Instruments and Technique

Unilateral Hydroureteronephrosis After a Mesh Procedure

Ates Karateke, MD*, Cetin Cam, MD, and Reyhan Ayaz, MD*From the Department of Obstetrics and Gynecology, University of Yeditepe, Bostanci (Dr. Kareteke) and the Department of Urogynecology, Zeynep Kamil

Maternity Hospital, Uskudar (Drs. Cam and Ayaz), Istanbul, Turkey.

ABSTRACT Synthetic mesh has become a popular treatment of pelvic floor relaxation and pelvic organ prolapse, with low complication

The authors have

products or comp

Corresponding au

Zeynep Kamil M

Caddesi, Uskudar

E-mail: drreyhana

Submitted Septem

2009.

Available at www

1553-4650/$ - see

doi:10.1016/j.jmig

rates. We describe the case of a woman with unilateral hydroureteronephrosis after a mesh procedure (Gynecare Prolift; Ethicon

Women’s Health & Urology, Ethicon, Inc., Somerville, New Jersey) successfully treated by neoureterocystostomy. A 39-year-

old woman with pelvic organ prolapse underwent the mesh procedure. Two months later, she had left flank pain, and hydro-

ureteronephrosis was diagnosed on the same side despite cystoscopic confirmation of ureteral passage at the first operation. The

arm of the mesh was removed surgically, and neoureterocystostomy was performed successfully. Mesh surgery is not without

serious complications, and surgeons should bear in mind the possible complications associated with this surgical procedure.

Journal of Minimally Invasive Gynecology (2010) 17, 232–234 � 2010 AAGL. All rights reserved.

Keywords: Hydroureteronephrosis; Mesh surgery; Neoureterocystostomy

Although their efficacy and safety remain generally un-

known, synthetic materials are used with greater frequency

in pelvic reconstructive surgery, in particular, to reduce

the rate of recurrent prolapse. As a result, complications

unique to these materials have emerged [1]. We report a pro-

cedure using synthetic material that was complicated by

hydronephrosis diagnosed 2 months after the procedure.

To our knowledge, this is the first reported case of hydro-

nephrosis related to ureteral obstruction after a synthetic

mesh procedure.

Case Report

A 39-year-old woman reported pelvic pressure and vagi-

nal bulge. Ultrasonography revealed a 50 ! 40 ! 40 mm

myoma located lateral to the uterus on the left side. Vaginal

examination revealed bilateral paravaginal defects and stage

3 anterior prolapse (Pelvic Organ Prolapse Quantification

System) [2]. Preoperative renal function was in the normal

range. The anterior prolapse was corrected using a synthetic

no commercial, proprietary, or financial interest in the

anies described in this article.

thor: Reyhan Ayaz, MD, Department of Urogynecology,

aternity Hospital, Zeynep Kamil Hastanesi, Nuh Kuyusu

, _Istanbul 34668, Turkey

yaz@hotmail.com

ber 12, 2009. Accepted for publication November 27,

.sciencedirect.com and www.jmig.org

front matter � 2010 AAGL. All rights reserved.

.2009.11.014

mesh (Gynecare Prolift; Ethicon Women’s Health &

Urology, Ethicon, Inc., Somerville, NJ).

Under general anesthesia, the patient was placed in the

lithotomy position with the hips in flexion and the buttocks

even with the edge of the table. A Foley catheter was inserted,

and the bladder was drained. A midline incision in the anterior

vaginal wall was made from the urethrovesical junction to the

anterior fornices, and the pubovesical fascia was dissected lat-

erally. A 4-mm incision was made to enable the guide with the

cannula installed to be inserted through the skin. The device

was pushed medially through the obturator membrane and

past the obturator internus muscle 10 mm from the proximal

end of the arcus tendineous fascia pelvis. The same procedure

was repeated contralaterally. A second 4-mm incision was

made 20 mm inferolateral to the first skin incision, and the

guide with the cannula was inserted through the skin. The de-

vice was pushed medially through the obturator membrane

and past the obturator internus muscle 10 mm from the ischial

spines anteriorly. The same procedure was repeated contralat-

erally. Mesh was placed, and cystoscopy was performed. Cys-

toureteroscopy was performed after introducing the cannulas.

Ureteric jets were observed on both sides and were of equal

flow. There was neither any impression of bulging of the lat-

eral bladder wall nor mucosal petechial bleeding sites indicat-

ing trauma to the muscularis layer of the bladder. The arms of

the mesh were adjusted and trimmed below the level of the

skin, and the incision was closed.

The postoperative hospital course was uneventful. At

postoperative month 2, the patient experienced left flank

Fig. 1. Intravenous pyelography revealed a dilated left ureter and pelviectasy

at the left kidney.

Fig. 2. Note extensive fibrosis and scarring around the ureter.

Karateke et al. Unilateral Hydroureteronephrosis After a Mesh Procedure 233

pain. Ultrasonography revealed hydronephrosis and an ob-

structed and dilated left ureter; these findings were confirmed

at computed tomography. Intravenous pyelography revealed

a dilated left ureter and pelviectasy at the left kidney (Fig. 1).

Renal function was normal according to cortical dye uptake.

At cystoureteroscopy, the double-J catheter could not be

inserted farther than the intramural part of the left ureter.

With the patient under general anesthesia, a Maylard incision

was made. An intraligamental myoma in close proximity to

the ureterovesical junction on the left side and an obstruction

in the left ureter at the ureterovesical junction with dilatation

of the part of the ureter proximal to the obstruction were ob-

served. The myoma was removed, although after removal it

was recognized that the myoma was not distorting the course

of the ureter. The ureter was dissected to its entrance to the

bladder. The posterior left arm of the mesh was in close prox-

imity with the ureter just before its entrance to the bladder.

Initially, ureterolysis was attempted; however, because of

the extensive fibrosis and scarring around the ureter

(Fig. 2), ureteroneocystostomy was performed. A submuco-

sal tunnel in the bladder wall was created, the bladder was

opened, the left ureter was passed through the tunnel, and

its distal end was sutured to the bladder whereas its extramu-

ral part was fixed to the bladder serosa. The anastomosis was

stabilized by suturing the bladder serosa to the psoas muscle.

A double-J catheter was placed, and the bladder was closed.

Six weeks later, the double-J catheter was removed via

urethrocystoscopy. Results of intravenous pyelography and

ultrasonography, and renal function were normal after re-

moval of the catheter. No prolapse has been observed at con-

sequent assessments.

Discussion

The transvaginal mesh procedure has become a popular

method for operative treatment of pelvic organ prolapse to al-

ways support the endopelvic fascia. These goals are not

reached without complications. Various major and minor

complications associated with the use of these materials

and their insertion techniques have been reported [1]. To

our knowledge, ours is the first case in the literature of unilat-

eral hydronephrosis resulting from anterior insertion of syn-

thetic mesh to treat prolapse. Similar complications may also

occur with conventional surgery [3], and the true incidence of

intraoperative ureteral obstruction diagnosed with intraoper-

ative cystoscopy is 5.1% in patients who underwent vaginal

surgery because of anterior or apical pelvic organ prolapse

[4]. Inexperience with these novel techniques may be one

of the reasons for the occurrence of such complications.

However, this unique complication occurred after more

than 20 procedures performed with mesh applied through

the transobturator route in a department of pelvic reconstruc-

tive surgery in a referral teaching hospital. The patient had

stage 3 anterior prolapse with previous unsuccessful anterior

colporraphy distorting the normal musculofascial layers of

the anterior vaginal wall, which must be adequately dissected

to reach the paravesical space. Even when instructions are

strictly followed by experienced surgeons, suboptimal surgi-

cal planes may be created unintentionally in such a distorted

environment, and similar complications may not be pre-

vented.

Ureteric injury can result in loss of renal function on the

ipsilateral side in 5% of cases, with delay in diagnosis of

the ureteric insult the most important factor for loss of kidney

function [5,6]. The posterior arms of an anterior mesh pass in

close proximity to the distal ureters at the pelvic floor. Strict

234 Journal of Minimally Invasive Gynecology, Vol 17, No 2, March/April 2010

adherence to the anatomy and operative techniques is essen-

tial in averting intraoperative complications. However, con-

ditions such as large cystoceles, previous surgeries,

intraligamental myomas, adhesions, and large uterine size

may alter the tract of the ureters, making them more vulner-

able to harm during surgery [7]. In our patient, ultrasonogra-

phy revealed a 50 ! 40 ! 40 mm myoma located lateral to

the uterus with close proximity to the ureterovesical junction

on the left side. Because of the preoperative assumption that

the myoma may have distorted or contributed to distortion of

the course of the left ureter and that removing the myoma

might relieve the obstruction and avert these life-threatening

conditions that could not be corrected via the transureteral

route, laparotomy was performed. Intraoperatively, the my-

oma was found to be in an intraligamental location without

distorting the course of the ureter, and was removed. It is

also possible that this complication could be inherent to the

patient’s exaggerated fibrotic response. Synthetic meshes

evoke a fibrotic response that is necessary for their physio-

logic function; however, some individuals may develop an

exaggerated fibrotic response causing dysfunction in adja-

cent structures. At laparotomy, we were unable to judge

whether the mesh was placed in the correct location or

whether the fibrotic reaction was exaggerated because the

normal anatomy was distorted from the primary operation,

and it was impossible to dissect the fibrotic tissue around

the obstructed ureter and the adjacent part of the bladder.

The size of the cystocele also could have distorted the course

of the ureter, and it would be wise to reduce it using fascial

plication sutures before or after insertion of the trocar and

placement of the mesh; however, the unsuccessful previous

surgery on the anterior vaginal wall distorted the fascial

planes, making reasonable fascial plication impossible. In ad-

dition, fascial plication is not a part of the insertion of this

particular device, and an undistorted fascial layer below the

mesh is essential for prevention of erosion.

Various attempts have been proposed to reduce the

incidence of delayed diagnosis of ureteral damage during

surgery [8]. Intraoperative cystoscopy may be helpful in de-

tecting complete ureteral obstruction; however, its value in

subtle conditions is less clear [9]. In our patient, intraopera-

tive cystoscopy did not enable detection of the pathologic

condition between the left posterior arm of the mesh and

the left ureter. This failure may be due to shrinking of poly-

propylene meshes, which demonstrates its effect on the ureter

in the late postoperative period. Although to our knowledge

no data exist, especially in cases with prolapse and a history

of reconstruction, that may influence the blind application of

the device, more active behavior during intraoperative

cystoscopy mimicking mesh shrinkage by pulling the arms

of the mesh to establish its possible effect on the ureters after

intravenous injection of indigo carmine dye could alert

surgeons of this complication. This emphasizes the impor-

tance of cystoscopic skill of the urogynecologic surgeon, as

well as of awareness of possible novel and unique complica-

tions of the new technique of mesh surgery in pelvic organ

prolapse.

References

1. Feiner B, Jelovsek JE, Maher C. Efficacy and safety of transvaginal mesh

kits in the treatment of prolapse of the vaginal apex: a systematic review.

BJOG. 2009;116:15–24.

2. Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology

of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet

Gynecol. 1996;175:10–17.

3. Pang MW, Wong WS, Yip SK, Law LW. An unusual case of bilateral

ureteric obstruction after anterior colporrhaphy and vaginal hysterectomy

for pelvic organ prolapse. Gynecol Obstet Invest. 2003;55:125–126.

4. Gustilo-Ashby AM, Jelovsek JE, Barber MD, Yoo EH, Paraiso MF,

Walters MD. The incidence of ureteral obstruction and the value of intra-

operative cystoscopy during vaginal surgery for pelvic organ prolapse.

Am J Obstet Gynecol. 2006;194:1478–1485.

5. Selzman AA, Spirnak JP. Iatrogenic ureteral injuries: a 20-year experi-

ence in treating 165 injuries. J Urol. 1996;155:878–881.

6. Parpala-Sparman T, Paananen I, Santala M, Ohtonen P, Hellstrom P. In-

creasing numbers of ureteric injuries after the introduction of laparoscopic

surgery. H Scand J Urol Nephrol. 2008;42:422–427.

7. Reisenauer C, Kirschniak A, Drews U, Wallwiener D. Anatomical condi-

tions for pelvic floor reconstruction with polypropylene implant and its

application for the treatment of vaginal prolapse. Eur J Obstet GynaecolReprod Biol. 2007;131:214–225.

8. Handa VL, Maddox MD. Diagnosis of ureteral obstruction during com-

plex urogynecologic surgery. Int Urogynecol J Pelvic Floor Dysfunc.

2001;12:345–348.

9. Dandolu V, Mathai E, Chatwani A, Harmanli O, Pontari M, Hernandez E.

Accuracy of cystoscopy in the diagnosis of ureteral injury in benign

gynecologic surgery [Comment]. Int Urogynecol J Pelvic Floor Dysfunct.2003;14:427–431.