Bilateral Ureteric Injury: Its Presentation, Management and Outcomes. A Case Report.
1Peter Olalekan Odeyemi (docpeto4all@yahoo.com; ORCID ID. 0000-0003-4239-9534), 2Is'haq Ishola Aremu. (iiaremu10@gmail.com; ORCID ID. 0000-0003-3485-3346), 3Musa Ayinde. (musaayinde150@gmail.com; ORCID ID. 0000-0002-1289-7447), Olusola Oyewole Oladosu (oladosudoc@gmail.com; ORCID ID. 0009-0002-5939-3112), 1Najeem Adedamola Idowu. (idowunajeem0@gmail.com; ORCID ID. 0000-0003-4231-7703.), 5Ibukun Adewumi Okunade (ibukunokunade70@gmail.com; ORCID ID. 0009-0003-0252-5564)
1Division of urology, Department of Surgery, Ladoke Akintola University of Technology Teaching Hospital, Ogbomosho; 2 Department of Surgery, General Hospital Ilorin, Nigeria.; 3Department of Obstetrics and Gynaecology, General Hospital Ilorin, Nigeria; 4Department of Anaesthesia, General Hospital Ilorin, Nigeria; 5Department of Family medicine, Bowen University Teaching Hospital, Ogbomosho , Nigeria.
ABSTRACT
Background: Iatrogenic ureteric injury is a common complication of pelvic surgery especially gynaecological procedures. However, bilateral ureteric injury is very rare with significant morbidity and occasional mortality. Total abdominal hysterectomy is responsible for most cases in our environment especially when performed by non-specialist medical professionals. While literature is sparse on the presentation, management and outcomes of this rare condition, the few ones available do not give a clear guideline.
CASE SUMMARY. A 48-year-old woman with 2 days history of not passing urine through the urethral catheter following abdominal hysterectomy by a general practitioner. Indication for the surgery was a symptomatic fibroid. There was associated progressive abdominal distension. Significant findings on examination were non draining 18Fr foley’s urethral catheter, lower abdominal midline surgical wound, significant abdominal distension with vague tenderness. Serial electrolyte, urea and creatinine showed significant progressive deterioration of the renal functions. Ultrasound showed bilateral hydroureteronephrosis with significant intraperitoneal fluid collection. Patient had emergency exploratory laparotomy with intra operative findings of 2.5L of intraperitoneal urine collection, dilated ureters, bilateral suture ligation of distal ureters with leakage of urine around suture lines. Patient had drainage of intraperitoneal collection, bilateral ureteroneocystostomy, bilateral ureteric stenting, peritoneal lavage and was placed on continuous bladder drainage.
CONCLUSIONS: Bilateral ureteric Injury is a urological emergence especially when the patient is rendered anephric by bilateral ureteric ligation. Prompt diagnosis and treatment are important to salvage the renal functions and achieve good outcomes.
Correspondence
Dr Peter Olalekan ODEYEMI
Division of Urology, Department of Surgery,
Ladoke Akintola University of Technology Teaching Hospital,
Ogbomosho, Nigeria.
docpeto4all@yahoo.com
INTRODUCTION
Iatrogenic injuries bring to mind the Latin phrase primum non nocere meaning ‘first do no harm’. When clinicians inadvertently injure the ureters they violate this basic principle.1 Injury to the ureter is one of the most serious complications of any abdominal or pelvic procedure whether from gynaecological, urological or general surgical disease with concern about the medico-legal implication.2 The incidence varies between 0.5 and 10% in most series.3-5 Traditionally, gynaecological procedures have been reported to account for between 50 and 75% of iatrogenic ureteric injuries (IUI) with hysterectomy accounting for majority of the cases.6 Since the ureter lies very near the female reproductive organs throughout its course from the pelvic brim to the bladder, gynaecological or pelvic disease can involve the ureter directly or can cause the course of the ureter to deviate. The normal anatomic relations of the ureter in the pelvis can also vary, thereby making it vulnerable to injury.7-10
In Sub-Saharan Africa, with an endemic scarcity of gynaecologists, the practice of major gynaecological surgical procedures is not limited to the specialists alone but also inexperienced non- specialists.5,11 Ureteric injury may result from such practices and if not properly managed could lead to increase in morbidity and mortality.5,11 Injuries may however be almost unavoidable in some situations, even in the hands of the most skilled and experienced gynaecologists. Though bilateral ureteric injuries are rare, it present a considerable reconstructive challenge.12,13Injuries recognised during the initial surgery are generally straightforward to treat involving immediate open repair over a ureteric stent.
The management of injuries presenting in the postoperative period has evolved over the past decade changing from a predominantly open approach to endourological retrograde or antegrade stent placement.4,12 In addition to the ureteric injury it must not be forgotten that pelvic surgery such as radical hysterectomy can affect lower urinary tract function, typically by injury to the pelvic nerves, resulting in a proportion of women experiencing long-term bladder dysfunction.14Issues surrounding the management of bilateral ureteric injury are more complex and are less considered in the literature despite the challenging reconstructive problem that they present. The standard methods of surgical management used for unilateral injury may need to be modified or used in combination for cases of bilateral injury and close observation is needed to minimise further loss of renal function and to avoid uro-sepsis.1
Objective: To present a case of bilateral ureteric injury, its presentation, diagnosis, management and outcomes.
CASE PRESENTATION
A 48 year old woman with 2 days history of not passing urine through the urethral catheter following abdominal hysterectomy by a general practitioner. Indication for the surgery was a symptomatic fibroid. There was associated progressive abdominal distension which became worse when kidneys were challenged with IVF and IV frusemide. There was difficulty in breathing presumably due to splitting of the diaphragm. Significant findings on examination was non draining 18Fr foley”s urethral catheter, lower abdominal midline surgical wound, significant abdominal distension with vague tenderness. There was also shallow respiratory and tachypnea. Paracentesis done in the accident and emergency yielded free flowing clear fluid presumable to be urine. Full blood count showed anaemia despite two units of blood transfusion from the referral centre. Serial electrolyte, urea and creatinine showed significant progressive deterioration of the renal functions. Ultrasound showed bilateral hydroureteronephrosis with significant intraperitoneal fluid collection.
Patient had emergency exploratory laparotomy by a urologist with intra operative findings of 2.5L of intraperitoneal urine collection, dilated ureters, bilateral suture ligation of distal ureters with leakage of urine around suture lines. Fig 1. Patient had drainage of intraperitoneal collection, bilateral ureteroneocystostomy, bilateral ureteric stenting, peritoneal lavage and was placed on continuous bladder drainage. Fig 2.
 |
Fig 1. Ligated ureters with leakage of urine
Fig.2. Ureteroneocystostomy with Stenting
Outcomes
Patient had significant improvements post operatively with stable vital signs. Renal functions returned to normal within 48 hours after surgery. Tables 1 and 2. She was subsequently discharged 4 days post op and had ureteric stents removed six weeks postoperative.
RESULTS
.
Table 1. Post Ureteric Injury EnU, Cr
|
Day |
Cr |
Ur |
Na |
K |
Cl |
|
2 |
245 |
11.4 |
140 |
4.4 |
107 |
|
3 |
379 |
17.3 |
137 |
_ |
100 |
Table. 2. 2-Day Post Ureteroneocystostomy EnU, Cr
|
Day |
Cr |
Ur |
Na |
K |
Cl |
|
2 |
100 |
3.6 |
136 |
2.3 |
112 |
Abbreviations; EnU,Cr – Electoryte, Urea and Creatinine. IVF – intravenous Fuid
DISCUSSION
Iatrogenic ureteric injuries are well recognised complications of gynaecological surgeries. Total abdominal hysterectomy accounts for the majority of the causes accounting for about 83%. Corroborating these, our patient had total abdominal hysterectomy.3,6,8
Our patient was 48 years; a similar pattern to what had been reported previously indicating that this often occurs in women during their reproductive periods.6,15,16,17
The practice of major gynaecological surgical procedures by inexperienced non-specialist is common in Sub-Saharan Africa.5,11 This may lead to increase incidence of ureteric injury and if not properly managed could lead to increase in morbidity and mortality.5,11 Our patient was operated by inexperienced non-specialist medical professional. Lack of specialist training and inadequate experience may contribute to this injury. However, an experienced non-specialist can safely perform some gynaecological surgical procedures without increase in the incidence of ureteric injury. Emergency surgeries account for majority of the cases.6 Although, our patient had elective surgery, bilateral ureteric injury might have occurred while the surgeon was trying to secure haemostasis. Bilateral ureteric injury is rare and mostly presents later with symptoms ranging from fistula to renal failure.
Our patient presented immediately after the surgery with non-draining urethral catheter, progressive abdominal distension and deterioration of the renal functions. Our patient may have presented later if only one ureter was injured. We infer that bilateral ureteric injury is one of the major factor for early presentation. The main stay of diagnosis is CT urogram. This could not be done in our patient due to financial constraints and deterioration of the clinical condition. We relied majorly on ultrasound findings of significant intraperitoneal collection and bilateral hydroureteronephrosis with progressive deterioration of the renal functions. Treatment depends on the type of injury, presentation, and surgeon choice. Injuries recognised during the initial surgery are generally straightforward to treat involving immediate open repair over a ureteric stent. The management of injuries presenting in the postoperative period generally ranges from endourological retrograde or antegrade stent placemen to open approach and sometimes nephrectomy.6,12,14
Our patient had open approach involving exploratory laparotomy, bilateral ureteroneocystostomy and stenting. Patients with urinary retention or bilateral ureteric obstruction is at risk of hydronephrosis follows by progressive renal damage as evidence by deranged renal functions with progressive elevation of urea and creatinine. Prompt relieve of the obstruction leads to resolution of hydronephrosis and progressive improvement in renal functions. If elevation of urea and creatinine persist despite resolution of the hydronephrosis, this may mean the patient has reached baseline and will not improve further.15
In our patient, serum creatinine and urea increased rapidly to 379 and 17.3 mmol/l respectively within 72 hours of injury suggesting rapid deterioration of the renal functions with possible contribution from peritoneal absorption. There was rapid reduction of creatinine and urea to normal with values of 100 and 3.6 mmol/l suggesting complete recovery of the renal functions within 48 hours of repair. As noted in other studies,6,12,14 our patient improved significantly with restoration of the renal functions and general clinical improvement.
CONCLUSIONS:
Bilateral ureteric Injury is a urological emergence especially when the patient is rendered anephric by bilateral ureteric ligation. Prompt diagnosis and treatment are important to salvage the renal functions and achieve good outcomes.
Conflict of Interest: The authors declare no conflict of interest
Ethical Issues: The informed consent of the patient was obtained and the case report was conducted in compliance with the guidelines of the Helsinki declaration on biomedical research in human subjects. Confidentiality of the patient and personal health information was maintained.
REFERENCES