Genitourinary Fistulas After Cerclage: A Case Series and Scoping Review.

Abstract

Importance: Genitourinary fistula is a rare complication of obstetric cerclage with limited evidence to guide prevention and management.

Objective: The aim of the study was to describe 5 new cases of vesicovaginal fistula (VVF) after cerclage and evaluate existing cases, including shared features, to generate hypothesis for future etiologic research.

Study design: Case series and scoping review.

Results: Five patients presented with VVF symptoms after cerclage placement; 4 were diagnosed during pregnancy, 1 postpartum. Two patients had prior cervical procedures and were noted to have difficult cerclage placements. Three cerclages remained until delivery, 1 was removed antepartum, and another was replaced. All VVFs were diagnosed by cystoscopy and were repaired postpartum transvaginally. In the scoping review, 14 studies met inclusion criteria, and 19 cases were identified. Compiled cases had a history of cervical procedure(s), shortened cervix, McDonald technique, anterior knot placement, and Mersilene tape use. Fistulas were identified by cystoscopy when performed. Most reports described VVFs near the bladder trigone and midline of the vagina. All VVFs required surgical repair.

Conclusions: Genitourinary fistula after cerclage is rare but may be more common after prior cervical surgery, shortened cervix, and McDonald cerclage. Methods to mitigate morbidity associated with fistula after cerclage placement include cystoscopy if bladder injury is suspected at the time of cerclage placement and consideration of abdominal cerclage when intravaginal access to the cervix is limited. Patients with urinary leakage after cerclage should be evaluated for genitourinary fistula, not just incontinence. Postpartum surgical repair remains the primary treatment for VVF, ideally by a vaginal approach.