Delayed diagnosis of ureteral obstruction and hydronephrosis

 despite intra-operative cystoscopy

John L. Washington MD

Central Carolina Gynecology & Urogynecology

Burlington NC

Assistant Clinical Professor

Department of Obstetrics and Gynecology

                                       University of North Carolina , Chapel Hill  

Summary: This paper presents a case of delayed hydronephrosis following anterior repair and trans-obturator sling in which intra-operative cystoscopy was not helpful.  

Abstract:

Background: Routine intra-operative cystoscopy is often advocated to improve the diagnosis of ureteral obstruction following gynecologic surgery. It is still possible for ureteral obstruction to occur in the immediate postoperative period and be missed by cystoscopy.  

Case: A patient had an anterior vaginal repair and trans-obturator sling. Intra-operative cystoscopy showed no abnormalities and demonstrated ureteral patency. Subsequently she developed unilateral hydronephrosis.  

Conclusion: Routine cystoscopy is advocated following pelvic dissection but is not certain to rule out the occurrence of hydronephrosis in the postoperative period. Symptoms suggesting hydronephrosis should still be evaluated with that in mind and the diagnosis should not be dismissed out of hand.  

        Case Report: Delayed diagnosis of ureteral obstruction and hydronephrosis

 despite intraoperative cystoscopy.

Introduction

            Routine cystoscopy has been considered in pelvic surgery, particularly hysterectomy, and especially when the cervix is removed because of the likelihood of unrecognized bladder or ureteral injury. ^(1;2) In hysterectomy, ureteral injury or obstruction has been estimated in from .02% to 6% of cases. ⁽²⁾ Slings, especially the Ulmsten type, whether from up-down or down-up always necessitate cystoscopy because of the relatively high incidence of bladder injury. (³) The question of using cystoscopy with trans-obturator slings is now being discussed in the literature. ^(4;5;5-7) Cystoscopy with anterior vaginal and paravaginal repairs has not been addressed in a systematic way. My preference has been to do cystoscopy any time there has been significant dissection in the pelvic floor or sidewall  or when instruments have been passed near the bladder or urethra.

            The rational for cystoscopy is, obviously, to find out if there has been trauma to the bladder or  the urethra. If either  has been damaged directly or if a stitch or sling is perforating either structure the problem will be immediately evident. Obviously if the ureter has been transected there will be no output on that side. However, it bears mentioning that indirect damage may not be evident intra-operatively.

Case Report

            A 71 year old patient had an anterior-paravaginal repair and a trans-obturator sling operation. She was taking antihypertensives, clopidogrel, and conjugated estrogens. The clopidogrel was discontinued several days preoperatively and anti-platelet function tests were normal. The repair was done with a porcine xenograft sutured to the arcus tendineus bilaterally without midline placation of the pubo-vessicocervical fascia. The trans-obturator sling was performed with helical needles in an outside-in procedure. During the anterior repair  increased bleeding was noted from the area of the lateral dissection bilaterally. Bovine thrombin was applied and the incision closed. A vaginal pack was inserted. The patient was given intravenous indigo carmine and cystoscopy was done. Blue dye was seen flowing through both ureteral orifices and there was no evidence of injury to the bladder or urethra.  In recovery the vaginal pack was extruded and the patient had more bleeding. She was returned to surgery and the wound was explored but discrete bleeding points could not be determined. The wound was resutured and a firm vaginal packing was inserted. The patient was given two units of platelets. The pack was removed after 12 hours and bleeding did not reoccur. Approximately 36 hours after surgery the patient began to complain of nausea and abdominal pain. An abdominal plain film was read as compatible with ileus. Vaginal exam showed no hematoma or unusual tenderness in the operative site. Diet was limited and suppositiories given. The pain was referred  to the left upper quadrant and the patient seemed to have some relief of pain with expelling flatus, but overall her condition did not improve. A CT was done and showed left hydronephrosis with the obstruction at the level of the bladder. She was returned to the operating room and a double J stent was inserted without difficulty. She had complete and immediate resolution of her symptoms.

Discussion

It is obvious that if the ureter is interrupted or completely ligated there will be immediate cessation of its transport function but it bears remembering that this is neither the only nor most likely mode of damage. The ureter in its course past structures of gynecological interest is more likely to suffer near misses than direct hits. If it is partially crushed by a clamp, kinked by a nearby repair, devascularized by a ligature or partly cooked by a cautery, the response may be delayed. It the above case it can only be hypothesized what the mode of injury was but it is most likely one of compression of the uretero-vessical junction by hematoma or by edema from the trauma of the surgery and the packing. Cautery was not used in this procedure and there were no stitches nearby.

 Conclusion

            It is evident from this case that routine cystoscopy is useful but not infallible in diagnosing ureteral obstruction following pelvic reparative surgery and that the surgeon must be alert for the occurrence of hydronephrosis even if ureteral patency has been demonstrated during the procedure.

Reference List

  (1)   Vakili B, Chesson RR, Kyle BL, Shobeiri SA, Echols KT, Gist R et al. The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy. Am J Obstet Gynecol 2005; 192(5):1599-1604.

  (2)   Visco AG, Taber KH, Weidner AC, Barber MD, Myers ER. Cost-effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy. Obstet Gynecol 2001; 97(5 Pt 1):685-692.

  (3)   Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1996; 7(2):81-85.

  (4)   Esinler I, Zeyneloglu HB. Routine cystoscopy is not needed in TOT outside-in. Eur Urol 2004; 46(5):675-676.

  (5)   Minaglia S, Ozel B, Klutke C, Ballard C, Klutke J. Bladder injury during transobturator sling. Urology 2004; 64(2):376-377.

  (6)   Domingo S, Alama P, Ruiz N, Perales A, Pellicer A. Diagnosis, management and prognosis of vaginal erosion after transobturator suburethral tape procedure using a nonwoven thermally bonded polypropylene mesh. J Urol 2005; 173(5):1627-1630.

  (7)   Abdel-Fattah M, Ramsay I, Pringle S. Lower urinary tract injuries after transobturator tape insertion by different routes: a large retrospective study. BJOG 2006; 113(12):1377-1381.

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