Pelvic surgery specialists repair fistulas and other severe complications after delayed pessary removal

Anthoula Douvalakis’ healthcare nightmare started at the height of the COVID-19 pandemic, during one of her regular visits to Greece.

After growing up in Chicago and raising her three boys here, Douvalakis, 75, began to periodically visit her homeland, spending several weeks to months at a time in Thessaloniki. She never had problems returning to the United States until travel between Greece and the U.S. was largely suspended in 2020 due to the spread of SARS-CoV-2, the virus that causes COVID-19.

Suddenly, Douvalakis was stranded, far from her immediate family.

Until then, she’d made sure to regularly visit her doctor in the U.S. to have her pessary maintained. That’s a small, disc or cube-like device used to support organs in the pelvis — like the bladder — that slip (or prolapse) as the body’s supporting tissue weakens.

Stuck in Greece, Douvalakis struggled to navigate the unfamiliar healthcare system and find a doctor knowledgeable about her specific pessary. As months passed, the tissue surrounding her pessary became infected. It became increasingly difficult to control her bladder and bowel functions.

Greek physicians encouraged her to go to the ER, but Douvalakis, who was otherwise healthy, felt apprehensive about becoming a patient mid-pandemic in a foreign hospital. By the time she was able to return to the U.S. and see her doctor in May 2021, the pessary was embedded in her vaginal wall.

The resulting pressure sore created four fistulas, or holes, in her bladder, rectum and ureters. The ureters are two tubes that carry urine from the kidneys to the bladder.

A doctor performed emergency surgery to remove the pessary. In order for the fistulas to heal, Douvalakis received a nephrostomy, a procedure where a small, flexible tube is inserted in each kidney to drain urine and deposit it into external bags. She also had a catheter placed to drain urine from her bladder and a colostomy to collect stool from her colon.

She spent the next five months in a skilled nursing facility, struggling with the slow pace of her recovery. Neither Douvalakis nor her family were satisfied with how she was healing.

"It was very painful at the nursing home because I had those tubes and my colostomy bag, too,” said Douvalakis.

Dimitri Douvalakis, Anthoula’s son, was as frustrated as his mom – and worried. She’d lost more than 30 pounds, and was down to a mere 88 pounds.

“I think the hardest part for me was having her in the nursing home,” he said.

Dimitri began searching online for specialists who could help. That’s when he came across Sandra Valaitis, MD, a urogynecologist and pelvic reconstructive surgeon at University of Chicago Medicine. Valaitis specializes in urogenital disorders, including pelvic organ prolapse and urinary incontinence.

“It was the worst case I’d ever seen, and the fact that there were four fistulas made it even more complicated to manage,” said Valaitis, who first saw Douvalakis in August 2021. “Usually, fistulas are smaller and related to complications from surgeries — maybe a wound didn’t heal properly, or the patient had radiation therapy.”

It was an incredibly complex case with a lot of moving parts. But it makes such a difference to have a good surgical team and surgeons you trust.

Due to the severity and complexity of the case, a team of specialists operated together on Douvalakis, including urologic surgeon Sarah Faris, MD, and colon and rectal surgeon Konstantin Umanskiy, MD.

“At UChicago Medicine, we see a lot of complicated cases that other places just reject,” said Umanskiy. “This was unfortunately a perfect storm, and another byproduct of COVID-19.”

The team’s to-do list was significant: close the fistulas, restore the ureters, fix a hernia that had developed in Douvalakis’ colostomy and repair her prolapsed bladder.

In October 2021, the team began the five-hour operation. Umanskiy reversed the colostomy and, using a segment of Douvalakis’ small bowel, created an ileostomy to drain digestive waste into an external bag and be more manageable during her healing process. Valaitis carefully sutured the fistulas, then repaired the prolapsed bladder. Finally, Faris mended the damaged ureters and reimplanted the delicate tubes into the top of the bladder.

“It was an incredibly complex case with a lot of moving parts,” said Faris. “But it makes such a difference to have a good surgical team and surgeons you trust.”

Afterwards, Douvalakis was readmitted for a week and given antibiotics to heal an abscess. She spent an additional four months in a nursing facility for care for her ileostomy, which was removed last March.

Now, she is back to being herself – back to living her life, and back to traveling.

“Thank goodness,” said Douvalakis.