212

ABSTRACT

A 53-year-old lady who underwent hysterectomy 5 days back, presented with left flank pain, fever and nausea. Imaging studies showed left hydronephrosis and left hydroureter. Cystoscopy and retrograde catheterization revealed left ureteric obstruction about 2 cm above the ureteric orifice.Ureteroneocystostomy was carried out and the obstructed left kidney was saved. Early recognition of unilateral ureteric ligation was the key to successful management and salvage of the renal unit.KEY WORDS: Hysterectomy, Ureteric Ligation, Ureteric reimplants.

CASE REPORT

EARLY POST-OPERATIVE RECOGNITION OF UNILATERALURETERIC LIGATION AND ITS MANAGEMENT

1 2 3 4 5 6KHALID FAROUK , SHAHIDA AKHTAR , RABBIA IJAZ , RIFFAT NAJEEB , MOHIBULLAH , HOMAIRA RIAZ

1. Professor of Urology2. Professor of Obstetrics & Gynae3. PGT of Urology4. Associate Professor of Obstetrics & Gynae

Foundation University Medical College &Fauji Foundation Hospital, Rawalpindi

5. Specialist in Urology6. Medical Officer

Fauji Foundation Hospital, Rawalpindi

Correspondence to:Khalid FaroukProfessor of Urology,Foundation University Medical College, RawalpindiE-mail: khalidfarouk@hotmail.com

ISRA MEDICAL JOURNAL | Volume 6 - Issue 3 (S) | Jul - Sep 2014

CASE REPORT

A 53-year-old ladywas referred to the Urology department of Foundation University Medical College and Fauji Foundation Hospital Rawalpindi with left flank pain, low gradefever and nausea. She hadanabdominal hysterectomy for fibroid uterus at a peripheral hospital five days back. On the second postoperative day,the patient complained of left flank pain and

rdnausea. She also developed low grade fever on 3 postoperative day and on clinical examination tenderness could be demonstrated in left flank. An ultrasound examination revealed moderate left hydronephrosis and left hydroureter. An urgent referral of this patientto our unit was made. On arrival in the urology department, the patient'sgeneral condition was stable and she had urine output around one liter in 24 hours. Her renal function tests were normal. An urgent CT scan of abdomen and pelvis confirmed moderate degree of left hydronephrosis and hydroureterup to the pelvic part (Fig 1). There was a faint excretion of contrast from the hydronephrotic left kidney while the right kidney showed normal contrast excretion and outline of the ureter (Fig 2).Uretherocystoscopy was performed onthe same day. A normal looking bladder mucosa and ureteric orifices were identified. A guide wire was advanced in ureteric orifices on each side. The guide wire went up the right ureter easily but on the left side it couldn't be passed beyond two cm. A ureteric catheter was passed into the left ureteric orifice; again an obstruction was encountered at the same level. An attempt was made to negotiate the guide wire beyond this obstruction with the help ofureteroscope but the guide wire could not cross the

obstruction. A decision to perform an open ureteroneo cystostomy was taken.Through a left lower quadrant incision the ureter was approached extraperitoneally. It was found markedly dilated. It was traced down till it was found buried in the ligature and surrounding fibrosis (Fig 3). The ureter was divided at this place and the proximal end was spatulated. A double J ureteric stent was passed proximally up the ureter into the kidney. A stented tunneled ureteric reimplant was carried out following Gregoire Lich technique (Fig 4). The patient made an uneventful recovery. The Foley catheter was removed on fifth post operative day and she was discharged home. The ureteric stent was removed three weeks later with flexible urethrocystoscope.

DISCUSSION

Iatrogenic ureteric injury is a known complication of abdomino pelvics urgery, and is associated with significant morbidity and

1 2possible loss of renal function . According to one study , the overall incidence of ureteric injury during obstetric and gynecologic procedures has been reported to be 0.5 to 1%.

3However, according to another study , in laparoscopic radical hysterectomy, the incidence of ureteric injury has been reported as high as 5-8 %. Previous pelvic surgery, endometriosis, pelvic adhesions, adnexal masses, cervical and broad ligament fibroids as well as congenital anomalies are

3,4other potential risk factors for ureteric and bladder injuries . Surprisingly, in developing countries the cases of ureteric injury are seen after open hysterectomies for benign conditions. In this patient also, an abdominal hysterectomy was carried out for uterine fibroids. Knowledge of pelvic anatomy,careful dissection and patience in difficult cases are the key factors to

4anticipate and prevent ureteric injury .Unilateral ureteric injury is more common than bilateral but is difficult to detect early postoperatively. Bilateral ureteric ligation, though far less common, is detected much earlier because the patient develops obstructive anuria and becomes

4acutely symptomatic . In unilateral injury patients' symptoms are easily attributed to recent surgery by the treating physician and the diagnosis is usually delayed. Other non specific symptoms in these cases may include nausea, fever or headache. Whenever a possibility of ureteric injury flashes across the mind of the treating physician radiographic investigations should be carried out expeditiously to confirm or

ISRA MEDICAL JOURNAL | Volume 6 - Issue 3 (S) | Jul - Sep 2014Khalid Farouk et al.

213

ureteric ligation was diagnosed and managed after an 6extraordinary delay of 46 days . Delay in diagnosis is the most

7important factor contributing to the morbidity .

5exclude the diagnosis of ureteric ligation .Higgins stated: "The venial sin is injury to the ureter, but the

2mortal sin is the failure of recognition" . Yasir Bilge has reported a case of ureteric ligation after hysterectomy in which the

FIGURE-1: CECT SCAN SHOWING LEFTHYDRONEPHROSIS FIGURE-OF CONTRAST FROM OBSTRUCTED LEFT KIDNEY

2: CECT SCAN SHOWING DELAYED EXCRETION

FIGURE-3: OBSTRUCTED URETER CAUGHT IN LIGATURE FIGURE-4: URETERONEOCYSTOTOMY