IATROGENIC URETERIC INJURIES COMPLICATING OPEN OBSTETRIC AND GYNAECOLOGIC OPERATIONS IN SOUTH EAST NIGERIA - CASE SERIES

*Nnabugwu I I1
Amu O C2
Dept of surgery, Federal Medical Centre, Asaba, Delta State, Nigeria
& Dept of surgery, Enugu State University Teaching Hospital, Enugu. Enugu State, Nigeria. E-Mail: iinnabugwu@yahoo.com

*Correspondence
Grant support: None
Conflict of Interest: None

Abstract

Background: Iatrogenic ureteric injury(IUI) in open obstetric and gynaecological surgeries is uncommon, with an incidence of 0.4-2.5%. It is however less uncommon in some specific vaginal and urethral suspension surgeries. The left ureter is more commonly damaged in the pelvis than the right ureter. The common mechanisms of injury include ligation, transection and crushing. Most of these injuries are unnoticed at the primary surgery, but are recognized in the immediate post-operative period. Iatrogenic ureteric injury increases morbidity, though mortality is rare.

Results: A total of six patients had iatrogenic ureteric injuries during open pelvic operations in this study between January 2009 and December 2010. All the patients had a mean age of 38.5years and a range of 27-50 years. The primary surgery for three of the cases were done by consultant gynaecologists, two by medical officers who were yet to undergo residency training, while the status of the surgeon in one case could not be ascertained. The left ureter was injured in 5(83%) patients, with ligation being the commonest mechanism of injury in 83% of cases. Recognition of the ureteric injuries was in the post-operative period in all the cases in this report. The commonest presenting feature was leakage of urine via a uretero-vaginal fistula in 67% of cases and through the surgical wound in one(17%) patient.

Conclusion: Iatrogenic ureteric injuries do complicate pelvic surgeries in this environment and often present as urinary fistula in the immediate post operative period; majority are missed intra-operatively.

Key words: Iatrogenic ureteric injuries, Obstetrics & Gynaecology surgeries, South East Nigeria.

INTRODUCTION

Iatrogenic ureteric injury (IUI) during obstetric and gynaecological surgery is the commonest cause of ureteric injury representing about 75% of ureteric trauma cases1. IUI occurs with an incidence of 0.4-2.5% of all open abdomino-pelvic surgeries 2,3,4. However the incidence gets as high as 11% in bladder neck suspension, urethropexy, sacrocolpopexy and vaginal vault suspension surgeries5.

In our environment, Caeserean section (CS) is responsible for 38% of cases and Caeserean hysterectomy for 25% of cases: they are the leading preceding surgeries according to Ozumba et al6. Other workers however identified abdominal hysterectomy instead7,8,9. This translates to a female preponderance of about 87%10.

The left ureter is injured more frequently than the right and typically the injuries involved the pelvic part of the ureter10.

In open obstetric and gynaecological surgeries, the ureter can be injured in a variety of ways: ligation, transection, resection, skeletonization, and crushing. While Chianakwana et al,7 identified ligation as the commonest mechanism of injury accounting for 87% of cases; Oboro et al,3 and Ozumba & Attah,6 identified transection as the commonest, occurring in 58% and 60% of cases respectively.

These injuries occur most times as a result of unanticipated primary haemorrhage8. In some instances, it is due to distorted anatomy and/or altered course of the ureter as obtained in pelvic adhesions and neoplasia11. It is also known that ureteric injury can occur in the absence of any obvious predisposing condition1.

The most important determinant of outcome is the interval between the injury and repair: the longer the interval, the worse the outcome12,13,14. Prompt intra-operative identification and appropriate correction decrease morbidity and eliminate mortality. Regrettably, most cases in our environment are identified in the post-operative period due to leakage of urine per vaginam or via surgical site or wound drain site. Other presenting features include ipsilateral loin pain, anuria, azotemia, uraemia, pylonephritis, or electively during radiological investigation for an unrelated medical condition8,10. Prior ureteric stenting does not reduce risk of injury to ureter, but increases intra-operative identification of eventual injury15,16.

Case Reports:

CASE 1.

I.C., a 46-year old Para 6+0 with secondary school education was referred 2 weeks post total abdominal hysterectomy (TAH) with leakage of urine per vaginam that started on the 5th day post-op. The surgical operation was done by a medical officer who had not received a formal postgraduate surgical training. The abdominal incision site had healed satisfactorily. She continued to sense bladder fullness and the urge to empty the bladder. On physical examination, she had ammoniacal odour, and a perineal pad soaked with urine. Vaginal examination demonstrated a pyogenic granuloma at the vaginal vault from which trickled urine. Methylene-blue instilled into the urinary bladder did not stain the gauze placed in the vagina.

Abdomino-pelvic ultrasonography and intravenous urography (IVU) revealed left hydro-ureteronephrosis, while the serum electrolytes, urea and creatinine values were within normal limits.

With a working diagnosis of left IUI, the left ureter was explored 6 weeks post TAH and found to be ligated along with left adnexial tissues. A left uretero-neocystostomy was done. Her post-op period was uneventful and repeat IVU done 3 months later showed normal caliber kidneys and ureters with no evidence of leakage.

CASE 2.

U.C, a 50-year old Para4+0 was noticed to be draining urine per vaginam 5 days post TAH + left oopherectomy done in a Mission hospital by a consultant gynaecologist. She maintained a satisfactory ability to void urine intermittently. Physical examination on the 10th day post operative day revealed a granuloma at the vault of the vagina through which urine leaked. The methylene-blue vaginal test was negative. Her serum electrolytes, urea and creatinine values were within normal ranges, while abdomino-pelvic ultrasonography and IVU revealed left hydro-ureteronephrosis. At laparotomy 6weeks post-op, the left ureter was found to be ligated with a proximal dilatation. A left uretero-neocystostomy was done and the urinary leakage stopped. Repeat IVU 3 months later revealed normal sized ureters and pelvis.

CASE 3.

A 32-year old lady, I.N, was found to be draining urine from the drainage tube four days after excision of a large left ovarian mass; she drained almost the same volume of urine through the drainage tube as was drained by the urethral catheter. Her serum electrolytes, urea and creatinine were within normal limits.

She was re-explored the next day. Intra-operatively, instillation of methylene-blue into the proximal left ureter using a 25G needle, confirmed the leakage to be from the left ureter at a crushed devitalized segment located within the pelvis 2cm from the urinary bladder. An uretero-neocystostomy was done. Subsequent IVU after three months showed normal kidneys with no features of obstruction.

CASE 4.

A.E, 45 years old, presented 6 months after TAH performed elsewhere with complaints of progressively worsening left flank pain of 1 month duration with intermittent leakage of urine.

There was no significant finding on physical examination and her serum electrolytes, urea and creatinine were within normal limits. Abdomino-pelvic ultrasonography and IVU revealed left hydro-ureteronephrosis.

AT exploratory laparotomy, a hugely dilated left ureter which was ligated in the pelvis was found. A left uretero-neocystostomy was done and the loin pain resolved.

CASE 5.

F.T, a 27-year old lady presented with 7 months history of leakage of urine per vaginam 7 days after a caesarian section for an obstructed labour; the surgery was performed by a medical officer. The caesarian section was the second in 26 months. On physical examination, she had an ammoniacal odour and a 0.5cm defect in the anteriorwall of the vagina. Methylene-blue vaginal test was positive and IVU revealed a right hydro-ureteronephrosis.

At exploratory laparotomy, a supratrigonal vesico-vaginal fistula (VVF) about 0.5cm in diameter was identified, in addition to a grossly dilated right ureter strictured by ligature in the pelvis. VVF repair and right uretero-neocystostomy were performed at the same session. The urine incontinence resolved completely. Post-op abdomino-pelvic ultrasonography demonstrated normal right and left kidneys .

CASE 6.

A 40-year old civil servant, A.B, presented with 3 weeks history of leakage of urine per vagina post total abdominal hysterectomy (TAH) performed by a consultant gynaecologist. This operation was a re-operation after an unsuccessful attempt by a medical officer at a Cottage hospital. After the TAH, the patient developed reactionary haemorrhage and was promptly re-explored and haemostasis secured. However, leakage of urine started 5 days post-op.

Abdomino-pelvic ultrasonography confirmed the absence of the uterus with hydro-ureteronephrosis .IVU also confirmed the hydro-ureteronephrosis which extended down to the pelvis.

At exploratory laparotomy, a dilated left ureter extending down to a ligatured point distally in the pelvis was identified. A left uretero-neocystostomy was done. Repeat IVU 3 months later showed normal left pelvis and ureter.

Discussion

Ureteric injuries complicating open gynaecologic and obstetric surgeries increase the morbidity associated with the surgeries4,6. Where there is significant delay in recognition, mortality can occur6,8.

Though it has been established that prophylactic retrograde ureteric catheterization during surgical procedures with increased risk of injury to the ureter has not decreased the incidence of injury15, such catheterization however, has increased chances of prompt recognition and repair at primary surgery should ureteric injury occur.

All the injuries in this series were recognized later than 72 hours post-operatively. One case was recognized 6 months after the causative surgical operation because the initial urinary leakage noticed in the immediate post operative period stopped spontaneously, only for left hydrouretero-nephrosis to be identified 6 months later.

Total abdominal hysterectomy was the commonest preceding surgical procedure in this series akin to findings elsewhere6,7,8.

Five (83%) of the 6 cases presented with leakage of urine via fistulous tracts to the exterior. In each case, the fistula ensured continuous decompression of the partly obstructed ipsilateral upper tract thereby minimizing renal damage. The presenting symptoms in all the patients were relieved postoperatively.

In 3 cases, consultant gynaecologists were the operating surgeons in the primary surgical operations; in 2 cases, medical officers without surgical training were the primary surgeons; and in 1 case, the status of the primary surgeon could not be ascertained.

The disparity in the commoner site of ureteric injury in this study is obvious: in 83% of cases the left ureter was ligatured. This pattern has been documented previously10. The anatomy of the left and right ureters is essentially similar12,17, however, Chan et al1 described the right ureter as 1cm longer than the left. Since the mechanism of most injuries to the ureter within the limited space of the pelvis points to desperate attempt at haemostasis in a tight space, the disparity highlights a subtle difference in vascular anatomy. This might explain the unexpected haemorrhage arising on the left and putting the left ureter at risk as haemostasis is applied. One of these cases was actually taken back to the operating room because of reactionary left adnexial haemorrhage. Some workers have suggested that right-handed surgeons operating in the pelvis from the right side of the patient would have compromised access to the structures in the left half of the pelvis, though surgeons are trained to stand at the appropriate side depending on their handedness. Further studies are required to evaluate these factors that could predispose to ureteric injuries during pelvic operations.

Conclusion

Iatrogenic ureteric injuries do complicate obstetrics and gynaecologic procedures in this environment and often present as urinary fistula in the immediate post-operative period; majority are missed intra-operatively, and the experience of the operating surgeon does not appear to influence recognition at surgery. Morbidity is high in this condition when it is not detected and corrected promptly.

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