A 71-year-old woman who had had a previous abdominal hysterectomy and Burch operation presented with stress urinary incontinence due to intrinsic urethral sphincter deficiency. She underwent a technically difficult placement of a TVT tape in April 2002. After an uneventful recovery she was discharged after 72 hours but presented almost 5 months later with small bowel obstruction. At laparotomy she had a loop of ileum adherent to the left lower side wall of the pelvis, with the TVT tape penetrating and traversing this loop. The ileal segment was excised and an end-to-end anastomosis performed. Her recovery was uneventful and she is maintaining her urinary continence. Patients who have had previous combined pelvic intra- and extraperitoneal surgery should be operated on by experienced surgeons and be observed for 24 hours. The placement of a Uratape (Porges-Mentor) via a transobturator approach should also be considered in such cases.

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Obstetric fistulae are still common in the rural areas of South Africa. This study describes the demographic and clinical characteristics of 41 women with obstetric urinary fistulae. All were from poor socioeconomic backgrounds and had limited or no access to antenatal care.

ABSTRACT.A 22-year-old female patient was treated for spino-renal fistula as a result of a high-velocity gunshot injury to her abdomen. The patient presented with meningeal signs, a headache and right monoparesis. A CT scan of her abdomen revealed a leak of contrast from the right kidney into the perirenal space and tracking further into the thecal sac. An MRI scan showed a stable fracture of L3 with slight compression of the thecal sac and features of cord contusion caused by the shockwave of the bullet. To the best of our knowledge a spino-renal fistula of traumatic origin has not previously been reported in the English language literature. Trauma is the leading cause of death in young South Africans. The genitourinary tract will be involved in about 3% to 10% of patients who experience traumatic injuries [1]. Of these, the most commonly involved organ is the kidney, followed by the bladder, urethra and ureter [1]. 85% to 95% of injuries to the kidney are due to blunt trauma, and the remainder are due to penetration injuries [2]. Complications after renal trauma occur in 3% to 33% of these patients [3]. A wide range of reported complications exists in those with renal trauma. In 2001, Blankenship et al [3] reported that one-third of conservatively treated renal trauma patients develop one or more urological complications, whereas other series have had much lower complication rates (closer to 5%) [4]. While the vast majority of traumatic urological injuries are not life threatening, failure to diagnose and a delay in treatment can lead to significant patient morbidity. Case reportA 22-year-old female patient suffered an abdominal gunshot injury with the entry wound on the right upper flank and exit wound above the left iliac crest. During a laparotomy, a hepatic flexure colonic injury and a right lower pole renal injury were debrided and repaired and a tube drain placed in the right paracolic gutter. Postoperatively, the patient complained of a headache and left lower-limb weakness. In addition, a persistent urinary leak was noted via the abdominal drain. A left lower-limb monoparesis, with sensory level at L3, was confirmed. An abdominal CT scan [ Figure 1] revealed a leak of contrast from the right kidney into the perirenal space and further tracking into the thecal sac. An MRI scan (Figures 2 and 3) showed a stable fracture of L3, with slight compression of the thecal sac and features of cord contusion caused by the shockwave of the bullet. The diagnosis of a spino-renal fistula was therefore confirmed. During re-exploration, a perinephric urinoma with lower pole injury and an active urinary leak was identified. Subsequently, a right subcapsular nephrectomy was performed. The patient recovered well and is undergoing rehabilitation for a neurological deficit. DiscussionThe presence of coincidental organ injury is not a complication in itself but it is a complicating factor of renal trauma. Associated organ injury is reported in 61% to 100% of reported cases of renal trauma involving penetration [5,6], and 35%...