Large Dumbbell Shaped Vesicovaginal Calculus Managed with Holmium Laser Cystolithotripsy Followed by Staged Repair of Vesicovaginal Fistula

Abstract

A 47-year-old female of Caucasian race presented with continuous urinary leak per vaginum since last four years. Since five months she had perineal and suprapubic pain and sensation of bearing down which was increasing gradually. She was operated for total abdominal hysterectomy five years back for dysfunctional uterine bleeding. Patient was informed about the intraoperative bladder injury which was repaired at the same time. Histopathology of the specimen showed benign fibroids. Following the surgery after catheter removal she developed a Vesicovaginal Fistula (VVF). Trans-abdominal VVF repair was attempted twice in other institutes. First was performed two months after the hysterectomy and second was performed after one year for the recurrence. Unfortunately she had persistent urine leak after second attempt of repair also. She did not seek further treatment until she presented to us. Per speculum and per vaginum examination revealed a calculus at the introitus without any significant vulval excoriation. Calculus was seen extending from bladder into vagina through a defect which had indurated margins. She did not have any positive family history of urinary stone disease.Serum creatinine was normal. Urine culture was positive for E. coli. Computed tomography with contrast (CECT) [Table/ Fig-1,2] showed 7x4.6cm (600HU) dumbbell shaped calculus extending from bladder into vagina through a rent in posterior wall of bladder and contrast extravasation was seen through the rent. Upper tracts were normal. On cystoscopy more than three centimeters vesicovaginal defect with oedematous margins was present involving right ureteric orifice. Urinary bladder capacity was adequate.With the due consideration to the total stone load and previous failed attempts of VVF repair, patient was planned for staged surgical approach. First stage was planned to make her stone free. VVF repair was considered electively in second stage. Perioperative antibiotics were started as per sensitivity. Intravesical part of stone was 3x4 cm, smooth, round in contour; which was difficult to be removed by cystolitholapaxy. Holmium laser cystolithotripsy was used to break the vesical portion of stone at the waist of the dumbbell, Complicated Vesicovaginal Fistulae (VVF) is prevalent in developing countries following obstetric injury. We report a rare case of a large dumbbell shaped vesicovaginal calculus measuring 7x 4.6cm in a patient with recurrent, complicated VVF managed successfully in two stages 6 weeks apart. Holmium laser (30 Watt) cystolithotripsy was used to break the vesical portion of the stone at the waist of the dumbbell, followed by delivery of vaginal part of the stone. Trans-abdominal VVF repair (O'Connor method) with omental interposition flap with right side ureteric reimplant was done after six weeks.Our case was unique because of occurrence of a larger sized fistula after a gynaecological surgery. She had developed larger stone (weight more than190gm-vaginal component) into the fistula tract. Also she had undergone multiple failed...