before she hadundergone an abortion at 17 weeks’ gestation. Ultrasoundexamination revealed a fetus in the bladder cavity. Evidently,dilatation of the cervical canal or curettage of the uterinecavity caused damage to the anterior uterinewall and the pos-terior bladderwall, allowing the fetus tomigrate into the blad-der. At cystoscopy a dead fetus and amouth of a fistula 2.0 cmin diameter on the rear wall of the bladder was discovered.4 Case Reports in MedicineThe patient underwent removal of the fetus from the bladderwith separate repair of defects of the bladder and uterus.Another publication by Gupta and coauthors presented areport about prolapse of amniotic sac through a vesicouterinefistula at 22 weeks of pregnancy [12]. The patient hadhistory of two Cesarean sections. The main clinical presenta-tions were severe pain and difficulty urinating. Examinationrevealed that the amniotic sac prolapsed through the urethraand could be displaced by finger or when placing the patientin Trendelenburg position. Cesarean section and vesicouter-ine fistula suturing were performed.Our clinical observation is unique in several ways. In par-ticular, beginning of the pregnancy was presented along withthe existence of vesicouterine fistula, which had developedmore than 10 years earlier. In contrast to the observation byBanale and coauthors, in our case we registered migration ofquite a large fetus (11 weeks) through the long-term fistuloustract with diameter of approximately 2.0 cm. Apparently, thefistula size increased as long as the size of the uterus wasincreasing, which enabled the fetus to move into the bladder.The exact time of the fetus migration was undetectable sincethe clinical picture had developed 3 days before the surgery;however, the morphologic changes conformed to the longertermof death of the fetus. Probably, the fetus had been alreadydead by the time of its migration, and after its transfer thefistulous tract significantly decreased.It should be noted that our patient had a history of twoCesarean sections. The clinical symptoms of vesicouterinefistula had not seriously bothered the patient until the admis-sion to the hospital, and 11 weeks of pregnancy had passedwithout any complications. Although the existing surgicalmethods applied to correct vesicouterine fistula involve bothpreservation and removal of the uterus, we utilized the non-organ-sparing option due to the age of the patient andaccording to her decision.For this patient the O’Connor’s technique was used [13].The procedure involves a sagittal cystotomy (bivalving thebladder) or posterior cystotomy that is carried toward theedge of the fistula. The fistula tract is excised and the bladderdefect is closed with a running suture. In our opinion,the technique is the most convenient in the patients withvesicouterine fistulas.4. ConclusionsThe onset of pregnancy is possible in the presence of thelong-term vesicouterine fistula. The migration of the fetusfrom the uterine cavity into the bladder presents one of thecomplications of vesicouterine fistulas.Competing InterestsThe authors declare that there is no conflict of interestsregarding the publication of this paper.References[1] A. B. Porcaro, M. Zicari, S. Z. Antoniolli et al., “Vesicouterinefistulas following cesarean section,” International Urology andNephrology, vol. 34, no. 3, pp. 335–344, 2002.[2] S.-K. Yip and T.-Y. Leung, “Vesicouterine fistula: an updatedreview,” International Urogynecology Journal and Pelvic FloorDysfunction, vol. 9, no. 5, pp. 252–256, 1998.[3] M. A. Bonillo Garc´ıa, J. J. Pacheco Bru, J. L. PalmeroMart´ı et al.,“Vesicouterine fistula. Our experience of 25 years,” Actas urolo-gicas espanolas, vol. 27, no. 9, pp. 707–712, 2003.[4] J. B. Hadzi-Djokic, T. P. Pejcic, and V. C. Colovic, “Vesico-uterine fistula: report of 14 cases,” BJU International, vol. 100,no. 6, pp. 1361–1363, 2007.[5] M. O. Karalti, S¸. Tinar, N. T. O¨ztu¨rk, and D. C. O¨ztu¨k, “A casewith vesicouterine fistula: mini review,” Archives of Gynecologyand Obstetrics, vol. 285, no. 3, pp. 667–670, 2012.[6] S. Krysiewicz, Y. H. Auh, and E. Kazam, “Vesico-uterine fistulaassociated with placenta percreta,” Urologic Radiology, vol. 57,pp. 438–439, 1985.[7] J. Nariculam, D. Aggarwal, S. Kapadia, R. Walker, and C.Croucher, “Spontaneous vesico-uterine fistula at the time ofmiscarriage: a case report,” British Journal of Medical andSurgical Urology, vol. 2, no. 3, pp. 124–126, 2009.[8] D. Fridman, S. Chakraborty, and N. Khulpateea, “Fistulabetween degenerated uterine leiomyoma and the bladder: casereport,” International Urogynecology Journal, vol. 22, no. 10, pp.1329–1331, 2011.[9] A. F. Youssef, “‘Menouria’ following lower segment cesareansection. A syndrome,”American Journal of Obstetrics and Gyne-cology, vol. 73, no. 4, pp. 759–767, 1957.[10] S. Guruvare, P. Kushtagi, and J.Thomas, “Spontaneous abortionthrough the bladder,” International Journal of Gynecology andObstetrics, vol. 87, no. 2, pp. 172–173, 2004.[11] K. Banale, T. Javali, P. Babu et al., “Fetus in bladder,” Indian Jour-nal of Urology, vol. 29, no. 4, pp. 351–352, 2013.[12] S. Gupta, N. Bhardwaj, A. Verma, M. Poonia, and Anita, “Bulg-ing bag of membranes through urethral opening at 22 weeksgestational age: a case of vesicouterine fistula,” The Journal ofObstetrics and Gynecology of India, vol. 64, supplement 1, pp.45–46, 2014.[13] L. J. Nesrallah, M. Srougi, and R. F. Gittes, “The O’Conor tech-nique: the gold standard for supratrigonal vesicovaginal fistularepair,” Journal of Urology, vol. 161, no. 2, pp. 566–568, 1999.Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

Fetus in the Bladder: Rare Complication of Vesicouterine Fistula

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Fetus in the Bladder: Rare Complication of Vesicouterine Fistula

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